Sei sulla pagina 1di 75

Antenatal Care Module

Tutors Guide

Jakarta, Indonesia
December 2012

Table of Contents
1. Introduction..................................................................4
Student Characteristics...........................................................4

2. How to Use the Antenatal Care Module...........................5


3. Learning Objectives.......................................................6
3.1 Develop knowledge base....................................................6
3.2 Develop clinical skills.........................................................8
3.3 Enhance professional development.....................................9

4. Core Topics and Clinical Conditions.................................9


5. Physical Examination and Procedural Skills...................10
6. Guide to Ethical Behaviour...........................................10
7. Teaching and Learning Programme...............................11
7.1 Overview.........................................................................11
7.2 The Programme...............................................................12
7.2.1 Introduction................................................................................12
7.2.2 Clinical Skills Session..................................................................12
7.2.3 Clinical Teaching.........................................................................12
7.2.4 Problem-based Learning.............................................................12
7.2.5 Topic Tutorials.............................................................................12
7.3 Topics, Teaching and Learning Methodology and
Assessment/Evaluation..........................................................13

8. Learning Resources.....................................................16
References........................................................................................... 16

9. Assessment.................................................................17
10. Procedural Skills Tutorial............................................18
10.1 Taking an Obstetric History............................................18
10.2 Performing an Obstetric Examination..............................23

11. Teaching and Learning Materials.................................27


11.1 Group Discussion...........................................................27
11.1.1 Group Exercise: Use of pregnancy calculator...........................27

11.1.2 Discussion: Birth and emergency preparedness plan...............29


11.2 Case-based Learning Case Triggers.................................33
Case Study 1: Focused Antenatal Care................................................33
Case Study 2: Health education for women following the basic
component of Focused Antenatal Care................................................38
11.3 Problem-based Learning Case Triggers............................39
Case Study 1: Counselling for HIV Testing During Antenatal Care.......39
Case Study 2: Antenatal Assessment and Care (Anaemia)..................41
11.4 Knowledge Assessment..................................................49
11.4.1 Knowledge Assessment on Focused Antenatal Care:................49
11.4.2 Knowledge Assessment:...........................................................49
Prevention and Management of Malaria and Other Causes of Fever In
Pregnancy............................................................................................ 49
11.4.3 Knowledge Assessment:...........................................................51
Preventing Mother-To-Child Transmission of HIV..................................51
11.4.4 Knowledge Assessment:...........................................................53
Postpartum family planning.................................................................53
11.5 Checklists......................................................................56
11.5.1 Checklist for Focused Antenatal care........................................56
11.5.2 Checklist for birth and emergency preparedness plan.............62
11.5.3 Checklist for demonstration of breast feeding..........................63
11.6 Learners Guide:............................................................65
11.6.1 Learners Guide: Antenatal Assessment - Taking an Obstetric
History................................................................................................. 65
11.6.2 Learners Guide: Antenatal Assessment - Physical Examination
............................................................................................................ 70
11.7 Counseling Guide for Postpartum Family Planning
Postpartum IUD.....................................................................75

1. Introduction
The module on antenatal careis an inter-related learning experience between several basic
sciences and clinical disciplines. These modules include:
- Anatomy and Embryology Modules for anatomy of the female genital tract and fetal growth
and development (third year)
- Physiology Module for physiology of pregnancy (third year)
- Microbiology and Infectious Disease Modules for STI/RTI and HIV (third year)
- Pharmacology Module for prescribing medicines in pregnancy and the puerperium (third
year)
- Haematology and Clinical Pathology Modules for urine and blood investigations (third year)
- Womens Health Module for obstetric and gynaecological issues (fifth year)
- Medicine Module for medical disorders in pregnancy (fifth year)
- Nutrition Module for nutrition during pregnancy and breastfeeding (third year)
- Community Medicine Module (third year)that will cover public health topics closely related to
Obstetrics and safe motherhood. These are:
Maternal and Neonatal Mortality and Morbidity
Initiatives to improve maternal and newborn health
Services for maternal and neonatal health in Indonesia
The Empathy Module (first year), Basic Clinical Skills Module including counseling (second
and third year) and subjects such as Ethics and Professionalism and Cultural Competence
are critical elements of antenatal care provision.
The Antenatal Care module is based on the WHO Antenatal Care model which has been used
extensively in low and middle-income countries as the Focused Antenatal Care model.
The Antenatal Care module is primarily for the doctor practising as a general practitioner at
the health centre/puskesmas level; and can also be used by midwives working at this level.

Student Characteristics
Students who can take the Antenatal Care module are those who have completed Stage 1 of
their education and have acquired learning skills of Stage 1 General Education. These
students must have achieved basic skills and attitudes, such as life-long learning skills,
generic skills and concern for the environment and the community.

2. How to Use the Antenatal Care Module


The Antenatal Care module is introduced in the third year and will be undertaken in the Basic
Clinical Skills Module (fourth year), Womens Health Module (fifth year) and in the Preinternship training.
This module contains the following information:
Learning Objectives
The Core Topics and Clinical Conditions you are to be able to address as a result of your
learning experience related to this module
Teaching/Learning materials:
- TheCase-Based and Problem-based Learning Case Triggers
- The worksheets for taking an obstetric history and conducting an obstetric examination as
part of procedural skills
- Checklists and Learners Guide
- A Counselling Guide for post-partum family planning
In the Fifth Year when going through the Womens Health rotation, you will complete a Clinical
Skills logbook which will reflect your tasks and observations related to antenatal care.

3. Learning Objectives
Antenatal care (ANC) is the care provided throughout pregnancy to help ensure that women
go through pregnancy and childbirth in good health and that their newborns are healthy. The
emphasis in this module is on Focused ANC (FANC), which relies on evidence-based
interventions provided to women during pregnancy by skilled healthcare providers such as
midwives, doctors, and nurses with midwifery and life-saving skills. Focused ANC includes
assessment of maternal and fetal well-being, preventive measures, preparation of a birth and
emergency preparedness plans and health messages and counseling.

3.1 Develop knowledge base


During the third year, a knowledge base will have been developed of the
following in the respective Modules:
Normal Anatomy and Physiology
Obstetrics: anatomy of the female pelvis, fetal growth and development
Obstetrics: physiology of pregnancy
Gynaecology: menstrual cycle
Microbiology
Sexually transmitted infections/Reproductive tract infections (gonorrhea and chlamydia
infections, syphilis, HIV/AIDS, candidiasis, trichonomas vaginitis, bacterial vaginosis, Human
Papilloma Virus (HPV) infection, genital herpes)
Haematology and Clinical Pathology
Haematological, biochemical and other laboratory investigations
Pharmacology
Safe prescribing of medicines in pregnancy and puerperium
Population health issues
Sexually transmitted infections/Reproductive tract infections
Mental health in obstetrics
Public health interventions conducted for the mother and newborn in Indonesia and
internationally
Community Medicine
Maternal and Neonatal Mortality and Morbidity
Initiatives to improve maternal and newborn health
Services for maternal and neonatal health in Indonesia

Cultural competence

In the Antenatal Module, the Learning Objectives are:


To explain management of the normal antenatal period:
Obstetrics:
Pre-pregnancy counseling
Evidence-based interventions and care during the antenatal period which can prevent and
treat complications of pregnancy
Focused antenatal care (FANC), basic elements of FANC assessment and care - first and
subsequent antenatal visits (assessment, interventions including referral, counseling and
advice) for the basic component of antenatal care
Common clinical problems in the antenatal period
Maternal nutrition and immunization
Birth and emergency preparedness plans and the relation to the Three Delays.
To explainmanagement of the normal post-partum period:
Obstetrics:
Postpartum care, breastfeeding, maternal complications
Gynaecology:
Contraception for women who breast feed and those who do not breast feed.
To explain early newborn care
Early newborn care, neonatal complications
To explain and interpret theinvestigations carried out routinely during the antenatal
period
Blood for Haemoglobin
Blood group and Rhesus
Blood sugar
Urine for protein, sugar, bacteriuria
Ultrasound scans
Perform, interpret and explain the following investigations: blood pressure, mid-upper arm
circumference.
interpret

and

explain

the

following

investigations:haemoglobin

estimation,

blood

sugar,urinalysis, urinary pregnancy test, genital swabs (high vaginal swab, endocervical
swab) and cervical smear.
To provide informationon common issues in pregnancy
Obtain knowledge to be able to provide information on:
-

Normal pregnancy
Nutrition requirements and mineral and vitamin supplements

Minor disorders in pregnancy

Investigations routinely carried out in antenatal period

Prevention of maternal to child transmission of HIV and syphilis

Immunization

Skilled attendance at delivery

Birth and emergency preparedness plans and the relation to the Three Delays

Post-partum care and newborn care in the early puerperium, including breast feeding.

To communicatewith clients, their families and other health professionals


Communicate clearly and sensitively with clients, their families and with other health
professionals during process of antenatal care.
Communicate effectively with clients and their families on diagnosis, procedures and
management in a culturally appropriate manner.
Appreciate the diversity of traditions and cultures of different population sub-groups and adapt
provision of care.
Communicate clearly and sensitively with clients and their families to abandon practices that
are harmful or of no proven effect on the mother and newborn.

3.2 Develop clinical skills


Obstetrics:
Develop basic clinical skills (obstetric history taking, calculate estimated date of delivery
(EDD) and physical examination) to arrive at a provisional diagnosis and differential
diagnoses.
Elicit history from an Obstetric patient.
Measure mid-upper arm circumference (MUAC)
Perform breast examination, an abdominal examination in women during pregnancy (early
pregnancy and pregnancy over 20 weeks) and recognize normal findings and common
abnormalities.
Identify women with specific conditions and complications of pregnancy who require referral
to a district hospital.
Gynaecology:
Perform bivalve speculum examination and recognize normal findings, signs of vaginal and
cervical infection and common abnormalities.

Communication and Counselling


Develop skills in communicating and counseling with the woman and her husband and family
on issues such as care of a normal pregnancy, birth and emergency preparedness,
postpartum and early newborn care (including breast feeding and family planning).
The skills developed during the Community Medicine rotation: the counseling process, the
guiding principles and the factors that can influence the counseling process will be reinforced
in this module.

3.3 Enhance professional development


Develop the following attitudes:
Inter-professional Relationship: Multi-disciplinary health care is an integral part of antenatal
care and this module offers an opportunity to develop inter-professional relationships.
Muilti-cultural Approach: Develop respect for the differing cultural positions in antenatal care.
Encourage traditional practices that are beneficial and be able to counsel on harmful
practices.Conceptualise the clinical problem in a clinical and social context.
Sense of Responsibility: By virtue of the unique and close relationship and involvement with
the client and her family in preventive and promotive activities and care throughout the
pregnancy, to develop a sense of responsibility.
Appreciate ethical issues
To develop an understanding of common ethical issues in provision of antenatal care related
to respect for the clients/patient, privacy and confidentiality; and an approach to issues where
the health providers stance is at variance with that of the client.

4. Core Topics and Clinical Conditions


The core topics and clinical conditions in the Antenatal Care Module will also be covered in
the related basic sciences, community medicine and clinical modules.
Normal pregnancy
-

Pre-pregnancy counselling and the use folic acid preconception and nutritional

requirements and lifestyle changes in pregnancy.


Consideration of past obstetric history, including mode of delivery
Safe drug prescribing in pregnancy and the puerperium
The risk of substance abuse in pregnancy
Nutrition requirements and mineral and vitamin supplements in pregnancy
Minor disorders in pregnancy
Changing demographics of pregnancy.

Focused antenatal care


-

Principles and concepts

Basic component of focused antenatal care


The booking visit (history and examination)

Routine investigations during antenatal period/visits

Prevention of maternal to child transmission of HIV and syphilis

Immunization

Care during subsequent visits (2nd, 3rd and 4th) for the Basic component of focused
antenatal care

Skilled attendance at delivery

Birth and emergency preparedness plans

Sexual relations during pregnancy

Immediate post-partum and early newborn care

5. Physical Examination and Procedural Skills


Take history in pregnancy (Obstetric history taking)
Perform breast and obstetric examination
Perform a speculum examination
Apply the Classifying Form to identify clients/woman for the basic component of antenatal
care
Identify women with complications for referral
Communicate and counsel the woman, her husband and family
Complete clinic medical records and Mother and Child Book (which is kept with the mother).

6. Guide to Ethical Behaviour


You are expected to apply the principles of ethical conduct that you learnt in The Empathy
Module (first year) and Basic Clinical Skills Module.
Respect for the patient
Respect for the patient includes deference to and acknowledgement of the patients right in
making decisions, treating the patient with compassion and dignity, maintaining confidentiality
and respect for patient privacy, avoiding misrepresentations, deception and nondisclosure,
and keeping promises.
Privacy
It is important to respect the client/patients privacy. Before starting a physical examination,
explain to the client/patient what you will be doing and obtain consent. Make sure you have

drawn the curtains. If you are a male student, you may want to ask a nurse or a fellow female
student to be present during the examination. Only the area to be examined should be
exposed at any time and do not leave the patient exposed longer than necessary. Speculum
or vaginal examination should be performed only with the client/patients consent and under
supervision of a doctor.
Consent

Your clinical handbook will explain the process of obtaining agreement/consent from
out-patient/ward staff to interview a client/patient. You should proceed to the

client/patient only when you have obtained the agreement.


Once agreement/consent is obtained, you should introduce yourself to the
client/patient you wish to interview that you are a medical student and explain why

you are there.


You need to obtain consent from every client/patient you wish to interview.
The client/patient must be made aware that their agreement

to

be

interviewed/examined is voluntary, that they are free to agree or refuse and that their
medical care will not be affected in any way by their decision.
Confidentiality

You are expected to uphold the same standards of confidentiality as doctors.


You should not reveal the name of any patient to anyone who is not involved in the
care of the client/patient. Details other than names can lead to identification of a

client/patient, so caution needs to be exercised in sharing such details.


Discussing the client/patient that you have seen with your tutors and fellow students
is an important part of medical education. It is acceptable to share your experiences
with family and friends but make sure that you do not disclose any identifying
information.

Other Points in Clinical interactions

Help the patient sit up and to get dressed (as appropriate)


Thank her for agreeing to be interviewed or examined
Dress appropriately out of respect for the client/patient and doctors who are helping

you in your medical education


Wear your photo identity card
Turn off mobile phones during tutorials and interactions with clients/patients

7. Teaching and Learning Programme


7.1 Overview
It is important to participate in all activities related to this module. You will be introduced to the
principles of antenatal care and focused antenatal care in the third year. The opportunity to
put your skills on taking an obstetric history and performing an obstetric examination will be

given in the fourth year and consolidated during the fifth year in the Womens Health module.
This includes clerking of in-patients (pregnant women/patients), participation in out-patient
clinics. These skills will be reinforced in the pre-internship rotation.

7.2 The Programme


7.2.1 Introduction
You will have an introductory lecture on antenatal care to develop some foundation in the
concepts of antenatal care, obstetric history taking and performing an obstetric examination.
7.2.2 Clinical Skills Session
You will have opportunities to take obstetric history during role play and perform an obstetric
examination on mannikins during the third year. In the fourth and fifth year, you will have the
experience of taking a history and performing an examination on women coming for antenatal
care or those admitted to the obstetric ward. You will encounter women with minor
disorders/ailments of pregnancy or those with complications during the antenatal period.
In the application of the Focused antenatal care model, basic antenatal care will be provided
to women who have an uncomplicated pregnancy. However, it is important to be able to
identify women who develop conditions or complications that require more specialized care.
Therefore, it is important for you to identify these women through performing a thorough
history and physical examination. You will also need to acquire the skills to communicate
effectively with women and their families (i) to adhere to the antenatal care visit schedule and
interventions, (ii) to plan for delivery and (iii) to convince them to seek care at the next referral
level/district hospital as required.
7.2.3 Clinical Teaching
You are expected to attend all the outpatient antenatal clinics which provides opportunities to
interact with pregnant women and their families. Problem-based learning (PBL) and clinical
tutorials will be scheduled to be at the outpatient clinic sessions.
7.2.4 Problem-based Learning
The problem-based learning (tutorials) will take place during the clinical weeks 2-6 and 8-9 of
the Womens Health rotation.
7.2.5 Topic Tutorials
There will be two topic tutorials scheduled each week: one in Obstetrics and Gynaecology
and another in Neonatal Paediatrics in the Womens Health rotation.

7.3 Topics, Teaching and Learning Methodology and Assessment/Evaluation


Table 1: Topics, Teaching and Learning Methodology and Assessment/Evaluation
Topic

Sub-topics to be covered

Method

Year

Assessment

Antenatal care (ANC)

Elements of care in pregnancy

Introduction Lectures

3rd

Evaluation
Assessment

Purpose of antenatal care


Concepts and Principles of FANC

Introduction Lectures

3rd

Goals of FANC

Presentation/Discussion

Focused

antenatal

(FANC)

care

Comparions

of

traditional

and

Self-assessment
Questions
Group discussion

focused

Case-based discussion

antenatal care
First antenatal Visit1

Directly

observed

Application of Classifying Form


Obstetric History

Role play

3rd,4th,5th

Clinical Examination

Interaction with Clients


Practice on mannikins

3rd,4th,5th

Mini CEX

Essential/Supporting Investigations

Examination on Clients
Introduction Lectures

3rd

Evaluation

Case-based discussion
Interventions for Basic ANC Component

Introduction Lectures

Assessment for Referral

Problem/Case-based

Advice, Questions and Scheduling


Birth and emergency preparedness
complication readiness
The Three Delays

&

and

discussion
Self-study
Group Discussion

practical skills
OSCE

Clinical Log Book


3rd

Directly

observed

practical skills
3rd

MCQ, MEQ,
Long

case

examination

based

Topic

Sub-topics to be covered

Method

Year

Assessment

Subsequent Visits (2nd, 3rd,

History and Clinical Examination

Presentation/Discussion

3rd,4th,5th

Evaluation
Research by

Interventions for Basic ANC Component

Problem/Case-based

Assessment for Referral

discussion

Common Minor Ailments

Advice, Questions and Scheduling


Nausea, Vomiting

Topic discussion

5th

Communication/Counsellin

Leucorrhoea, etc
Anaemia

Problem/Case-based

3rd

Nutrition

discussion

Counselling for Testing for HIV and syphilis

Role play on different

(pre-test counseling, provider-initiated

scenarios

th

4 )

&
student

group

counseling counseling and testing, post- test


counseling)
Postpartum care and Early

Postpartum family planning


Mother

Clinical morning discussion

Newborn Care

Postpartum care and hygiene

Topic discussion

3rd

Nutrition
Breast-feeding
Family planning
Danger signs in post-partum period
Sexual relations in the puerperium
1In providing FANC, health service providers give emphasis to individualised assessment and the actions needed to make decisions about antenatal care by the provider
andthe pregnant woman together. Each visit comprises of eliciting history/information; conducting an examination and supporting investigations/tests; assessing the need for
referral; implementing interventions; counselling, responding to questions and scheduling the next visit; and maintaining complete records

Topic

Sub-topics to be covered

Method

Year

Assessment
Evaluation

Baby
Thermal protection
Cord care
Sleeping patterns
Hygiene (washing, bathing)
Pre-pregnancy counselling

Danger Signs for newborn


Pre-pregnancy counselling
Use of folic acid preconception
Lifestyle changes in pregnancy

Self study

3rd

&

8. Learning Resources
Lecture notes will be available one day before the activity. There are useful references on the
website that will be sent out prior to the learning activity.
References
WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model
(2002) WHO
WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal
care (2001) Villar, J et al Lancet 357 1551- 64
Standards for Maternal and Newborn Care (2007) Department of Making Pregnancy Safer
WHO
Pregnancy, Childbirth, Postpartum and Newborn Care (2006), WHO
Managing Newborn Problems, (2003) WHO
Decision-making tool for family planning providers and clients (2007) WHO and JHPIEGO
WHO Reproductive Health Library
Oxford Handbook of Obstetrics and Gynaecology (2008) 2nd edition
Basic Maternal and Newborn Care: A Guide for Skilled Providers (2004)AuthorsBarbara
Kinzie and Patricia Gomez - ACCESS JHPIEGO/Maternal and Neonatal Health Program
Best Practices in Maternal and Newborn Care - A Learning Resource Package for Essential
and Basic Emergency Obstetric and Newborn Care(2008) JHPIEGO USAID- ACCESS
Postpartum Intrauterine Contraceptive Device Services Trainers Notebook (2010)
JHPIEGO USAID- ACCESS
Antenatal Care, Part 2 - Blended Learning Module for the Health Extension
ProgrammeEthiopian Federal Ministry of Health, the Ethiopian Office of UNICEF, The Open
University UK and AMREF (the African Medical and Research Foundation).
Pocket Book of Maternal Health Care Indonesia (2011 Draft)

Thaddeus, S and Maine, D (1994) Too Far To Walk: Maternal Mortality in Context

9. Assessment
Self-assessment Questions (SAQ)
- Self-Assessment Questions after the introduction lectures.
Group discussion
-

Calculating expected date of delivery


Discussion on birth and emergency preparedness plans

Clinical Log Book


Case-based discussion
-

Case Study 1: Focused Antenatal Care


Case Study 2: Health education for women following the basic component of focused
antenatal care

Problem-based discussion

Case Study 3: Counselling for HIV Testing During Antenatal Care


Case Study 4: Antenatal Assessment and Care- anaemia

Directly observed Practical Skills


-

Checklist for obstetric history taking


Checklist for obstetric examination
Checklist for birth and emergency preparedness plans
Checklist for postpartum family planning (postpartum IUD insertion)
Checklist for demonstrationof breastfeeding

MCQ, MEQ,
OSCE
Obstetric history taking
Obstetric examination
Interpretation of investigations from first and subsequent antenatal visits
Demonstration of breastfeeding
Mini Clinical Evaluation Exercise (Mini CEX)

10. Procedural Skills Tutorial


10.1 Taking an Obstetric History
Identification
Name, Age
Husbands name, Husbands Age
Address, Phone Number
Religion
Current Pregnancy History
The first day of last menstrual period (LMP)
Expected date of delivery (EDD)
Maturity by Dates
Menstrual cycle, Regularity
Vaginal bleeding
Leucorrhea
Nausea and vomiting
Problems in current pregnancy
Use of medications and herbs (jamu)
Gynacological (including Contraceptive History)
Previous contraceptive history
Recent history of contraception before pregnancy
Any surgical procedures
Period(s) of infertility: when? duration? cause?
Previous Obstetric History
Number of pregnancy
Number of delivery, Number of labours at term/ Number of preterm labour
Date (month and year) of outcome of each event (live birth, still birth, miscarriage, abortion,
ectopic, hydatidiform, mole) specify (validate) preterm births and type of abortion if possible.
Number of living children, birth weight, and sex, Infant weight of <2.5 kg or> 4 kg

Presence of problems in previouspregnancy, labour and puerperium:


Mother: Bleeding in previous pregnancy, labour, and puerperium (placenta abruption,
placenta praevia); Presence of hypertension, pre-eclampsia, gestational diabetes in previous
pregnancies;

breech

or

transverse

presentation;labour:

(spontaneous,

induced,

LSCS);delivery: spontaneous, assisted with vacuum, forceps, LSCS;obstructed labour e.g.


shoulder dystocia;PPH, puerperal sepsis;exclusive breast feeding.

Baby: Malformed or abnormal baby, macrosomic (4500g) newborn, IUGR, resuscitation or


other treatment of newborn;twins; anyperinatal, neonatal or fetal death.
The Obstetric History is usually summarized in a pre-formatted table (Table 2).

Medical History
Heart disease
Hypertension
Diabetes mellitus (DM)
Liver diseases (hepatitis)
Tuberculosis (TB)
Chronic Renal conditions
Thalassemia and other hematological disorders
Asthma
Psychiatric disorders
Epilepsy
Sexually transmitted infections
HIV status if known
History of surgery, operations other than cesarean section
Any regular medication - specify
Allergy to medicines/food
History of trauma/accident
Blood group (if Known)
History of blood transfusion, Rhesus (D) antibodies
Status of tetanus immunization
Use of medications and herbs (jamu).

Table 2: Summary of Obstetric History


Index

Age & Sex

Pregnancy

of Child

(Normal
complicated)

or

Duration of

Delivery

pregnancy

(Normal

Postpartum
or

complicated
)

(Normal

or

complicated)

Birth weight

Status
birth

at

Other
note

issues

of

Family History
Hypertension
Diabetes mellitus
Twins
Congenital abnormalities
Socio-economic History
Marital status, number of times married and age of marriage(s)
Occupation and daily activities
Occupation of the spouse
Education
Income (if possible)
Ethnic group
Eating or drinking habits
Smoking habit, use of recreational drugs and alcohol
Options of place for delivery
Maternal and family responses to pregnancy and labour preparedness
Number of family members helping at home
Decision maker in the family
Sexual life, history of casual sex and sexual history of the spouse
Housing: type, size, number of occupants
Sanitary conditions: type of toilet, source of water
Electricity or source of heating and lighting
Cooking facilities

Table 3: Summary of History to be Completed at First Visit


(based on table in draft pocket book of Maternal Health Care)
Identity
Name, Age
Husbands name
Address
Phone Number
Religion

Current Pregnancy History


Leucorrhea
Nausea and vomiting
Vaginal bleeding
Other problems/abnormalities
Use of medication, traditional medicine and
herbs

Menstrual History
The first day of last menstrual period
Menstrual cycle
Expected date of delivery
Maturity by dates
Contraceptive History
Previous contraceptive history
History of contraception before pregnancy
Previous Obstetric History
Number of pregnancies
Number of deliveries
Number of labour at term, preterm labor
Mode of delivery
Number of living children, birth weight, and
sex
Number of miscarriage(s), abortion(s)
Bleeding in previous pregnancy, labour, and
puerperium
Presence of hypertension, pre-eclampsiain
previous pregnancies
Other problems in previous pregnancies,
labours and puerperium
Breech or transverse presentation
Duration of exclusive breast feeding
Infant weight of <2.5 kg or> 4 kg
IUGR
Twins
Perinatal, neonatal, fetal death

Family History
Diabetes mellitus
Hypertension
Multiple pregnancy
Congenital abnormalities
Other Medical History
Heart disease
Hypertension
Diabetes mellitus (DM)
Liver diseases such as hepatitis
Tuberculosis (TB)
Chronic renal disease
Malaria
Asthma
Epilepsy
Any regular medication
Allergy to medication, food
History of surgery (other than CS)
Sexually transmitted diseases
HIV status if known
History of blood transfusion
Blood group
History of trauma/accident
Status of tetanus immunization

Socio-economic History
Marital status, number of times married and Number of family members helping at home
age of marriage(s)
Occupation and daily activities
Decision maker in the family
Occupation of the spouse
Maternal and family responses to pregnancy
and labor preparedness
Education
Options of place for delivery
Income (if possible)
Housing
Eating or drinking habits
Sanitation conditions
Ethnic group
Electricity
Smoking, use of recreational drugs and Cooking facilities
alcohol
Sexual life, history of casual sex

10.2 Performing an Obstetric Examination


General physical examination at the first visit:

General status, appearance, co-operativeor not

Face: is there palpebral edema or pallor

Eyes, mouth and dental hygiene, caries, thyroid

Vital signs: (blood pressure, body temperature, pulse rate, respiratory rate)

Body weight

Height

Mid Upper arm circumference (MUAC)


Heart, lungs, breast (if there are lumps), nipples, abdomen (surgical scar), spine, extremities
(edema, varicose veins, patellar reflex), as well as cleanliness of the skin.
Measure mid-upper arm circumference (MUAC)
Measure the MUAC just before or just after checking the blood pressure
Use a soft tape-measure, as for symphysis-fundal height
Measure the MUAC at any gestation, or during or after labour
Measurethearmcircumferenceineithertherightorleftarm,midwaybetweenthetipoftheshoulder(acr
omion)and the tip of the elbow (olecranon)
Record the measurement to the nearest 1 mm
The arm should hang freely (elbow extended)
Record the MUAC on the antenatal card
An MUAC 33 cm:

Suggests obesity
Is associated with an increased risk of pre-eclampsia and maternal diabetes
Is associated with an increased risk of delivery of a larger than normal infant
Indicates that blood pressure measurement with a normal-sized adult cuff may be an
overestimation

An MUAC<23 cm:

Suggests undernutrition or a chronic wasting illness


Is associated with delivery of a smaller than normal infant

Breast Examination
Visual Inspection of the Breasts
O
O
O
O

- Help the woman prepare for examination


- Ask the woman to uncover her body from the waist up.
- Have her remain seated with her arms at her sides.
- Visually inspect the overall appearance of the womans breasts, such as contours,
skin, and nipples; note any abnormalities.

Contours are regular with no dimpling or visible lumps.

Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no


lesions, sores, or rashes.
O
Normal variations:
O
O
O
O

- Breasts may be larger (and more tender) than usual.


- Veins may be larger and darker, more visible beneath the skin.
- Areolas may be larger and darker than usual, with tiny bumps on them.

Nipples - There is no abnormal nipple discharge.


Nipples are not inverted.
O
Normal variations:
O
O
O
O
O

- Nipples may be larger, darker, and more erectile than usual.


- Colostrum (a clear, yellowish, watery fluid) may leak spontaneously from nipples
after 6 weeks gestation.
- Place the thumb and fingers on either side of the areola and gently squeeze.
- If the nipple goes in when it is gently squeezed, then it is inverted.

Palpation
Palpation of both breasts with the flat of the hand and then with the fingers while the woman
in the sitting position, and thenwhen she is lying down/supine.
Palpate the axillary and supraclavicular nodeslymph nodes.
O
C

Obstetric physical examination at the first visit:

- Shape of abdomen (note any surgical scars)

- Fundal height
Vaginal Examination
O - Vulva/perineum to check for presence of varicose veins, condylomata, edema,
hemorrhoids, or other abnormalities.

- Speculum examination to assess cervix, signs of infection, and fluid from the uterine os.
O - Vaginal examination to assess: cervix*, uterus*, adnexa*, Bartholins, urethral, Skenes
glands (*when gestational age is <12 weeks). This is usually not carried out in Indonesia.

O
C

Obstetric physical examination at each subsequent visit:


O - Monitor fetal growth and development by measuring uterine fundal height (Table 4). A chart
should be used to determine uterine height. Figure 1 is an option if a local standard chart is
not available.
Palpate abdomen using Leopolds maneuvers I-IV as shown below:
Leopold I: determining uterine fundal height and fetal parts located in the uterine fundus
(carried out since the early first trimester).
Leopold II: determining position of the fetal back (performed by the end of second trimester).

Leopold III: determining fetal parts located at the bottom ofthe uterus (carried out by the end
of second trimester).
Leopold IV: determining how far fetus enters the pelvis (doneat the end of the second
trimester).
Auscultate fetal heart rate using a fetoscope or Doppler (ifgestational age is > 16 weeks).
Assessment of fetal heart rate with a fetoscope can be started around 20week of gestation.
With the help of ultrasonic Doppler fetal heart beating can be detected between 14 and 20
weeks of gestation.
Assessment of fetal heart with fetoscope (Pinard stethoscope)
The best place to hear the fetal heart is through the fetal back. It is better to assess the fetal
heart beat after determining the fetal lie, position and presentation. If the position of the fetus
seems to be left occipital anterior the wide end of the Pinard stethoscope should be placed at
about half way between the umbilicus and the symphysis pubis and about 5 cm to the left. If
presentation of the fetus is breech, the stethoscope should be placed above the umbilicus.
Position the bell end of the stethoscope over the place on the maternal abdomen under which
the baby's back is felt.
Apply the ear to the flat end. Apply gentle pressure and indent the abdomen nearly a
centimeter, depending on the thickness of the abdominal wall.
Take your hand away from the stethoscope and listen. You are listening for a sound that feels
more like a vibration than a sound, or something similar to watch ticking under a pillow. If you
hear a slow shooching noise, feel the maternal pulse at the same time and if it coincides
with the shooching you are hearing the uterine vessels.
Normal fetal heart rate is regular, with a range is 120-160 beats per minute.

Table 4: Estimated uterine fundal height


Gestational age
12 weeks
16 weeks
20 weeks

Uterine Fundal Height


By Palpation
By Tape Measure
Palpable above the pubic
symphysis
In between the pubic
symphysis and umbilicus
At the umbilicus
(20 2) cm
(Gestational age in weeks
2) cm

22-27 weeks
28 weeks

in between the umbilicus and


the xiphoid process

(Gestational age in weeks

29-35 weeks
36 weeks

(28 2) cm

At the xiphoid process

2) cm
(36 2) cm

Adapted from Pocket Book of Maternal Health Care Final Draft (Department of Obstetrics
and Gynaecology, Faculty of Medicine, University of Indonesia and WHO, Indonesia)
Figure 1: Uterine height values by weeks of gestation
Belizan, J et al American Journal of Obstetrics and Gynaecology (1978)

Leopold Maneuvers: I, II, III and iV

11. Teaching and Learning Materials


11.1 Group Discussion
11.1.1 Group Exercise: Use of pregnancy calculator
1

Divide students into groups.

Give groups examples: Exercises for Calculating Expected Date of Delivery


(EDD) of LMP dates.

Give instructions to participants to provide gestation and EDD.

Ask one representative of each group to write the answer on the board.

1. Mrs. A. comes to the antenatal clinic on 3 January. She tells you that her last normal
menstrual period started on 10 October. How many weeks pregnant is she? What is her
EDD?

2. Mrs. B. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?
3. Mrs. C. comes to the antenatal clinic on July 11. She tells you that her last normal
menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?
4. Mrs. D. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 1 January. How many weeks pregnant is she? What is her EDD?
5. Mrs. E. comes to the antenatal clinic for first visit on 20 April. She tells you that her last
normal menstrual period started on 10 November. How many weeks pregnant is she? What is
her EDD?
6. Mrs. F. comes to the antenatal clinic for the first time today, 14 June. This is her first
pregnancy. She does not have regular menses and does not remember when she had her
last menses. She does remember that she felt some breast changes and nausea at the
beginning of March and the baby began moving yesterday. On examination you measure her
uterus at 1 cm below the umbilicus and you hear the fetal heart at 156 beats/min.
Approximately how many weeks pregnant is she and when will her date of delivery be?
Answer Key

Due DateCalendar Method Add 7 days to the date of the first day of the last normal
menstrual period. Subtract 3 months. (If the first day of the last normal menstrual period is in
January to March, add 9 months)

Gestation and Due DateGestation Wheel MethodCalculate on the gestation/pregnancy


wheel (if available).
1. Mrs. A. comes to the antenatal clinic on 3 January. She tells you that her last normal
menstrual period started on 10 October. What is her EDD?Her gestational age is 12 weeks.
Her EDD is July 16 by wheel and July 17 of the following year (Oct 10 + 7 minus 3 months =
July 17).
2. Mrs. B. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 6 March. What is her EDD?Her gestational age is 10 weeks and
her EDD is December 12 by wheel and December 13 by calculation of same year (March 6 +
7 = March 13 minus 3 months = Dec 13).
3. Mrs. C. comes to the antenatal clinic on July 11. She tells you that her last normal
menstrual period started on 6 March. What is her EDD?Her gestational age is 18 weeks. Her
EDD is December 12 by wheel and December 13 by calculation of same year (March 6 + 7 =
March 13 minus 3 months = Dec 13).

4. Mrs. D. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 1 January. What is her EDD?Gestational age is approximately
19weeks. Her EDD is October 9 by wheel and October 8 (calculation) of the same year (Jan 1
+ 7 = Jan 8 minus 3 months = Oct. 8).
5. Mrs. E. comes to the antenatal clinic for first visit on 20 April. She tells you that her last
normal menstrual period started on 10 November. What is her gestation? What is her EDD?
Gestationalage=23weeks. Due date is August 16 by wheel and August 17 by calculation (Nov.
10 + 7 = Nov 17 minus 3 months = Aug. 17).
6. Mrs. F. comes to the antenatal clinic for the first time today, 14 June. This is her first
pregnancy. She does not have regular menses and does not remember when she had her
last menses. She does remember that she felt some breast changes and nausea at the
beginning of March and the baby began moving yesterday. On examination youmeasure her
uterus at 1 cm below the umbilicus and you hear the fetal heart at 156 beats/min.
What is her approximategestational age and when will be her date of delivery?
Her gestational age is approximately 20 weeks. Her due date isapproximately 3 November.
(From Best Practices in Maternal and Newborn Care - A Learning Resource Package for
Essential and Basic Emergency Obstetric and Newborn Care - 2008 (JGPIEGO USAIDACCESS)
11.1.2 Discussion: Birth and emergency preparedness plan
Divide into groups of four to discuss birth and emergency preparedness plans displayed in
PowerPoint slide.
Reassemble and discuss answers in large group.
Discuss reasons for having a Birth and Emergency Readiness Plan. What do you
understand by the Three Delays?
The Three Delays
Delay in deciding to seek medical care

Failure to recognize danger signs

Lack of money to pay for medical expenses and cost of transportation

Fear of being ill-treated in the health facility

Reluctance from the mother or the family due to cultural constraints

The woman or family member present at childbirth lack power to make a decision

Lack of encouragement from relatives and community members to seek care

No available person to take care of the children, the home and livestock

Lack of a companion in going to the health facility


Delay in identifying and arriving at the health facility

Distance from a womans home to a facility or provider

Lack of roads or poor condition of roads

Lack of emergency transportation whether by land or water

Lack of awareness of existing services

Lack of community support

Weak referral system includes transportation and communication


Delay in the provision ofappropriate and adequate care at the health facility

Lack of healthcare personnel

Gender insensitivity of healthcare providers

Shortages of supplies, i.e. emergency medicines or blood

Lack of equipment for emergency obstetric care (EmOC)

Lack of competence of health care providers to deliver EmOC

Administrative delays
(Reference: S Thaddeus and D Maine (1994) Too Far To Walk: Maternal Mortality in
Context)
Birth and Emergency Readiness Plan
Assist the woman in developing a birth plan that includes both birth preparedness (all the
arrangements that should be made for a normal birth) and emergency/complication readiness
(an exact plan for what to do if a danger sign arises). The womans family, husband, or other
key decision makers in her life should be involved in this process; if she permits, invite them
to join in this discussion. Honour the womans choices except when doing so may put her or
her newborn at risk. Also, be sensitive to cultural beliefs or social norms (e.g. superstitions
that urge against buying items for a baby not yet born) that may impede the planning process.
Onthefirstvisit,introducetheconceptofabirthplan(including emergency/complicationreadiness):
Ensurethatthewomanandherfamilyunderstandthattheyshouldaddresseachoftheitemswellbefor
e the estimated date of delivery (EDD). Oneachreturnvisit,reviewandupdatethebirthplan:
What arrangements have been made since the last visit?
Has anything changed?
Have any obstacles or problems been encountered?
By32weeks,finalizethebirthplan.Thewomanandherfamilyshouldhavemadeallofthe
arrangements by now. If needed, provide additional assistance at this time to complete the
plan.

Components of the Birth and Complication Readiness Plan


(Note: Although this section focuses on what the skilled birth attendant/provider, the woman,
and her family can do to prepare for birth and possible complications, birth
preparedness/complication readiness is actually a community-wide issue. In order for an
individual birth plan to be effective in saving a womans life, it must also have supportin the
form of actions, resources, skills, and attitudesfrom policymakers, healthcare facilities, and
individual community members.)
Note: Items to be included in the emergency/complication readiness plan, which should be
discussed/reviewed at every encounter/visit with the woman during the entire childbearing
cycle, are indicated with an asterisk (*).
Women are encouraged to have delivery in a health facility (health centre/puskesmas or
district hospital). If she decides to deliver at home, the birth should be attended by a skilled
birth attendant.
Skilled Birth Attendant/Provider
Assist the woman in arranging for a skilled birth attendant/provider to attend the birth; this
person should be trained in supporting normal labour/childbirth and managing complications,
if they arise.
Note: Ensure that the woman knows how to contact the skilled birth attendant/provider or
thehealthcare facility at the appropriate time. The attendant is usually a midwife from the
puskesmas.
Items Needed for Clean and Safe Birth and the Newborn
Make sure the woman has gathered necessary items for a clean and safe birth. Discuss the
importance of keeping items together for easy retrieval when needed.
Items needed for the birthinclude:perinealpads/cloths;soap;cleanbed cloths; placenta
receptacle; clean, unused razor blade; waterproof/plastic cover; clean cord ties.
Items needed for the newborninclude:blankets,diapers/napkins,hat, clothes, etc. that have
been washed and dried in the sun. Ensure that the woman has an appropriate place for the
birth to take place based on her individual needs. For complication readiness, assist the
woman in choosing the appropriate healthcare facility (e.g., district hospital, health centre) to
go to if danger signs arise.

Note: Items needed depend on the individual requirements of the intended place of birth,
whether in a healthcare facility or in the home.
Transportation*
Ensure that the woman is familiar with local transportation systems and has transportation to
an appropriate place for the birth based on her individual needs.For emergency/complication
readiness, assist the woman in identifying (and choosing) emergency transportation to an
appropriate healthcare facility if danger signs arise.
Funds*
Assist the woman in planning to have funds available when needed to pay for care during
normal birth. For example, putting aside even a small amount on a weekly basis can result in
savings.
For complication readiness, discuss emergency funds that are available through the
community and/or healthcare facility if danger signs arise.
Decision-Making*
Discuss how decisions are made in the womans family (who usually makes decisions?), and
decide the following:
- Howdecisionswillbemadewhenlabourbeginsorifdangersignsarise(who is the key decision
maker?)
- Whoelsecanmakedecisionsifthatpersonisnotpresent
Support*
Assist the woman in deciding on/making arrangements for necessary support, including the
following:
- Companionofherchoicetostaywithherduringlaborandchildbirth,and accompany her during
transport if needed
- Someonetocareforherhouseandchildrenduringherabsence
Blood Donor*
O

Ensure that the woman has identified an appropriate blood donor and that this person will be
available in case of emergency.
Danger Signs* and Signs of Labor

Ensure that the woman knows the danger signs which indicate a need to enact the
emergency/complication readiness plan:

Vaginal bleeding
Breathing difficulty
Fever
Severe abdominal pain

Severe headache/blurred vision


Convulsions/loss of consciousness
Foul-smellingdischarge/fluidfromvagina
Decreased/absentfetalmovements
Leakingofgreenish/brownish(meconium-stained)fluidfromthevagina

Also ensure that she knows the signs of labour, which indicate a need to contact the skilled
provider and enact the birth preparedness plan:

Regular, progressively painful contractions


Lower back pain radiating from uterus
Bloody show
Rupture of membranes

(Reference: Basic Maternal and Newborn Care: A Guide for Skilled Providers:
JHPIEGO/Maternal and Neonatal Health Program, 2004)

11.2Case-based Learning Case Triggers


Case Study 1: Focused Antenatal Care
Directions
Read and analyze this case study individually. When the others in your group have finished
reading it, answer the case study questions. The other groups in the room are working on the
same or a similar case study. When all groups have finished, we will discuss the case studies
and the answers each group developed.
Client Profile
A 29-year-old pregnant woman called Sara comes to see you. She tells you that this is her
third pregnancy and the last time she had her menstrual period was 25 weeks ago.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Sara?
Assessment(Information gathering through history, physical examination and testing)
2. What history will you include in your assessment of Sara, and why?
3. What physical examination will you include in your assessment of Sara, and why?
4. What laboratory tests will you include in your assessment of Sara, and why?
Diagnosis (Interpreting information to identify problems/needs)
You have completed your assessment of Sara and your main findings include the following:

History:

According to Saras menstrual history, she is 25 weeks pregnant.

She came for antenatal care now as she felt well.

She has noted fetal movements for about a month.

She is not taking any medication at present.

Her two previous pregnancies were uneventful and she delivered at the local puskesmas

All other aspects of her history are normal or without significance.


Physical examination:

Sara has mild conjunctival pallor.

All other aspects of her physical examination are within normal range.

Her blood pressure is 110/70 mm Hg.

Her breast examination is normal.

Saras fundal height measurement is 24 weeks, consistent with the EDD.

Fetal heart rate is 136 beats/minute and regular.

O
O

Tests: Hemoglobin is 9 g/dL. Other test results: RPR non-reactive; HIV negative; blood
type - A, Rh-positive.

5. Based on these findings, what is Sara's diagnosis, and why?

Care Provision (Implementing plan of care and interventions)


6. Based on your diagnosis (problem/need identification), what is your plan of care for
Sara, and why?

Evaluation
O

Sara comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is
120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 32week size. What do these signs suggest and what actions would you take?
Sara says that she would like to space her pregnancy and may consider not to have further
children after this delivery. Previously she has not used a modern method of contraception but
the pregnancies were spaced by breastfeeding.

7. Based on these findings, what is your continuing plan of care for Sara?
Case Study 1: Focused Antenatal Care Answer Key
Directions
As all groups have finished, we will discuss the case studies and the answers each group

developed.
Client Profile
A 29-year-old pregnant woman called Sara comes to see you. She tells you that this is her
third pregnancy and the last time she had her menstrual period was 25 weeks ago.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Sara?
O

Sara should be greeted respectfully and with kindness and offered a seat to help her feel
comfortable and welcome, establish rapport and build trust. A good relationship helps to
ensure that the client will adhere to the care plan and return for continued care.
You should confirm (through written records and/or verbal communication) with the clinic staff
member who received Sara when she first arrived at the clinic that she has undergone a
Quick Check. If she has not, you should conduct a Quick Check of her vital signs now to
detect signs/symptoms of life-threatening complications that need immediate/emergency
care.
Assessment (Information gathering through history, physical examination and testing)
2. What history will you include in your assessment of Sara, and why?
3. What physical examination will you include in your assessment of Sara, and why?
4. What laboratory tests will you include in your assessment of Sara, and why?
As Sara is already 25 weeks pregnant, you should cover all the services of the first and the
second FANC visits. As this is her first visit, you should take a complete history (calculate the
EDD) to guide further assessment and help individualize care provision.
Give close attention to investigating her medical, obstetric, menstrual, medical,family
andsocial history.When asking about medications, it will be important to know whether Sara is
taking iron tablets.
3. What physical examination will you include in your assessment of Sara, and why?
Perform a complete physical examination, including a general examination, blood pressure,
pulse, temperature, respiration rate, breast examination, mid-upper arm circumference,
abdominalexamination to measure fundal height, check for presentation and lie of the fetus
and listen to the fetal heart sound.
The purpose is to determine Saras eligibility to follow the basic component of FANC. Also
advise her on nutrition, hygiene and rest.

4. What laboratory tests will you include in your assessment of Sara, and why?
Sara will have routine investigations (as mentioned under Tests).
O

5. Based on these findings, what is Sara's diagnosis, and why?


Sara is eligible to follow the Basic Component of FANC. However, her two children are 3
years and 18 months respectively.

Care Provision (Implementing plan of care and interventions)


6. Based on your diagnosis (problem/need identification), what is your plan of care for
Sara, and why?
Discuss birth and emergency preparedness (birth preparedness, complication readiness and
emergency planning) with her. As she has breast fed her babies in the previous pregnancies,
reinforce her breast feeding practices.
If she is healthy and the pregnancy appears to be progressing normally, tell her that the next
visit should be at 30-32 weeks of pregnancy - but she must seek help at once if she
experiences any of the danger symptoms such as bleeding or foul smelling discharge from
her vagina, fever, blurred vision, or feeling dizzy and confused.
Pale conjunctiva suggests that Sara may be anaemic, so ask her about her nutrition - what
does she eat and how much food does she get each day? Perform a multiple dipstick test on
a sample of her urine to see if it contains excess sugar or protein. If her urine test is normal,
counsel her on improving her nutrition and provide her with iron and folate tablets.Give
injection tetanus toxoid.

Evaluation
O

Sara comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is
120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 32
weeks size. What do these signs suggest and what actions would you take?
Sara says that she would like to space her pregnancy and may consider not to have further
children after this delivery. Previously she has not used a modern method of contraception but
the pregnancies were spaced by breast feeding.

7. Based on these findings, what is your continuing plan of care for Sara?
As the fundal height is equal to dates at 32 weeks, she can be reassured that her pregnancy
is continuing well. Discuss with her and her family about the birth plan.Reinforce information
on the normal (physiological) changes in puerperium, breast feeding the baby and postpartum family planning.

Counsel on the importance of family planning

If appropriate, ask Sara if she would like her husband or another family member to be
included in the counselling session.

Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become
pregnant as soon as four weeks after delivery. Therefore it is important to start thinking early
on about what family planning method they will use.

She mentioned that she might not want more children. As her two previous children had an 18
month birth interval, inform her that waiting at least 2 years before trying to become pregnant
again is good for the mother and for the baby's health.

Information on when to start a method after delivery will vary depending whether a woman is
breastfeeding or not.(see the Decision-making tool for family planning providers and clients
for information on methods and on the counselling process).

Method options for the breastfeeding woman


Can be used immediately postpartum
Lactational amenorrhoea method (LAM)
Condoms
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (within 48 hours or delay 4 weeks)
Delay 6 weeks
Progestogen-only oral contraceptives: Progestogen-only injectables, Implants
Diaphragm
Delay 6 months
Combined oral contraceptives
Combined injectables
Fertility awareness methods
Counsel Sara on safer sex including use of condoms for dual protection from sexually
transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or
HIV.G4
If Sara and her husband chooses female sterilization: it can be performed immediately
postpartum if no sign of infection(ideally within 7 days, or delay for 6 weeks). Plan for delivery
in hospital or health centre where they are trained to carry out the procedure. Ensure
counselling and informed consent prior to labour and delivery.
If Sara chooses to use a temporary, long-term method, e.g. an intrauterine device (IUD): it

can be inserted immediately postpartum if no sign of infection (up to 48 hours, or delay 4


weeks) plan for delivery in hospital or health centre where they are trained to insert the IUD.
(Reference: Pregnancy, Childbirth, Postpartum and Newborn Care, WHO, 2006,
Decision-making tool for family planning providers and clients, WHO and JHPIEGO, 2007)

Case Study 2: Health education for women following the basic component of Focused
Antenatal Care
Trigger
Nina, a 20 year-old married woman in her first pregnancy comes for her first antenatal visit at
16 weeks. She is found to be eligible to follow the basic component of focused antenatal care
(FANC). What health education will you give her?
Answer
Health education to Nina, her husband and her family will include:
-

Healthy lifestyles
Healthy diet
Support and care in the home (including adherence to advice on prophylactic

treatments such as iron supplementation, and use of insecticide-treated bednets)


Preparation for parenthood
Exercises to prepare the woman for the process of birth.
Maternal and neonatal health needs and self-care during pregnancy and the

postnatal period, including the need for social support during and after pregnancy;
Prepare emotionally and physically the pregnant woman and her partner and, where

required, supporters for birth


Support care-seeking behaviour, including recognition of danger signs for the woman

and the newborn;


Birth and emergency preparedness plans
Promote postpartum family planning/birth spacing

Trigger
Nina and her husband want to know more about diet in pregnancy. They belong to the middleincome group and they do not have any food taboos. How will you advise them?

Answer
Nutritional Support
Based on Ninas dietary history, the resources available to her and her family, and any other
relevant findings or discussion, individualize the following key nutrition messages.
Nina (and all women) should:
Eatabalanceddietconsistingofbeansandnuts,starchyfoods(e.g.rice,potatoes,cassava,maize),
animal products (fish,eggs,meat, milk, yogurt), and fruits and vegetables.

Eata variety of foods each day, including foods rich in:


Iron:redmeat,liver,eggs,peanuts,lentils,darkgreenleafyvegetables,andshellfish.Substancesthat
inhibit iron absorption, such as coffee or tea should be avoided or taken 2 hours after meals.
Vitamin A: liver, milk products, eggs, sweet potatoes, pumpkin, carrots, and papaya.
Calcium: milk,darkgreenleafyvegetables,shrimp,driedfish,beans,lentils, and oil seeds.
Magnesium:cereal,darkgreenleafyvegetables,seafood,nuts,legumes,andgroundnuts.
VitaminC:orangesorothercitrusfruits,tomatoes,andpotatoes. Pregnant women should also
eatatleastoneadditionalservingofstaplefoodper

day

andeatsmaller,morefrequentmealsifunabletoconsumelargeramountsinfewermeals. She should


takemicronutrientsupplementsasdirected.

11.3 Problem-based Learning Case Triggers


Case Study 1: Counselling for HIV Testing During Antenatal Care
Trigger
Marina, a 24 year-old married woman in her first pregnancy comes for her first antenatal visit
at 14 weeks. She has recently moved to this area.
What points will you focus on when taking her history?
While obtaining an obstetric history, Marina mentions that she has lived in another part of
Indonesia and that her husband is a long-distance truck driver. You realize that Marina
resided in an area where STI and HIV prevalence is above the national prevalence and that
her husbands occupation could have exposed him to casual sex.
Based on her history, what will be included in your interventions/supporting tests?
You will offer HIV testing and counselling services and explain about HIV testing:

What is HIV and how it affects the mother and baby


How the test is performed.
How confidentiality is maintained.
Emphasize non-discrimination
When and how results are given (A Rapid test is usually performed and she should

get the results while she is in the clinic)


Support and treatment will be offered if test results are positive
Ask her if she has any questions or concerns.

You will also offer syphilis testing and counseling:

What is syphilis and how it affects the mother and baby


How the test is performed.
How confidentiality is maintained.
When and how results are given (A Rapid test is usually performed and she should

get the results while she is in the clinic)


Support and treatment will be offered if test results are positive
Ask her if she has any questions or concerns.

Perform a speculum examination to check for cervicitis (gonococcal or chlamydial)


Outcome: Marina comes back with the test results which are both negative
The speculum examination is also normal.
Counsel on implications of the HIV test result
Discuss the HIV results with her alone (or with the person of her choice). State test results in
a neutral tone and in a non-judgemental, non-discriminatory manner. Give her time to express
any emotions.
As the Test Result Is Negative:
Explain to Marina that a negative result can mean either that she is not infected with HIV or
that she is infected with HIV but has not yet made antibodies against the virus (this is
sometimes called the window period).
Counsel on the importance of staying negative by safer sex including use of condoms.
Counsel on implications of the syphilis test result
Counsel on the importance of staying negative by safer sex including use of condoms.
If Marina had refused to be tested, you will call her back and counsel her in a weeks time.
If Marina had tested positive for syphilis or HIV, refer her to the district level
Explain that:
For HIV
Another HIV test will be performed to confirm/refute the results of the Rapid Test and a nurse
will accompany her to the district hospital.A positive test result means that it is likely she is
carrying the infection and has the possibility of transmitting the infection to her unborn child
without any intervention.
Let her talk about her feelings. Respond to her immediate concerns.
Inform her that she will need further assessment to determine the severity of the
infection,appropriate care and treatment needed for herself and her baby. Treatment will slow
down theprogression of her HIV infection and will reduce the risk of infection to the baby.
Provide information on how to prevent HIV re-infection. Inform her that support and
counselling is available if needed, to cope on living with HIV infection. Discuss disclosure and
partner testing. Ask Marina if she wants additional information.

For Syphilis
If RPR or VDRL is reactive, refer her to the district hospital where TPHA will be carried out. A
positive test result means that it is likely she is carrying the infection and has the possibility of
transmitting the infection to her unborn child without any intervention.
Tell Marina that another test will be performed and a nurse will accompany her to the district
hospital for this test.
Let her talk about her feelings. Respond to her immediate concerns.
Inform her that she will need treatment needed for herself and her baby. If positive, she will be
treated with Benzathine penicillin. Inform her that support and counselling is available if
needed. Discuss disclosure and partner testing. Ask Marina if she wants additional
information.

Case Study 2: Antenatal Assessment and Care(Anaemia)


Directions
Read and analyze this case study individually. When the others in your group have finished
reading it, answer the case study questions. The other groups in the room are working on the
same or a similar case study. When all groups have finished, we will discuss the case studies
and the answers each group developed.
Client Profile
Mrs. B., a 26-year-old gravida 3/para 2, presents for her first antenatal clinic visit. Her children
are 18 months and 8 months of age. Both are well. She and her family live in a rural village
that is in a malaria-endemic area. You note that Mrs. B. looks pale and tired.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Mrs. B.?
Assessment (Information gathering through history, physical examination and testing)
2. What history will you include in your assessment of Mrs. B., and why?
3. What physical examination will you include in your assessment of Mrs. B., and why?
4. What laboratory tests will you include in your assessment of Mrs. B., and why?
Diagnosis (Interpreting information to identify problems/needs)
You have completed your assessment of Mrs. B. and your main findings include the following:
History:

According to Mrs. B.s menstrual history, she is 28 weeks pregnant.

She admits to feeling weak, tired and dizzy.

She reports that she has been treated for malaria twice in the past 12 months; the most
recent episode was 4 months ago, during which she was treated with antimalarial drugs.
She denies any symptoms of malaria now.

She reports that she had no signs or symptoms of anemia during her previous pregnancies.

She is not taking any medication at present.


She and her family have an adequate food supply at present, but Mrs. B.s appetite has been
poor lately. She does not have any food taboos.

Mrs. B.s mother-in-law provides some help with childcare and housework.

All other aspects of her history are normal or without significance.


Physical examination:

Mrs. B. has mild conjunctival pallor.

All other aspects of her physical examination are within normal range.

Her blood pressure is 100/70 mm Hg, and her temperature is 37.6C. (Although
temperature is not a routine part of antenatal care, because she comes from a malarious
area, this is part of the assessment.)

Her breast exam is normal.

Mrs. Bs fundal height measurement is 28 weeks, consistent with the EDD.

Fetal heart rate is 136 beats/minute and regular.

The vaginal examination is normal.

O
O

Testing: Hemoglobin is 9 g/dL Other test results: RPR non-reactive; HIV negative; blood
type - O, Rh-positive.

5. Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?

Care Provision (Implementing plan of care and interventions)


O

6. Based on your diagnosis (problem/need identification), what is your plan of care for
Mrs. B., and why?
Evaluation

Mrs. B. comes back to the antenatal clinic on the appointed date, and on assessment your
findings are as follows:

She has taken her iron/folate tablets as directed, even though she has had mild
constipation.

She has been able to rest more because her mother-in-law has provided more help than
usual. She also reports that her appetite has improved.

She appears less tired and is not as pale, generally, as she was at her first antenatal visit.
She says that she feels much better.

On physical examination, you find that she still has mild conjunctival pallor.

She does not have a fever.

The fetal heart rate is normal, and Mrs. B. says that the fetus is active.

Mrs. B.s hemoglobin is now 10 g/dL. It was also measured at the last visit.

O
O

7. Based on these findings, what is your continuing plan of care for Mrs. B.?

Case Study 4: Antenatal Assessment and Care (Anemia) Answer Key


Directions
As all groups have finished, we will discuss the case studies and the answers each group
developed.
Client Profile
Mrs. B., a 26-year-old gravida 3 para 2, presents for her first antenatal clinic visit. Her children
are 18 months and 8 months of age. Both are well. She and her family live in a rural village
that is in a malaria-endemic area. You note that Mrs. B. looks pale and tired.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Mrs. B.?
O

Mrs. B. should be greeted respectfully and with kindness and offered a seat to help her feel
comfortable and welcome, establish rapport and build trust. A good relationship helps to
ensure that the client will adhere to the care plan and return for continued care.

You should confirm (through written records and/or verbal communication) with the clinic
staff member who received Mrs. B. when she first arrived at the clinic that she has undergone
a Quick Check. If she has not, you should conduct a Quick Check now to detect
signs/symptoms of life-threatening complications that need immediate/emergency care.

O
O

Assessment (Information gathering through history, physical examination, and testing)


2. What history will you include in your assessment of Mrs. B., and why?

As this is her first visit, you should take a complete history (including calculating the EDD) to
guide further assessment and help individualize care provision. Some responses may point
toward the underlying reason for her pale/tired appearance, or may indicate a special need or
life-threatening complication that requires special care and/or immediate attention.

O
O

Ask Mrs. B. if she is experiencing weakness, tiredness, dizziness, breathlessness or fainting


to help determine severity of anemia; ask about fever, chills/rigor, headache or muscle/joint
ache to ascertain whether she may currently have malaria.

When asking about contraceptive history/plans: As Mrs. B. has had three pregnancies in 3

years, it will be important to determine whether she has ever used a modern method of
contraception and what her plans are about doing so in the future. Pregnancies that are
closer together than 3 years increase the risk of maternal and newborn complications.
O

When asking about medical history and obstetric history:

It will be important to know whether Mrs. B. has been treated for anemia and/or malaria,
during or since her last pregnancy and, if so, how her condition was treated. Living in a
malaria-endemic area and/or episodes of malaria in pregnancy may lead to anemia (even
uncomplicated malaria can lead to anemia), and while the malaria may have been treated, the
associated anemia may not have been.

O
It will also be important to determine whether Mrs. B. was anemic during her previous
pregnancies and, if so, how her condition was managed. If she does not know whether she
was anemic during her previous pregnancies, she should be asked whether she had
symptoms of anemia (e.g., tiredness, breathlessness).
O

Ask whether she had fever/infection during previous pregnancies/childbirths or postpartum


hemorrhage, and whether her previous babies were preterm or of low birth weight, as these
factors can also be associated with anemia in pregnancy.

O
O

When asking about medications, it will be important to know whether Mrs. B. is taking iron
tablets and, if so, how often and for how long she has been taking them. Pregnant women
require increased iron intake to prevent anemia and for their bodies to use in forming fetal red
blood cells. If she has been taking an adequate dose of iron supplementation, it is less likely
that her anemia is caused by dietary deficiency.

O
O

When asking about daily habits and lifestyle: Mrs. B should be asked about her social
situation, in particular to determine whether she has anyone to help with child care, cooking,
cleaning, etc., and whether she has access to nutritious foods, especially those rich in iron. A
poor diet, especially one that lacks iron-rich foods, could lead to anemia, and a heavy
workload could increase an already high level of fatigue.

O
O

3. What physical examination will you include in your assessment of Mrs. B., and why?
O

As this is her first visit, you should perform a complete physical examination (i.e., well- being,
blood pressure, conjunctiva, breasts, abdomen [fundal height, lie and presentation after 36
weeks, fetal heart rate after 20 weeks], and genital examination) to guide further assessment
and help individualize care provision. Some findings may point toward the underlying reason
for her pale/tired appearance, or may indicate a special need/condition that requires
additional care or a life-threatening complication that requires immediate attention.

Mrs. B. should be checked carefully for conjunctival pallor, abnormal respiratory rate, rapid
pulse, and breathlessness. Conjunctival pallor is a sign of anemia. When it is accompanied by
a respiratory rate of 30 or more or breathlessness at rest, severe anemia should be
suspected.

O
O

Mrs. B. should be checked for fever, which might indicate current malaria infection.

It will also be important to determine whether fetal growth is consistent with EDD, because
anemia in pregnancy is associated with low birth weight.

O
O

4. What laboratory tests will you include in your assessment of Mrs. B., and why?
As this is her first visit, you should conduct all routine laboratory tests if available (i.e., RPR
for syphilis, HIV [if she does not opt out], blood group, hemoglobin, and tests for other
conditions if applicable to guide further assessment and help individualize care provision.
Some findings may point toward the underlying reason for her pale/tiredappearance, or may
indicate a special need/condition that requires additional care or a life- threatening
complication that requires immediate attention.
Diagnosis (Interpreting information to identify problems/needs)
You have completed your assessment of Mrs. B., and your main findings include the
following:

History:
O

According to Mrs. B.s menstrual history, she is 28 weeks pregnant.


O

She admits to feeling weak, tired and dizzy.

She reports that she has been treated for malaria twice in the past 12 months; the most
recent episode was 4 months ago, during which she was treated with antimalarial drugs.
O She denies any symptoms of malaria now.

She reports that she had no signs or symptoms of anemia during her previous pregnancies.

She is not taking any medication at present.


O

She and her family have an adequate food supply at present, but Mrs. B.s appetite has been
poor lately.

Mrs. B.s mother-in-law provides some help with childcare and housework.

All other aspects of her history are normal or without significance.

O
O

Physical examination:

Mrs. B has mild conjunctival pallor.


O

All other aspects of her physical examination are within normal range: Her blood pressure is
100/70 mm Hg, and her temperature is 37.6C. (Although temperature is not a routine part of
antenatal care, because she comes from a malarious area, this is part of the assessment.)

Her breast examination is normal. Mrs. B.s fundal height measurement is 28 weeks,
consistent with the EDD. Fetal heart rate is 136 beats/minute and regular. The vaginal
examination is normal.
O
O

Testing: Hemoglobin is 9 g/dL.Other test results: RPR non-reactive; HIV negative; blood
type - O, Rh-positive.

O
O

Based on these findings, what is Mrs. B.s diagnosis (problem/need), and why?
Mrs. B, has a special need: She has signs/symptoms consistent with mild to moderate
anemia. Hemoglobin test confirms that Mrs. B. has mild/moderate anemia.
O
O

Mrs. B.s anemia is likely to be associated with the episode of malaria she had earlier in her
pregnancy. Women who live in malaria-endemic areas or who have malaria during pregnancy
are particularly prone to anemia; however, Mrs. B. was not started on iron at the time of her
most recent episode of malaria.

O
O

Mrs. B.s anemia is not likely chronic because she reports that she has an adequate food
supply and that she was not anemic during her previous pregnancies.

The fetus appears to be growing at a rate consistent with EDD.

Otherwise, Mrs. B. is healthy and her pregnancy is progressing normally.

Care Provision (Implementing plan of care and interventions)


6. Based on your diagnosis (problem/need identification), what is your plan of care for
Mrs. B., and why?
O

Mrs. B. should receive basic care provision (i.e., nutritional support, birth planning, additional
health messages and counseling on self-care and other healthy behaviors [e.g.,
hygiene/prevention of infection, sexual relations and safer sex, rest and activity, use of
potentially harmful substances], immunizations and other preventive measures), which will
help support and maintain her normal pregnancy, and ensure a healthy labour/childbirth and
postpartum/newborn period.

O
O

Iron/folate supplementation and related counseling are especially important:

O
Mrs. B. should be given iron/folate, 1 tablet 2 times daily. Taking iron/folate on a regular basis
for the remainder of her pregnancy (and for three months postpartum) should rectify Mrs. B.s
anemia.

She should be advised to take the iron/folate with meals, at the same time each day, or at
night, with water or fruit juice. Iron/folate should not be taken with tea, coffee or cola as these
interfere with its absorption.
Some women experience constipation when taking iron tablets, so side effects such as
constipation and nausea should be discussed. Mrs. B. should be encouraged to continue
taking the iron/folate if these symptoms occur. Adding more fruits and vegetables to the diet
and drinking more water can help avoid constipation.
A sufficient supply of iron/folate should be dispensed to last until her next antenatal visit.
Mrs. B. should be also counseled about protective measures against malaria, such as
sleeping under a long-lasting insecticide-treated bed net and wearing protective clothing.
In counseling about rest and activity: It is especially important to encourage Mrs. B. to rest
when possible and lighten her workload. Again, a heavy workload and not enough rest could
increase an already high level of fatigue.
In counseling about nutrition: The importance of eating foods that are rich in iron, as well as
foods rich in vitamin C (because vitamin C helps iron to be absorbed), should be emphasized.
Foods rich in iron include lean meat, liver, dried beans, peas, lentils, egg yolks, fish, nuts and
raisins. Foods rich in Vitamin C include citrus fruits (lemons, limes, oranges and grapefruits),
tomatoes, cabbage, potatoes, cassava leaves, peppers and yams. A diet that lacks iron- rich
foods could lead to anemia or worsen existing anemia.
In family planning counseling: Child spacing and family planning methods should be
discussed to encourage Mrs. B. to think about child spacing for the future. Evidence shows
that outcomes for mothers and babies improve if pregnancies are spaced at least 3 years
apart and that the risk of maternal anemia, infection and hemorrhage is decreased.
In scheduling a return visit: Mrs. B. should be asked to return for a follow-up visit in one
month, but told that she can return to the clinic any time before then, if she has any concerns.
Because Mrs. B. needs to be monitored closely until her anemia has resolved, the minimum
of four ANC visits are not sufficient in her case.
O

Evaluation Mrs. B. comes back to the antenatal clinic on the appointed date, and on
assessment your findings are as follows:

O
O

She has taken her iron/folate tablets as directed, even though she has had mild constipation.

She has been able to rest more because her mother-in-law has provided more help than
usual. She also reports that her appetite has improved.

She appears less tired and is not as pale, generally, as she was at her first antenatal visit.
She says that she "feels much better."

On physical examination, you find that she still has mild conjunctival pallor.

She does not have a fever.

The fetal heart rate is normal, and Mrs. B says that the fetus is active.

Mrs. B.s hemoglobin is now 10 g/dL. It was also measured at the last visit.

O
O

7. Based on these findings, what is your continuing plan of care for Mrs. B.?

Mrs. B. should be counseled about continuing to take iron/folate. A sufficient supply of


iron/folate tablets should be dispensed to last until her next antenatal visit. She should be
encouraged to add more vegetables, fruits and fluids to her diet, to help lessen her
constipation. She should be encouraged to continue to eat iron-rich and vitamin C-rich foods,
and to rest as much as possible.

O
O

Mrs. B. should continue to be monitored closely until her hemoglobin is 11 g/dL; she should
be asked to return for a follow-up visit in 2 weeks, but told that she can return to the clinic any
time before then, if she has danger signs, cannot comply with instructions, or has any
concerns.

Mrs. B. should continue to sleep under long-lasting insecticidal nets.

O
O

When Mrs. B.s hemoglobin reaches 11 g/dL, providing there are no other danger signs or
concerns, she can resume the normal schedule of antenatal visits.

(Reference: Best Practices in Maternal and Newborn Care: Learning Resource Package:
Prevention and Management of Malaria and Other Causes of Fever in Pregnancy)

11.4Knowledge Assessment

11.4.1Knowledge Assessment on Focused Antenatal Care:


Instructions: Which of the following statements is false? In each case, explain what is
incorrect.
1. Focused antenatal care focuses on the pregnant woman alone.
2. Women in the basic component receive only 4 FANC visits, unless warning signs or
symptoms are detected at any stage.
3. Pregnant women do not need to prepare any equipment for labour and delivery.
4. The birth plan in FANC is essentially the same for every woman and she is told about it at
the fourth visit.
5. Prophylaxis in FANC focuses on prevention of sexually transmitted infections, including
mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia and tetanus.

Answer Key
1 is false. Focused antenatal care does not focus on the pregnant woman alone (this used to
happen in the traditional approach). FANC includes the womans partner and if possible the
whole family in caring for her during pregnancy, watching for danger symptoms, and
preparing for the birth, complication readiness and emergency planning.
2 is true. Women in the basic component receive only 4 FANC visits, unless warning signs or
symptoms are detected at any stage.
3 is false. A pregnant woman should prepare for labour and delivery by assembling very clean
cloths, a new razor blade, very clean new string, soap and a scrubbing brush, clean water for
washing and drinking, buckets and bowls, supplies for making drinks, and a flashlight.
4 is false. The birth plan in FANC is individualised for every woman and her partner and
respects her wishes and preferences. It is discussed at the third visit and revised if necessary
at the fourth visit.
5 is true. Prophylaxis in FANC focuses on prevention of sexually transmitted infections,
including mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia,
urinary tract infections and tetanus.
11.4.2 Knowledge Assessment:
Prevention and Management of Malaria and Other Causes of Fever In Pregnancy
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.
1. Malaria affects:
a.

Nearly as many people as TB and HIV combined

b.

Twice as many people as TB, HIV, leprosy and measles combined

c.

Five times as many people as TB, HIV, leprosy and measles combined
2. In malaria-endemic areas, malaria during pregnancy may account for:

a.

Up to 15% of maternal anemia

b.

514% of low birth weight

c.

30% of preventable low birth weight (LBW)

d.

a) and b)

e.

All of the above


3. Malaria prevention and control in pregnancy includes:

a.

Focused antenatal care and health education

b.

Intermittent preventive treatment (IPT)

c.

Insecticide-treated nets (ITNs)

d.

a) and c)

e.

All of the above


Instructions: Which of the following statements is false? In each case, explain what is
incorrect.
4. Malaria is less severe in women during their first or second pregnancies than it is in
subsequent pregnancies.

5.

In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.

6.

Women who are HIV positive have increased resistance to malaria.

7.

IPT should not be used during the first 16 weeks of pregnancy.

8.

Quinine is the drug of choice for the treatment of complicated malaria.


11.4.3 Knowledge Assessment:
Prevention and Management of Malaria and Other Causes of Fever In Pregnancy
Answer Key
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.
1. Malaria affects

a.

Nearly as many people as TB and HIV combined

b.

Twice as many people as TB, HIV, leprosy and measles combined

c.

Five times as many people as TB, HIV, leprosy and measles combined
2. In malaria-endemic areas, malaria during pregnancy may account for:

a.

Up to 15% of maternal anemia

b.

514% of low birth weight

c.

30% of preventable low birth weight (LBW)

d.

a) and b)

e.

All of the above


3.

Malaria prevention and control in pregnancy includes:

a.

Focused antenatal care and health education

b.

Intermittent preventive treatment (IPT)

c.

Long-lasting insecticide-treated nets

d.

a) and c)

e.

All of the above


Instructions:
Which of the following statements is false? In each case, explain what is incorrect.
4. Malaria is less severe in women during their first or second pregnancies thanit is in

subsequent pregnancies.
5.

In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.

6.

Women who are HIV + have increased resistance to malaria.

7.

IPT should not be used during the first 16 weeks of pregnancy.

8.

Quinine is the drug of choice for the treatment of complicated malaria.


4 is False
5 is False
6 is False
7 is True
8 is True
11.4.3Knowledge Assessment:
Preventing Mother-To-Child Transmission of HIV
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.
1. A key risk factor for mother-to-child transmission of HIV is:
a. High viral load of the mother
b. Advanced age of the mother
c. Parity of the mother
2. Some intrapartum interventions to reduce the risk of MTCT include:
a. Using good infection prevention measures
b. Avoiding artificial rupture of membranes and unnecessary trauma
c. Avoiding prolonged rupture of membranes
d. a) and b)
e. All of the above
Instructions: Which of the following statements is false? In each case, explain what is
incorrect.

O
O 3.Counseling to prevent acquiring HIV is important for HIV-negative women but not for HIVpositive women.
O 4. ARVs should be provided during pregnancy for the health of the baby but not for the
mother.
O 5. There is no evidence of increased MTCT from vaginal rather than C-section delivery if
appropriate ARVs are used and the viral load is controlled.
O 6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.
O 7. For HIV survival, all women for whom replacement feeding is not acceptable, feasible,
affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed

their infant for 6 months.


Knowledge Assessment: Preventing Mother-To-Child Transmission of HIVAnswer
Key
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.
1. A key risk factor for mother-to-child transmission of HIV is:
a. High viral load of the mother
b. Advanced age of the mother
c. Parity of the mother
2. Some intrapartum interventions to reduce the risk of MTCT include:
a. Using good infection prevention measures
b. Avoiding artificial rupture of membranes and unnecessary trauma
c. Avoiding prolonged rupture of membranes
d. a) and b)
e. All of the above
Instructions: Which of the following statements is false? In each case, explain what is
incorrect.
O

3. Counseling to prevent acquiring HIV is important for HIV-negative womenbut not for HIVpositive women.

4. ARVs should be provided during pregnancy for the health of the baby but not for the
mother.
5. There is no evidence of increased MTCT from vaginal rather than C-section delivery if
appropriate ARVs are used and the viral load is controlled.
6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.
7. For HIV survival, all women for whom replacement feeding is not acceptable, feasible,
affordable, sustainable and safe (AFASS) should beencouraged to exclusively breastfeed
their infant for 6 months.
4. The answer is False
5. The answer is True
6. The answer is True
7. The answer is True
11.4.4 Knowledge Assessment:
Postpartum family planning
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.

1. Appropriate timing for postpartum family planning counseling includes:


1 a) 6 weeks postpartum
2 b) Immediate postpartum
3 c) Antenatal
4 a) and b)
5 All of the above
2. The criteria for LAM are:
a) Fully or nearly fully breastfeeding, less than 4 months postpartum, menses have not
returned, and baby still feeds at least once during the night
b) Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses have not
returned
c) Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have not
returned
3. IUDs can be inserted:
a) Within 24 hours and after 6 weeks postpartum
b) Within 24 hours and after 4 weeks postpartum
c) Within 48 hours and after 4 weeks postpartum
d) Post-placental only (within 10 minutes of delivery) and after 6 weeks postpartum

4. IUD use:
6 a) Is associated with infertility
7 b) Increases risk of PID
8 c) is contraindicated in any woman who is HIV+
9 d) None of the above
10 e) All of the above
Instructions: In the space provided, print a capital T if the statement is true or a capital F if
the statement is false.
6. The breastfeeding woman can begin oral progestin-only pills at 6 weeks after delivery.___
O 7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks
postpartum.______
O

8. IUDs and hormonal contraception may increase the risk of acquisition of HIV.

9. LAM provides 98% protection from pregnancy. _____


O 10. Fertility awareness methods (such as Standard Days Method) can be started at 6
weeks postpartum for both breastfeeding and non-breastfeeding women. _____

O11. Vasectomy is not effective immediately, so the use of a backup contraceptive method
for 1 month after the procedure is recommended. _____
O

12. IUDs are the most cost-effective reversible method if used for 2 years or more.____

Knowledge Assessment: Postpartum family planning Answer Key


1. Appropriate timing for postpartum family planning counseling includes:
a.

6 weeks postpartum

b.

Immediate postpartum

c.

Antenatal

d.
e.

a) and b)
All of the above

2.The criteria for LAM are:


a. Fully or nearly fully breastfeeding, less than 4 months postpartum, menses have not
returned, and baby still feeds at least once during the night
b. Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses
havenot returned
c.

Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have
not returned

3. IUDs can be inserted:


a.
b.
c.
d.

Within 24 hours and after 6 weeks postpartum


Within 24 hours and after 4 weeks postpartum
Within 48 hours and after 4 weeks postpartum
Post-placental only (within 10 minutes of delivery) and after 6 weeks postpartum

4. IUD use:
a. Is associated with infertility
b. Increases risk of PID
c.

Is contraindicated in any woman who is HIV+

d. None of the above


e. All of the above
Instructions: In the space provided, print a capital T if the statement is true or a capital F if
the statement is false.
6. The breastfeeding woman can begin oral progestin-only pills at 6 weeks after delivery. True
O 7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks
postpartum. True
O

8. IUDs and hormonal contraception may increase the risk of acquisition of HIV. False

9. LAM provides 98% protection from pregnancy. True

O 10. Fertility awareness methods (such as Standard Days Method) can be started at 6
weeks postpartum for both breastfeeding and non-breastfeeding women. False
O11. Vasectomy is not effective immediately, so the use of a backup contraceptive method
for 1 month after the procedure is recommended. True
O

12. IUDs are the most cost-effective reversible method if used for 2 years or more.True

(Reference: Best Practices in Maternal and Newborn Care Learning Resource Package
JHPIEGO)

11.5 Checklists
11.5.1 Checklist for Focused Antenatal care
First Visit
Antenatal Assessment (History, Physical Examination, Testing) and Care
(To be used by the Facilitator/Teacher at the end of the module)

Rate the performance of each step or task observed using the following rating scale:
1 Needs Improvement: Step or task not performed correctly, performed out of sequence (if
sequence necessary), or omitted
2 Competently Performed: Step or task performed correctly and in proper sequence (if sequence
necessary), but learner does not progress from step to step efficiently
3 Proficiently Performed: Step or task performed correctly, in proper sequence (if sequence
necessary), and efficiently
Learner------------------------------------------------- Date Observed---------------Antenatal Assessment First Visit
(History, Physical Examination, Testing) and Care.
Some of the following steps/tasks should be performed simultaneously
Step/Task

Cases

Getting Ready
1. Prepare the necessary equipment.
2. Greet the woman respectfully and with kindness and introduce
yourself.
3. Offer the woman a seat.
4. Tell the woman what is going to be done, listen to her and
encourage her to ask questions.
5. Provide reassurance and emotional support as needed.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
History
1. Ask the woman how she is feeling and respond immediately to
any urgent problem(s).
2. Ask the woman her name and age
3. Ask the woman number of

previous

pregnancies

breastfeeding (number of children, mode of delivery)


4. Ask the woman menstrual history including

LMP

and
and

contraceptive history.
5. Calculate the EDD and gestational age.
6. Ask the woman whether she has felt fetal movements within the

last day (if visit is after 16 weeks).


7. Ask the woman about medical conditions, medications and
hospitalizations, including HIV status if known.
8. Ask woman about daily habits, lifestyle, social support and
traditional beliefs and customs.
9. Ask the woman about tetanus immunization.
10. Ask the woman if she is using treated bed nets at all times (in
malarious areas).
11.
Askthewomanaboutotherproblemsorconcernsrelatedtoherpregnancy.
12. Record all pertinent information on the womans record/antenatal
card.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Physical Examination
1. Ask the woman to empty her bladder and save and test the urine.
2. Observe the womans general appearance.
3. Help the woman on to the examination table and place a pillow
under her head and upper shoulders.
4. Wash hands thoroughly with soap and water and dry them.
5. Explain each step of the physical examination to the woman.
6. Take the womans blood pressure, temperature and pulse.
7. Measure mid-upper arm circumference.
8. Check her heart and respiratory system
9. Examine the breasts.
10. Measure/estimate fundal height.
11. Examine abdomen and determine lie and presentation (after 36
weeks).
12. Listen to the fetal heart (second and third trimesters).
13. Wash hands thoroughly with soap and water and dry.
14. Inform the woman about the speculum examination
15. Put examination gloves on both hands.
16. Check external genitalia for sores and/or swelling.
17. Check the vaginal orifice for bleeding and/or abnormal
discharge.
18. Check cervix for signs of cervicitis.
19. Immerse both gloved hands in 0.5% chlorine solution and
remove gloves, wash hands.
20. Summarize findings and explain to the woman.
21. Record all relevant findings on the womans antenatal card.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Pre-test counseling
Conduct pre-test counseling for HIV and syphilis
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Screening Procedures
1. Put examination gloves on both hands.
2. Draw blood and do hemoglobin, blood group and Rh, RPR and
HIV tests (if opt-in), interpreting results accurately.
3. Perform urinalysis for protein, sugar and bacteriuria
4. Empty and soak the test tubes in 0.5% chlorine solution for 10

minutes.
5. Dispose off needle and syringe in puncture-proof container.
6. Immerse both gloved hands in 0.5% chlorine solution and remove
gloves.
7. Wash hands thoroughly with soap and water and dry.
8. Record results on the womans antenatal card.
9. Discuss the findings with her.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Identify problems/needs
Identify the womans individual problems/needs, based on the
findings of the antenatal history, physical examination and screening
procedures.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Provide Care/Take Action
1.Treat the woman for syphilis if the RPR test is positive, provide
post-test counseling on HIV and safer sex, and arrange for referral if
HIV positive.
2. Provide tetanus immunization based on need.
3. Provide counseling about necessary self-care topics.
4. Provide counseling about the use of insecticide-treated bed nets.
5. Dispense other necessary medications such as iron and folate.
6. Develop or review individualized birth plan with the woman;
develop or review her emergency preparedness plan, including
danger signs.
7. Record the relevant details of care on the womans
record/antenatal card.
8. Ask the woman if she has any further questions or concerns.
9. Ask her if she wants to bring her husband or family member on
her next antenatal visit.
10. Thank the woman for coming and tell her when she should come
for her next antenatal visit.

Adapted from Best Practices in Maternal and Newborn Care Learning Resource Package
JHPIEGO USAID ACCESS (2008)
Subsequent Visits
Antenatal Assessment (History, Physical Examination, Testing) and Care
Antenatal Assessment Subsequent Visits
(History, Physical Examination, Testing) and Care.
Some of the following steps/tasks should be performed simultaneously
Step/Task
Getting Ready

Cases

1. Prepare the necessary equipment.


2. Greet the woman respectfully and with kindness and introduce
yourself.
3. Offer the woman a seat.
4. Tell the woman what is going to be done, listen to her and
encourage her to ask questions.
5. Provide reassurance and emotional support as needed.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
History
1. Ask the woman how she is feeling and respond immediately to
any urgent problem(s).
2. Verify her name and age
3. Check the EDD and gestational age.
4. Ask the woman whether she has felt fetal movements within the
last day (if visit is after 16 weeks).
5. Ask the woman about any medical conditions and medications.
6. Ask the woman if she is taking iron and folate.
7. Ask the woman if she is using treated bed nets at all times (in
malarious areas).
8. Ask her if there has been any change in her social situation since
the last visit.
9. Record all pertinent information on the womans record/antenatal
card.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Physical Examination
1. Ask the woman to empty her bladder and save and test the urine.
2. Observe the womans general appearance.
3. Help the woman on to the examination table and place a pillow
under her head and upper shoulders.
4. Wash hands thoroughly with soap and water and dry them.
5. Explain each step of the physical examination to the woman.
6. Take the womans blood pressure.
7. Measure/estimate fundal height.
8. Examine abdomen and determine lie and presentation (after 36
weeks).
9. Listen to the fetal heart (second and third trimesters).
10. Wash hands thoroughly with soap and water and dry.
11. Inform the woman about the findings.
12. Record all relevant findings on the womans antenatal card.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Screening Procedures
1. Put examination gloves on both hands.
2. Draw blood and do hemoglobin if less than 7 g/l at first visit.
3. Perform urinalysis for protein, sugar and bacteriuria
4. Empty and soak the test tubes in 0.5% chlorine solution for 10
minutes.
5. Dispose off needle and syringe in puncture-proof container.

6. Immerse both gloved hands in 0.5% chlorine solution and remove


gloves.
7. Wash hands thoroughly with soap and water and dry.
8. Record results on the womans antenatal card and discuss them
with her.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Identify problems/needs
Identify the womans individual problems/needs, based on the
findings of the antenatal history, physical examination and
supportingtests/procedures.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Provide Care/Take Action
1. Provide counseling about necessary self-care topics.
2. Provide counseling about the use of insecticide-treated bed nets.
3. Dispense other necessary medications such as iron and folate.
4. Review individualized birth plan with the woman.
5. Review her emergency preparedness plan
6. Discuss signs of onset of labour
7. Discuss danger signs in pregnancy
8. Discuss postpartum family planning
9. Discuss self-care in post-partum period
10. Discuss breast feeding
11. Discuss care of the newborn
12. Record the relevant details of care on the womans
record/antenatal card.
13. Ask the woman if she has any further questions or concerns.
14. Thank the woman for coming and tell her when she should come
for her next antenatal visit.

11.5.2 Checklist for birth and emergency preparedness plan


To refer to 11.1.2 Birth and emergency readiness plan
Check List- Birth and emergency preparedness plan
Item
Yes No
The discussion between the provider and the pregnant woman, her husband and
family includes: The provider
1. At the first visit, explains why abirthplan(including emergency/complication
readiness) is important
2. Advises her to have delivery in a health facility (puskesmas or district
hospital).
3. Advises that if she decides to deliver at home, the birth should be attended
by a skilled birth attendant
4. Assists the woman in choosing the appropriate healthcare facility (e.g.,
district hospital, health center)
5.Assists the woman in identifying a skilled birth attendant/provider
6. Ensures that the woman is familiar with local transportation systems
7. Checks that she has transportation to an appropriate place for the birth
based on her individual needs.
8. Assists the woman in planning to have funds available when needed to pay
for care during normal birth.
9. For emergency/complication preparedness, discuss emergency funds that
are available through the community and/or healthcare facility if danger signs
arise.
10. Discusses how decisions are made in the womans family. (who usually
makes decisions?)
11.
Assists

the

woman

in

deciding

companionofherchoicetostaywithherduringlaborandchildbirth,and
her during transport if needed.
12.
Assists
the
woman

in

making

the

accompany

arrangements

for

someonetocareforherhouseandchildrenduringher absence.
13. Ensures that the woman has identified an appropriate blood donor and that
this person will be available in case of emergency.
14. Ensures that the woman knows the danger signs which indicate a need to
O

enact the emergency/complication readiness plan.


15. Ensures that she knows the signs of labour
During Visits at 32 weeks and after thatthe discussion between the provider and the
pregnant woman, her husband and family includes: The provider
16. Checks that the woman and family have finalized thebirthplan.
17. Checks what arrangements have been made since the last visit? (Has
anything changed? Have any obstacles or problems been encountered?)
18. Ensures that the woman knows the danger signs which indicate a need to
enact the emergency/complication readiness plan.
19. Makes sure the woman has gathered necessary items for a clean and safe
birth

Item
20. Makes sure the woman has gathered necessary items for the newborn

Yes

No

11.5.3 Checklist for demonstration of breast feeding


The tutor can use the checklist to assess if the student/trainee can demonstrate the technique
of breastfeeding. The student/trainee can also use the checklist as a guide to demonstrate the
technique of breastfeeding.
Item
Positioning

Yes
The mother is comfortable with back and arms supported.
Babys head and body are aligned; babys abdomen is
turned toward the mother.
Babys face is facing the breast with nose opposite nipple.
Babys body is held close to the mother.
Babys whole body is supported.
The baby is brought to the nipple height.
The mother maysupporttheweightofher breast with her

Holding

hand and shape her breast by putting her thumb on the


upper part, so that the nipple and areola are pointing
toward the babys mouth; OR
Shemaysupportthebreastbyplacingher fingers flat against
the chest wall, while bringing the baby to her breast to
suckle.
Nippleandareolaaredrawnintothebabys mouth rather than

Attachment
and Suckling

only the nipple into the mouth.


Thebabysmouthiswideopen;lowerlipis curled back below
base of nipple.
Thebabys chin touches the mothers breast
Thebabytakesslow,deepsucks,oftenwith visible or audible
swallowing.
Thebabypausesfromtimeto time.
The baby may make smacking sounds.
Mother does not complain of, or appear tohave,

Mother
comfort
Finishing
breast feed

the

nipple/breast pain during the breastfeed.


The newborn should release the breast her/himself rather
than being pulled from the breast.
Feeding may vary in length, anywhere from 4 to 40
minutes per breast.
Breasts are softer at the end of the feed compared to full
and firm at thebeginning.
Newborn looks sleepy and satisfied atthe end of a feed.
Burp the baby at the end of the feed

No

11.6 Learners Guide:


11.6.1 Learners Guide: Antenatal Assessment -Taking an Obstetric History
The Guide can be used by the student/trainee.
The Facilitator/Teacher can use the Guide at the end of the module and grade the
performance of the student/trainee.
Rate the performance of each step or task observed using the following rating scale:
1 Needs Improvement: Step or task not performed correctly, performed out of sequence (if
sequence necessary), or omitted
2 Competently Performed: Step or task performed correctly and in proper sequence (if sequence
necessary), but learner does not progress from step to step efficiently
3 Proficiently Performed: Step or task performed correctly, in proper sequence (if sequence
necessary), and efficiently
Learner------------------------------------------------- Date Observed---------------Step/Task
Preamble
1. Prepare the necessary documents.
2. Greet and welcome the woman and introduce yourself
3. Ask her if someone is accompanying her, if so invite her
companion
4. Offer the woman a seat.
5. Explain that you will proceed with a history taking and obtain
consent
6. If you are a male student, you may want to ask a nurse or a fellow
female student to be present during the history taking.
7. Make sure you have drawn the curtains to ensure privacy.
Introductions
1. Ask her name, age, address, phone number.
2. Ask her husbands name
3. Observe the womans general appearance and whether she is
cooperative or not.
Menstrual History
1. Ask her the first day of last menstrual period
2. Ask her if her menstrual cycle is regular and the length of each
cycle.
3. Calculate the expected date of delivery
4. Calculate thematurity by dates
5. Ask the woman whether she has felt fetal movements within the
last day (if visit is after 16 weeks).
Current Pregnancy History
1. Ask her if she noticed any leucorrhea
2. Ask her if she experienced nausea and vomiting
3. Ask her if she had any vaginal bleeding
4. Ask her if she experienced other problems/abnormalities

Case

Case

Case

5. Ask her if she has usedmedication, traditional medicine and herbs


Previous Obstetric History
1. Ask her the number of pregnancy/pregnancies
2. Ask her the number of delivery/deliveries
3. Ask her the number of labours at term, preterm labours
4. Ask her the mode of delivery
5. Ask her the number of living children, birth weight, and sex
6. Ask her the number of miscarriage, abortion
Note: The obstetric history is usually entered in a tabular form,
see following section.
7. Ask her if she had bleeding in previous pregnancy, labour and
puerperium
8. Ask her if she had hypertension, pre-eclampsiain previous
pregnancies
9. Ask if she had abnormal presentations such as breech or
transverse presentation
10. Ask her if she had other problems in previous pregnancies,
labours and puerperium
11. Ask her if she breast fed her babies and if so, the duration of
exclusive breast feeding
Note: If she mentioned any of the above problems in 7,8,9 or if
she had a C.S., further details need to be elicited. See the
subsequent table.
12. Ask if any of the babies weighed<2.5 kg or> 4 kg
13. Ask her if any baby was small for gestational age (IUGR)
14. Ask if she has delivered twins or triplets, etc
15. Ask if any of her babies had a perinatal, neonatal or fetal death
Note: If she experienced a perinatal, neonatal or fetal death, further details need to be
elicited. See the subsequent table.
Gynaecological (including previous contraceptive) History
1. Ask for history of contraception before pregnancy
2. Ask if she had any surgical procedures
3. Ask if there were period(s) of infertility: If so, when? For how long?
and if she knew the reason cause?
Medical History (ask for the following conditions)
1.Known/diagnosed heart disease
2.Hypertension
3.Diabetes mellitus (DM)
4.Liver diseases such as hepatitis
5.Tuberculosis (TB)
6.Chronic renal disease
7.Malaria
8.Asthma
9.Epilepsy
10.Any regular medication prior to pregnancy and continuing during
pregnancy
11.Any allergy to medication, food
12.History of surgery (other than CS)
13.Sexually transmitted diseases2
2The student could ask this point later after obtaining the social history and if the student feels
that the woman could be at increased risk of STI

14.HIV status if known


15.History of blood transfusion
16.Blood group
17.History of trauma/accident
18.Status of tetanus immunization
Family History
1. Ask her if her parents had Diabetes mellitus
2. Ask her if her parents had Hypertension
3. Ask her if her mother, her sister or herself hadmultiple or higher
order pregnancy
4.Ask if there is a history of congenital abnormalities in her family
Socio-economic History Ask her
1.Marital status, number of times married and age of marriage(s)
2.Her occupation and daily activities
3.Education level
4.Income (if possible)
5.The husbands occupation and income
6.Eating or drinking habits
7.Ethnic group
8.Religion
9.Smoking, use of recreational drugs and alcohol
10.Sexual life, history of casual sex
11.Beliefs, perceptions or concerns regarding pregnancy or labour
12.Number of family members helping at home
13.Birth and emergency preparedness plans
14.Who is the decision maker in the family
15.Options of place for delivery
16.Housing
17. Sanitation conditions
18.Electricity
19.Cooking facilities
Thank her and explain that you will be examining her next
To ask in more detail if the following were mentioned in the obstetric history. Only the
more common conditions are covered.
Antepartum haemorrhage
At which month of pregnancy did she bleed?
Was it associated with pain?
Was it repeated and recurrent?
Did she need blood transfusion; if yes, how many units?
Did she need a surgical operation for the bleeding?
Did she have any complications afterwards?
What was the condition of the baby?
Post-partum Haemorrhage
When did she start to bleed?
Did she need blood transfusion; if yes, how many units?
Did she need a surgical procedure for the bleeding?
Did she have any complications afterwards?
Pre-eclampsia
At which month of pregnancy did she have high blood pressure?
Was the urine tested for protein?
Did she have fits?
Did she have headache, blurred vision, abdominal pain?
Did she have a spontaneous delivery or was it induced?

Did she need a surgical procedure?


Did she have any complications afterwards?
What was the condition of the baby?
History of caesarean section
Why was the operation done?
Where was the operation done?
Who performed the operation?
What was the outcome of the baby?
Did she have any complications after the operation?
History ofperinatal, neonatal or fetal death
What was the gestational age of the baby?
Was her antenatal period normal or were there complications?
Were the laboratory investigations normal?
Did she have medical conditions complicating pregnancy? What
treatment did she receive?
Did she have preterm labour or premature rupture of the
membranes?
Did she have spontaneous labour or was it induced?
Was the labour prolonged?
Did she have a normal delivery or assisted vaginal delivery or an
operation (LSCS)?
What is the birth weight of the baby?
Did the baby cry at birth?
Did the baby have any visible abnormalities?
Did the baby need resuscitation?
Was the baby admitted to a special care unit?
Did you breastfeed the baby?
At what age did the baby die?
Do you know what treatment was given to the baby?
What was the reason for the babys death?
History Taking at subsequent visits
After greeting her and asking her to sit down
How she is feeling since her last visit?
Are there are any concerns or complaints e.g. bleeding?
Are there any changes in her personal history since theprevious
visit?
Has she taken medication other than iron-folate, herbal medicines
Has she had other medical consultations, hospitalization?
Does she notice fetal movement? When did she first notice them?
Check on habits e.g. smoking
Has she decided where she will deliver?
If home delivery, has she identified the midwife who will assist her?
Check her birth and emergency preparedness plans.
Has she had any pain or bleeding?

11.6.2 Learners Guide: Antenatal Assessment - Physical Examination


The Guide can be used by the student/trainee.
The Facilitator/Teacher can use the Guide at the end of the module and grade the
performance of the student/trainee.

Rate the performance of each step or task observed using the following rating scale:
1 Needs Improvement: Step or task not performed correctly, performed out of sequence (if
sequence necessary), or omitted
2 Competently Performed: Step or task performed correctly and in proper sequence (if sequence
necessary), but learner does not progress from step to step efficiently
3 Proficiently Performed: Step or task performed correctly, in proper sequence (if sequence
necessary), and efficiently
Learner------------------------------------------------- Date Observed---------------Following obstetric history taking, the student/trainee will proceed with an obstetric
examination: the general examination, examination of the cardiovascular and respiratory
system and breast examination. The student/trainee may also need to perform a speculum
examination.
(The general examination and examination of the cardiovascular and respiratory system will
not be elaborated here)
Because of the sensitive nature of these examinations, developing rapport with the patient is
extremely important.
Step/Task
Preamble
1. Prepare the necessary equipment.
2. Explain that you will proceed with a physical examination and
obtain consent
3. If you are a male student, you may want to ask a nurse or a fellow
female student to be present during the examination.
4. Make sure you have drawn the curtains to ensure privacy.
Physical Examination
1. Ask the woman to empty her bladder and save and test the urine.
2. Observe the womans general appearance and gait.
3. Help the woman on to the examination table and place a pillow
under her head and upper shoulders.
4. Wash hands thoroughly with soap and water and dry them.
5. Explain each step of the physical examination to the woman.
6. Conduct a general examination: check eyes for anaemia,
palpebral edema, tongue, thyroid
7. Take the womans blood pressure, temperature and pulse.
8. Measure the Mid-upper arm circumference (MUAC) just before
or just after checking the blood pressure
8.1 Use a soft tape-measure
8.2 Measure the arm circumference in either the right or left arm,
midway between the tip of the shoulder (acromion)and the tip of the
elbow (olecranon)
8.3 The arm should hang freely (elbow extended)
8.4 Record the measurement to the nearest 1 mm
8.5 Record the MUAC on the antenatal card or in the labour ward

Case

Case

Case

Step/Task

Case

Case

Case

admission notes
9. Expose her chest and check her heart and respiratory system.
10. Examine the breasts.
10.1 Inspection: skin, contour
10.2 Protraction or retraction of nipple
10.3 Expression of the nipple
10.4 Palpation of both breasts in the sitting and supine positions
10.5 Palpation of the breasts with the flat of the hand and then with
fingers
10.6 Palpation of the lymph nodes, including axillary and
supraclavicular nodes
10.7 Cover the chest and breasts
11. Abdominal examination
Tell the woman that you will proceed with an abdominal examination.
Expose the abdomen adequately (put a cover sheet to the lower part
of abdomen)
12. Inspection
- Note apparent size of abdominal distension
- Note any symmetry
- Note any fetal movements
- Note cutaneous signs of pregnancy linea nigra, straie gravidarum,
straie albicans, flattening/eversion of umbilicus
- Note any prominent superficial veins
- Note any surgical scars
(Note: Pfannenstiel scar may be obscured by pubic hair,
laparoscopy scars hidden within the umbilicus)
13. Measure/estimate symphisio-fundal height.
- palpated < 20 weeks
- measured in cm if more than 20 weeks put the end of the tape
measure to the symphiyis and bring it up to the fundus.
14. Examine abdomen and determine lie and presentation (after 36
weeks).
14.1 Leopold I (Fundal grip) determining uterine fundal height and
fetal parts located in the uterine fundus (carried out since the early
first trimester).
14.2 Leopold II: determining position of the fetal back (performed by
the end of second trimester).
14.3 Leopold III: determining fetal parts located at the bottom of the
uterus (carried out by the end of second trimester).
14.4 Leopold IV: determining how far fetus enters the pelvis (done at
the end of the second trimester).
15. Assess amount of liquor (second and third trimesters)
Note: during the examination, maintain eye contact with the woman from time to time
16. Determine where the fetal back is and listen to the fetal heart
(second and third trimesters).
17. Check extremities for oedema.
18. Cover the womans abdomen and help her sit up

Step/Task
19. Wash hands thoroughly with soap and water and dry.
20. Explain/summarize the findings
If bivalve (Cuscos) speculum examination will be done: after
step 15 of obstetric examination
1. Cover the womans abdomen
2. Inform the woman about the speculum examination and the
purpose. Explain that shemight feel a little discomfort and that the
examination should be over fairly quickly. If they have any questions
or concerns then answer them.
3. Obtain consent
Note: Make sure that Point 2 and 3 of Preamble are in place
Make sure all equipment are ready: spot lamp, speculum, KY
jelly, swabs etc). Turn on the spot lamp to the examination site.
4. Ask her to raise her legs in the dorsal position
5. Cover her legs and lower abdomen with drapes
6. Wash hands
7. Put examination gloves on both hands.
Note: Swab the external genitalia
Talk to the woman while you are examining her
8. Inspection: Check external genitalia
8.1 Check for any swelling, inflammation
8.2 Check for skin changes
8.3 Check for ulcers, lesions
8.4 Check the vaginal orifice for bleeding and/or abnormal
discharge.
9. Check if there are any haemorrhoids
10. Speculum introduction and examination
Note: Tell her you will be introducing the speculum
Insert an appropriate sized speculum, you may need to warm the
speculum. Swab the external genitalia.
10.1 The Labia minora are parted with left hand
10.2 Insert the closed speculum, upwards and backwards
10.3 Advance into vagina fully
10.4 Direct visualization as blades open to expose cervix
10.5 if cervix is not seen, close blades, withdraw slightly, change
direction and open again
10.6.Take swabs if there is vaginal discharge as required
10.7 Check for vaginal abnormalities, e.g. septum
10.8 Check cervix: normal or signs of cervical lesions, tumour
10.9 Speculum removal: ensure blades are open while sliding over
cervix
10.10 Partially close blades while withdrawing the speculum and
inspect vaginal walls
10.11 Blades should be closed at introitus, not trapping any vagina
11. Cover the womans thighs with drapes
12. Immerse both gloved hands in 0.5% chlorine solution and
remove gloves, wash hands.
13. Remove drapes, help her to get up and get dressed

Case

Case

Case

Step/Task
14. Ask her to sit down
15. Summarize findings and explain findings to the woman.
Inform her if the findings are normal or if any conditions/
abnormalities were detected
16. Record all relevant findings on the womans antenatal card.

Case

Case

Case

11.7Counseling Guide for Postpartum Family Planning Postpartum IUD


Place a Yes in case box if task/activity is performed satisfactorily, an X if it is not performed satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the
standard procedure or guidelines Not Observed: Step, task or skill not performed by learner during evaluation by trainer
Learner

Date Observed----------------------

COUNSELLING ON PPIUD SERVICES


ITEM
STEP/TASK
GREETEstablish good rapport and initiate counseling on PPFP.
1. Establishes a supportive,
Greets the woman, using her name and introducing self.
trusting relationship
Shows respect for the woman and helps her feel at ease.
2. Allows the woman to talk and

Encourages the woman to explain her needs and concerns and ask questions.

listens to her.

Listens carefully and supports the womans informed decisions.

3. Engages womans family

Includes womans partner or important family member in the discussion, as the woman desires and

members.

with her consent.

ASKDetermine reproductive intentions, knowledge of pregnancy risk and use of various contraceptives.
4. Determines any previous
Explores womans knowledge and beliefs about the return of fertility and the benefits of pregnancy
experiences with family planning.

spacing or limiting (as desired).


Asks whether she has had prior experience with family planning methods, any problems, reasons for
discontinuing, etc.

5. Assesses partner/family

Explores partners/familys knowledge and beliefs about the return of fertility and the benefits of

attitudes about family planning.

pregnancy spacing/limiting.

71

ASSESSMENT

6. Assesses reproductive

Asks about desired number of children, desire to space or limit births, desire for long-term family

intentions.
7. Assesses need for protection

planning, etc.
Explores womans need for protection from STIs, including HIV.

against sexually transmitted


infections (STIs).
8. Determines interest in a

Explains and supports condom use, as a method of dual protection


Asks whether she has a preference for a specific method based on prior knowledge.

particular family planning method.


TELLProvide the woman with information about PPFP methods.
9. Provides general information
Advises that to ensure her health and the health of her baby (and family), she should wait at least 2
about benefits of healthy
pregnancy spacing (or limiting, if
desired).

years after this birth before trying to get pregnant again.


Advises about the return of fertility postpartum and the risk of pregnancy. Advises how LAM and
breastfeeding are different.
Advises about the health, social and economic benefits of healthy pregnancy spacing (or limiting, if
desired).

Note: For item 10, if the woman and husband already have a method in mind which is suitable to be used during the post-partum period, the provider may wish to
discuss on the method of choice and LAM and might not need to provide information on other methods that can be used during the post-partum period. The
explanations on the methods should be made in simple, easy-to-understand language.
10. Provides information about

Based on availability and on womans prior knowledge and interest, briefly explains the advantages,

PPFP methods.

limitations and use of the following methods:


LAM
Condoms
POPs
DMPA (injections)
- PPIUD
- No-scalpel vasectomy (male sterilization)
- Postpartum tubal ligation (female sterilization)
Shows the methods (using poster or wall chart or flip chart) and allows the woman to touch or feel the

72

items, including the IUD, using a contraceptive tray.


Corrects any misconceptions about family planning methods.
HELPAssist the woman in making a choice; give her additional information that she might need to make a decision.
11. Helps the woman to choose a
method.

12. Supports the woman's choice.

Gives woman additional information that she may need and answer any questions.
Assesses her knowledge about the selected method; provides additional information as needed.
Acknowledges the womans choice and advises her on the steps involved in providing her with her
chosen method.

EVALUATE and EXPLAINDetermine whether she can safely use the method; provide key information about how to use the method (focus on PPIUD,
per her choice)
13. Evaluates the womans health

Asks the woman about her medical and reproductive history.

and determine if she can safely


use the method.
14. Provides key information
about the PPIUD with the woman:

Effectiveness: Prevents almost 100% of pregnancies


Mechanism for preventing pregnancy: Causes a chemical change that damages the sperm BEFORE
the sperm and egg meet
Duration of IUD efficacy: Can be used as long (or short) as woman desires, up to 12 years (for the

15. Discusses advantages of the


PPIUD:

Copper T 380A)
Removal: Can be removed at any time by a trained provider with immediate return to fertility
Simple and convenient IUD placement, especially immediately after delivery of the placenta
No action required by the woman after IUD placement (although one routine follow-up visit is

16. Discusses limitations of the

recommended)
Immediate return of fertility upon removal
Does not affect breastfeeding or breast milk
Long-acting and reversible (as described above)
Heavier and more painful menses for some women, especially first few cycles after interval IUD (less

PPIUD:

relevant or noticeable to postpartum women)

73

17. Confirms that the woman


understands the method.

Does not protect against STIs, including HIV


Higher risk of expulsion when inserted postpartum (though less with immediate postpartum insertion)
Encourages the woman to ask questions.
Asks the woman to repeat key pieces of information.

RETURNPlan for next steps and for when she will arrive to hospital for delivery.
18. Plans for next steps.

Makes notation in the womans medical record about her PPFP choice or which methods interest her.
If the woman cannot arrive at a decision at this visit, asks her to plan for a follow-up discussion at her
next visit; advises her to bring partner/family member with her.
Provides information about when the woman should come back for her next antenatal visit OR
continue with the next item on her management plan.

If the woman has PPIUD insertion, the following information should be provided prior to discharge from hospital (in addition to other information).
1. Discusses warning signs;
explains that she should return to
the clinic as soon as possible if
any arise.
2. Confirms that the woman
understands instructions.
3. Concludes the interaction

Bleeding or foul-smelling vaginal discharge (different from the usual lochia)


Lower abdominal pain, especially if the first 20 days after insertionaccompanied by not feeling well,
fever or chills
Concerns she might be pregnant
Concerns the IUD has fallen out
Encourages the woman to ask questions.
Asks the woman to repeat key pieces of information.
Thanks her

74

75