1 An Care Resource KBT 19 Dec-1

Antenatal Care Module
Reference Material
Jakarta, Indonesia
December 2012
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Table of Contents
1. Preface ............................................................................................................................... 5
2. Modules related to the Antenatal Care Module ................................................... 5
3. Care in pregnancy .......................................................................................................... 6

3.1 Elements of care in pregnancy ......................................................................................... 6
3.2 Purpose of Antenatal care .................................................................................................. 7
4. Focused antenatal care................................................................................................. 7

4.1. Focused antenatal care: concepts and principles ..................................................... 7
4.2 Goals of Focused Antenatal care ...................................................................................... 9
4.3 Comparions of traditional and focused antenatal care .........................................10
4.4 Evidence-based FANC.........................................................................................................11
4.6 Counselling ............................................................................................................................13
4.7 Classifying Form ..................................................................................................................13
5. The Basic Component of Focused Antenatal Care ............................................ 17

5.1 The First FANC visit ............................................................................................................17
5.1.1 History Taking in Obstetrics/Elicit Information........................................................... 17
5.1.2 Physical Examination including Obstetric Examination............................................ 21
5.1.3 Supporting investigations/tests .......................................................................................... 23
5.1.4 Assess for Referral..................................................................................................................... 23
5.1.5. Interventions .............................................................................................................................. 24
5.1.6 Counselling, questions and answers, and scheduling the next appointment
...................................................................................................................................................................... 24
5.1.7. Maintain Complete Records ................................................................................................. 25
5.1.8 Final Notes .................................................................................................................................... 25
5.2 The Second FANC visit ......................................................................................................25
5.2.1 History/Elicit Information ..................................................................................................... 25
5.2.2 Perform physical examination ......................................................................................... 26
5.2.3 Supporting investigations/tests...................................................................................... 29
5.2.4 Assess for referral ................................................................................................................... 29
5.2.5 Interventions:............................................................................................................................ 30
...................................................................................................................................................................... 30
5.2.7 Maintain complete records .................................................................................................... 30
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5.3 The Third FANC visit ..........................................................................................................31
5.3.1 History/Elicit Information ..................................................................................................... 31
5.3.2 Perform physical examination .......................................................................................... 32
5.3.3 Supporting investigations/tests...................................................................................... 32
5.3.4 Assess for referral .................................................................................................................. 32
5.3.5 Interventions: ........................................................................................................................... 33
5.3.6 Counselling, questions and answers, and scheduling the next
appointment.......................................................................................................................................... 33
5.3.7 Maintain complete records ............................................................................................... 33
5.4 The Fourth FANC visit ........................................................................................................33
5.4.1 History/Elicit Information.................................................................................................... 34
5.4.2 Perform physical examination ........................................................................................ 35
5.4.3 Supporting investigations/tests: ................................................................................... 35
5.4.4 Assess for referral .................................................................................................................. 35
5.4.5 Interventions ............................................................................................................................ 36
5.4.6 Counselling, questions and answers, and scheduling the next
appointment.......................................................................................................................................... 36
5.4.7 Maintain complete records ............................................................................................... 36
6. Birth and emergency preparedness ..................................................................... 39

6.1 The Three Delays.................................................................................................................39
6.2 Birth and emergency preparedness .............................................................................39
7. The Postpartum and Postnatal Visit ..................................................................... 45
8. Late Enrollment and Late Visits ............................................................................. 46
9. Special Recommendations ....................................................................................... 47

9.1 Twins .......................................................................................................................................47
9.2 Spacing between Visits ......................................................................................................47
9. Specific Issues During Antenatal Care ................................................................. 48

9.1 Counselling for Nutrition ..................................................................................................48
9.2 Counselling for HIV screening ........................................................................................49
9.3 Postpartum and early newborn care ...........................................................................52
9.3.1 Care of the Mother ..................................................................................................................... 52
9.3.2 Care of Newborn ........................................................................................................................ 59
9.4 Pre-pregnancy counselling ..............................................................................................63
9.5 Minor Disorders in Pregnancy .......................................................................................64
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10. Conclusion ................................................................................................................... 65
11. References ................................................................................................................... 67
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1. Preface
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 Pre-
internship training. The Antenatal Care module focuses on care provided for normal
pregnancy and complements the Womens Health Module which covers pathological
conditions in pregnancy, delivery and post-partum period. The Reference Material will need to
be read in conjunction with the Antenatal Care module: Trainers Guide.
2. Modules related to the Antenatal Care Module

The module on antenatal care is 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 (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.
This 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.
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3. Care in pregnancy
3.1 Elements of care in pregnancy
The essential elements of care in pregnancy are as follows:

Pregnancy surveillance of the woman and her unborn child
Recognition and management of pregnancy-related complications
Recognition and treatment of underlying or concurrent illness or disease
Preventive measures, including immunization (especially with tetanus toxoid), de-
worming, iron and folic acid and insecticide treated bednets (ITN)
Screening for underlying conditions anddiseases such as anaemia, malaria, sexually
transmitted infections, HIV infection and underlying mental health problems and/or
symptoms of stress or domestic violence
Advice and support to the woman and her family in developing a birth and emergency
preparedness plan
Appreciating the perspectives and respecting the wishes of the woman and her family
in planning for care.
Health education and promotion for the woman and her family
- to increase awareness of maternal and neonatal health needs and self-care during
pregnancy and the postnatal period, including the need for social support during and
after pregnancy
- to promote healthy behaviours in the home, including healthy lifestyles, healthy diet,
health and safety/injury prevention, and support and care in the home (including
adherence to advice on prophylactic treatments such as iron supplementation, and
use of insecticide-treated bednets)
- to support care-seeking behavior, including the recognition of danger signs for the
woman and the newbornas well as transport and funding plans in case of
emergencies
- to promote postpartum family planning/birth spacing; and
- to help the pregnant woman and her husband prepare emotionally and physically for
birth and care of their baby, particularly preparing for early and exclusive
breastfeeding and essential newborn care and considering the role of a supportive
companion at birth.
Health care providers need to be aware of culture, tradition and myths on maternal
and newborn health and care when interacting with women and their families; during
counseling and providing care.
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3.2Purpose of Antenatal care
Antenatal Care comprisesa broad range of health services.
To provide evidence based interventions and care which can prevent and treat
complications of pregnancy
To encourage skilled attendance at delivery
To provide health education on key issues
To discuss plans for emergency transport and funds in the case of an emergency and
to identify the nearest site of Emergency Obstetric Care
To provide a link between women and the health care system
To build rapport between the woman and the health care provider.
4. Focused antenatal care
4.1. Focused antenatal care: concepts and principles

Historically, the traditional antenatal care service model was developed in the early 1900s.
This model assumes that frequent visits and classifying pregnant women into low and high
risk by predicting the complications ahead of time, is the best way to care for the mother and
the fetus. The traditional approach was replaced by focused antenatal care (FANC) - a goal-
oriented antenatal care approach, which was recommended by researchers in 2001 and
adopted by the World Health Organization (WHO) in 2002.
An updated approach to antenatal care emphasizes quality over quantity of visits (Kinzie and
Gomez 2004; MNH Program 2001). This approach, focused antenatal care, recognizes three
key realities: First, antenatal care visits are a unique opportunity for early diagnosis and
treatment of problems in the mother and prevention of problems in the newborn. Second, the
majority of pregnancies progress without complication. Third, all women are considered at
risk of complications because most complications cannot be predicted by any type of risk
categorization. Therefore, all women should receive essential care and monitoring for
complications that are focused on individual needs.
The World Health Organization (WHO) recommends four antenatal care visits for women
whose pregnancies are progressing normally, with the first visit in the first trimester (ideally
before 12 weeks but no later than 16 weeks), and at 2428 weeks, 34-36 weeks and the
fourth visit: beforeexpected date of delivery or when the pregnant woman feels she needs to
consult health worker. This model has been further defined by what is done in each visit, and
is often called focused antenatal care.
Each visit should include care that is appropriate to the womans overall condition and stageof
pregnancy, and help her prepare for birth and care of the newborn. If problems or potential
problems that will affect the pregnancy and newborn are detected, the frequency and scope
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of visits are increased. FANC emphasizes the quality of care over the quantity of visits,
focusing on the individual needs of women and the delivery of high-quality care based on
proven interventions.
FANC aims to promote the health of mothers and their babies through targeted
assessments of pregnant women to facilitate:
- Identification and treatment of already established disease- early detection of complications
and other potential problems that can affect the outcomes of pregnancy
- Prophylaxis and treatment for anaemia, malaria, and sexually transmitted infections (STIs)
including HIV, urinary tract infections and tetanus.
FANC also aims to give holistic individualised care to each woman to help maintain the
normal progress of her pregnancy through timely guidance and advice on:
- Birth preparedness
- Nutrition, immunization, personal hygiene and family planning
- Counselling on danger symptoms that indicate the pregnant woman should get immediate
help from a health professional.
Underlying Principles of Provision of Care

While antenatal care alone will not prevent global maternal and newborn mortality, the quality
of care a woman receives during pregnancy plays a vital role in ensuring the healthiest
possible outcome for mother and baby.
There are several general principles that are integral to the provision of high-quality focused
antenatal care for pregnant women. Care should be:
Woman-friendly: The womans health and survival, basic human rights and comfort are
given clear priority. The womans personal desires and preferences are also respected.
Inclusive of a womans husband or other family member: Respect for thehousehold

decision-making process, communication, participation and partnership in seeking and
making decisions about care help to ensure a fuller and safer reproductive health experience
for the woman, her newborn and her family.
Culturally appropriate: Every culture has specific beliefs, rituals, taboos and practices
surrounding pregnancy and childbirth. Cultural awareness, competency and openness are
essential in a care relationship with a woman during this important time in her life.
Individualized: By taking into consideration all of the information known about a woman
current health, medical history, daily habits and lifestyle, household situation, cultural beliefs
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and customs, and other unique circumstances - the skilled provider can individualize
components of care for each woman.
Part of the household-to-hospital continuum of care: Many of the components of focused
antenatal care can be provided at the community level; however, linkage with the formal
health care system is imperative to ensure adequate training and supervision of community
health workers and functional referral systems.
Integrated: Focused antenatal care includes STI and HIV testing/counseling, malaria
detection and prevention, micronutrient provision, birth planning, emergency planning and
family planning counseling.
4.2 Goals of Focused Antenatal care

The provision of high-quality, basic antenatal care - safe, simple, cost-effective interventions
that all women should receive - helps maintain normal pregnancies, prevent complications
and facilitate early detection and treatment of complications. The major goalof focused
antenatal care is to help women maintain normal pregnancies through:
Targeted assessment based on the womans individual situation to ensure normal

progress of the pregnancy and postpartum/newborn period, and to facilitate the early
detection of and special care for complications, chronic conditions and other potential
problems that can affect the mother and newborn; and
Individualized care to help maintain normal progress, including preventive measures,

supportive care, health messages and counseling (including empowering women and families
for appropriate and effective self-care), and birth preparedness and emergency/complication
readiness planning.
In FANC, health service providers give much emphasis to individualised assessment and the
actions needed to make decisions about antenatal care by the provider andthe pregnant
woman together. As a result, rather than making the traditional frequent antenatal care visits
as a routine activity for all, and categorising women based on routine risk indicators, the
FANC service providers are guided by each womans individual situation.
This approach also makes pregnancy care a familyresponsibility. The health service provider
discusses with the woman and her husband the possible complications that she may
encounter; they plan together in preparation for the birth, and they discuss postnatal care and
future childbirth issues. Pregnant women receive fundamental care at home and in the health
institution; complications are detected early by the family and health service provider; and
interventions are begun in good time, with better outcomes for the women and their babies.
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4.3Comparions of traditional and focused antenatal care
The traditional antenatal care service model assumes that frequent visits and classifying
pregnant women into low and high risk by predicting the complications ahead of time, is the
best way to care for the mother and the fetus. A multi-country randomised control trial led by
the WHO and a systematic review showed that essential interventions can be provided over
four visits at specified intervals, at least for healthy women with no underlying medical
problems. The result of this review led tothe new model of antenatal care (ANC) based on
four goal-oriented visits (WHO, 2002).
The traditional approach has been replaced by focused antenatal care (FANC)- a goal-
oriented antenatal care approach, which has been adopted in many countries.
Table 1 summarises the basic differences between the traditional and focused antenatal care
approaches.
Table 1: Basic differences between traditional and focused antenatal care.
Characteristics Traditional antenatal care Focused antenatal care
4 for women categorised in the basic

Number of visits 1618 regardless of risk status
component (as described later)
Integrated with PMTCT of HIV,

counselling on danger symptoms,
Vertical: only pregnancy issues are
Approach risk of substance use, HIV testing,
addressed by health providers
malaria prevention, nutrition,
vaccination, etc.
More frequentvisits for all and

Assumes all pregnancies are
categorising into high/low risk helps
potentially at risk. Targeted and
Assumption to detect problems. Assumes that
individualised visits help to detect
the more the number of visits, the
problems
better the outcomes
Relies on routine risk indicators,

Does not rely on routine risk
such as maternal height <150 cm,
Use of risk indicators. Assumes that risks to the
weight <50 kg, leg oedema,
indicators mother and fetus will be identified in
malpresentations before 36 weeks,
due course
etc.
Shared responsibility for birth and

Prepares the To be solely dependent on health
emergency preparedness/
family service providers
complication readiness
Communication One-way communication (health Two-way communication
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Characteristics Traditional antenatal care Focused antenatal care
education) with pregnant women (counselling) with pregnant women

only and their husbands
Incurs much cost and time to the Less costly and more time efficient.
pregnant women and health service Since majority of pregnancies
Cost and time
providers, because this approach is progress smoothly, very few need
not selective frequent visits and referral
Leads to complacency by the health

Alerts health service providers and
service provider and by the family in
family in all pregnancies for potential
Implication those not labelled at risk, and
complications which may occur at
makes the family unaware and
any time
reluctant when complications occur
4.4 Evidence-based FANC
Standards
All pregnant women should have at least four antenatal care (ANC) assessments by or under
the supervision of a skilled provider. These should, as a minimum, include all the
interventions outlined in the WHO antenatal care model (2001) and be spaced at regular
intervals throughout. Generic standards for maternal and newborn care were developed by
WHO in 2007 to be adapted and implemented according to the needs, financial and health
systems capacities in different countries. The interventions in the Antenatal Care Module are
primarily based on these WHO publications. Other reference materials are listed in Section 11.
The following interventions have been recommended:

- Prevention and treatment of anemia
Iron/folate supplementation for at least 6 months of pregnancy and 2 months
postpartum
De-worming medication inareas where parasites are common
- Tetanus Toxoid immunization
- Prevention of malaria in pregnancy
Intermittent preventive treatment (IPT) for malaria
Insecticide treated bednets (ITNs)
- Recognitionandtreatmentofsexuallytransmitted infections (STIs)
- Detection of pre-existing conditions which may complicatepregnancy
- Monitoring blood pressure and signs and symptoms of pre-eclampsia/eclampsia
- Urinalysisforproteinuriainthirdtrimesterifsigns of pre-eclampsia
- Confirmationoffetalpositionby36weeksof pregnancy
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- Birth and Emergency Preparedness (BirthPreparednessandComplicationReadiness)
- Promotion of active management of the third stage of labor for the prevention of postpartum
hemorrhage
- OptoutcounselingandtestingforHIVand education and clinical services forthe prevention of
maternal to child transmission(PMTCT) including use of condoms during pregnancy
indiscordant couples
- Measurement of weight/body mass index (BMI) and assessment of nutritional status
Health Promotion and Disease Prevention

It is essential for providers and women to discuss important issues affecting the womans
health, her pregnancy and her plans for childbirth and the postpartum and newborn period.
Discussions should include how pregnancy progresses and how to prepare for birth; how to
recognize danger signs, what to do if they arise and where to get help; benefits of good
nutrition and adequate rest; importance of good hygiene; risks of using tobacco, alcohol and
drugs; benefits of child spacing; benefits of exclusive breastfeeding; and need for protection
against STIs and HIV.
Focused antenatal care includes the following preventive interventions for all pregnant
women:
Immunization against tetanus with tetanus toxoid, a stable, inexpensive vaccine, that helps to
prevent neonatal and maternal tetanus.
Reduction of iron deficiency anemia through nutritional counseling and iron/folate

supplementation: Iron deficiency anemia is the single most prevalent nutritional deficiency
affecting pregnant women. In endemic countries, the prevention and treatment of hookworm
infection and the prevention and treatment of malaria are also important interventions to
reduce non- nutritional anemia.
Perform screening for syphilis and provider initiated counseling and testing for HIV: Perform
an on-site syphilis test in all pregnant women at the first ANC visit and provider initiated
counseling and testing for HIV in accordance with national guidelines.
In areas of detrimental conditions, diseases or nutritional deficiencies, the following services

should be provided in accordance with national policies and guidelines:
Protection against malaria for women living in malaria-endemic zones: This is through the use
of insecticide-treated nets; intermittent preventive treatment; and effective case management
of malarial illness.
Presumptive treatment for hookworm to prevent hookworm infection
Protection against vitamin A and/or iodine deficiency: This is through supplementation in
areas/populations of significant vitamin A and/or iodine deficiency.
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Early Detection and Treatment of Complications and Existing Diseases
As part of focused assessment, the skilled provider talks with and examines the woman for
problems that may harm her health or that of her newborn. Complications such as severe
anemia, infection, vaginal bleeding, pre-eclampsia/eclampsia, abnormal fetal growth and
abnormal fetal position after 36 weeks may cause or be indicative of a life-threatening
condition. Existing conditions, such as malaria or tuberculosis; HIV, syphilis and other STIs;
and diabetes, heart disease, anemia or malnutrition require special treatment during the
antenatal period.
4.6 Counselling
The purpose of counselling and health messages is to provide the woman with essential
information for improving or maintaining her health or the health of her newborn, and to
facilitate decision-making and when necessary, behaviour change. Through providing
counselling and health messages, the woman is empowered to become an active participant
in her healthcare and that of her newborn. When counseling, the health provider offers
assistance and support to help the woman apply health messages to her life, adopt healthy
practices, solve problems and make informed decisions.The provision of effective health
messages and counselling is based on the principles of communication.
The key steps of counselling: the counseling process, guiding principles and the factors that
can influence the counseling will need to be considered. Counselling and the decision-making
process are also influenced by local culture, religion, gender roles, family structure and
household decision-making, local beliefs and pregnancy related to maternal and neonatal
health and opinions about the health system.
Topics include: nutrition; birth and emergency preparedness and complication readiness;
common discomforts; danger signs; syphilis and HIV pre- and post-test counseling; safer sex;
family planning; and care of the newborn. Health messages will vary throughout the process
of care during the childbearing cycle and newborn period. (Basic Maternal and Newborn
Care: A Guide for Skilled Providers: JHPIEGO/Maternal and Neonatal Health Program 2004).
Counselling is covered in detail in the Community Medicine Module.
4.7 Classifying Form
At the outset, the focused antenatal care model (WHO 2002) segregates pregnant women
into tow groups: those eligible to receive routine care (the basic component) and those who
need special care based on their specific health conditions or risk factors. Pre-set criteria are
used to determine the eligibility of women for the basic component.The women selected to
follow the basic component are considered not to require any further assessment or special
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care at the time of the first visit. The remaining women are given care corresponding to their
detected condition or risk factor. The women who need special care will represent, on
average, approximately 25 percent of all women initiating antenatal care. Women are
questioned and examined at the first antenatal visit to see if they have any of the following
factors:
Previous pregnancy:
Ended in stillbirth or neonatal loss
History of three or more consecutive spontaneous abortions
A low birth weight baby (<2500 g)
A large baby (>4000 g)
Hospital admission for hypertension, pre-eclampsia or eclampsia.
Previous surgery on reproductive tract (cervical cerclage, cone biopsy, myomectomy,
etc)
Current pregnancy:
Diagnosed or suspected twins, or a higher number of multiple pregnancies
Maternal age less than 16 years
Maternal age more than 40 years
Mother has blood type Rhesus-negative
Mother has vaginal bleeding
Mother has a growth in her pelvis
Mothers diastolic blood pressure is 90 mmHg or more at booking
General Medical
The mother has one of the following:
Diabetes
Heart disease
Kidney disease
Known substance abuse, alcohol drinking
Communicable disease such as TB, malaria, HIV/AIDS or another sexually
transmitted infection (STI), cancer, hypertension
IfYES to any ONE of the above questions means that the woman is not eligible for the basic
component of antenatal care. She is categorised in the specialised component and requires
more close follow-up and referral to specialty care
Women in the specialised component will be referred to a higher level health facility for
additional monitoring and specialised care determined by specialists in these areas, while the
doctor and midwife at the health centre/puskesmas will continue to follow the activities of the
basic component with these women
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Specialized care, additional
evaluation/assessment or
Any condition or Yes follow-up in clinic or
All women Classifying risk factors elsewhere
at first visit Form detected in
Transfer of patients between
applying the
basic component &
Classifying Form
specialized care is possible
No throughout ANC
Basic component of ANC

programme
Figure 1: Focused Antenatal care model (WHO, 2001)
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Figure 2:CLASSIFYING FORM
Criteria for classifying women in the basic component of ANC model
Name of patient: Clinic record number:
Address: Telephone:
INSTRUCTIONS: Answer all of the following questions by placing a cross mark in the corresponding box.
OBSTETRIC HISTORY No Yes
1. Previous stillbirth or neonatal loss?
2. History of 3 or more consecutive spontaneous abortions?
3. Birthweight of last baby < 2500g?
4. Birthweight of last baby > 4500g?
5. Last pregnancy: hospital admission for hypertension or pre-eclampsia/eclampsia?
6. Previous surgery on reproductive tract?

(Myomectomy, removal of septum, cone biopsy, classical CS, cervical cerclage)
CURRENT PREGNANCY No Yes
7. Diagnosed or suspected multiple pregnancy?
8. Age less than 16 years?
9. Age more than 40 years?
10. Isoimmunization Rh (-) in current or in previous pregnancy?
11. Vaginal bleeding?
12. Pelvic mass?
13. Diastolic blood pressure 90mm Hg or more at booking?
GENERAL MEDICAL No Yes
14. Insulin-dependent diabetes mellitus?
15. Renal disease?
16. Cardiac disease?
17. Known 'substance' abuse (including heavy alcohol drinking)?
18. Any other severe medical disease or condition?
Please specify
A "Yes" answer to any ONE of the above questions (i.e. ONE shaded box marked with a cross) means that the
woman is not eligible for the basic component of the new antenatal care model.
Is the woman eligible? (circle) NO YES

If NO, she is referred to
Date Name Signature

(staff responsible for ANC)
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5. The Basic Component of Focused Antenatal Care
5.1 The First FANC visit
The first FANC visit should ideally occur before 16 weeks of pregnancyto achieve
thefollowing objectives:
Determine the womans medical and obstetric history to collect evidence of her
eligibility to follow the basic component of FANC, or determine if she needs special
care and/or referral to a higher health facility.
Obtain a thorough obstetric history taking and perform basic examinations (pulse rate,
blood pressure, respiration rate, temperature, pallor, etc.).
Obtain information on her social and economic background.
Perform a Quick Check (pulse rate, blood pressure, respiration rate, temperature,
pallor, etc.) to detect any emergency condition that requires immediate response or
referral.
If the pregnancy is beyond the first trimester, to determine the gestational age of the
fetus by measuring fundal height.
Provide nutritional advice and routine iron and folate supplementation (Refer to the
NutritionModule). Advise against misconceptions about diet.
Provide HIV counselling and testing. (Refer to Section 9.2 and the Infectious Disease
Module).
Give advice on malaria prevention and if necessary provide insecticide-treated bed
nets (ITNs). Malaria prevention and treatment is covered in the Medicine Module.
Check her urine for sugar using the dipstick test (Refer to Haematology and Clinical
PathologyModule).Refer her to the health facility if you suspect she may have
diabetes(Medicine Module).
Discuss options for place of delivery.
Advise her and her partner to save money in case she needs referral, especially if
there is an emergency requiring transport to a health facility.
Provide specific answers to the womans questions or concerns, or those of her
partner.
5.1.1History Taking in Obstetrics/Elicit Information

Identification
Name, Age
Husbands name, Husbands Age
Address, Phone Number
Religion
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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 previous pregnancy, 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; any perinatal, neonatal or fetal death.
The Obstetric History is usually summarized in a pre-formatted table (Table 2).
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Index Age & Sex Pregnancy Duration of Delivery Postpartum Birth weight Status at Other issues of
of Child (Normal or pregnancy (Normal or (Normal or birth note
complicated) complicated) complicated)
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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).
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
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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
5.1.2Physical Examination including 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(acromi
on)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
21
Breast Examination
Visual Inspection of the Breasts
- 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.
Normal variations:
- 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.
Normal variations:
- 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.
Obstetric physical examination at the first visit:

- Shape of abdomen (note any surgical scars)
- Fundal height
Vaginal Examination
- 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.
- 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.
22
5.1.3Supporting investigations/tests
Blood Haemoglobin
Blood group and Rh
Check urine for protein,sugar andbacteriuria using the dipstick test
Counsel for HIV testing (Provider Initiated Counselling and Testing) and syphilis testing.
Counsel and perform rapid test for syphilis, if positive you should treat her
Perform rapid test for HIV and conduct post-test counseling. Depending on the results of the test:
(i) if positive refer her for confirmatory test, (ii) if negative, counsel her for safe sexual behavior. If
she opts out, plan to counsel her at the next visit. (For details, see Section 9.2 Counselling for
HIV)
5.1.4 Assess for Referral

Check to see if the woman has any of the following conditions. If she does, follow the referral
procedures listed below.
Table 2: Conditions identified and corresponding actions

Condition Action
Diabetes mellitus Refer, she must have continued higher level

care
Heart disease Refer and continue management according
to severity and the advice of the specialist.
advice
Renal disease Refer and continue management according
tothe advice of the specialist.
Epilepsy Give advice on continued medication
Drug/substance abuse Refer for specialized care
Signs of severe anaemia and Hb <70 g/l Increase iron dose or refer if she has
shortness of breath
Primigravida Give advice on the benefits of institutional
delivery
Previous stillbirth Refer and continue according tothe advice of
the specialist.
Previous growth-retarded fetus (validated Refer to higher level of care and continue
IUGR) according to the advice of the specialist.
Hospital admission for eclampsia or pre- Refer and continue according to the advice of
eclampsia the specialist.
Previous caesarean section Stress for a hospital delivery
High blood pressure (>140/90 mm Hg) Refer for evaluation
MUAC Refer for nutritional evaluation if MUAC less

than or more than 23 cm. The cut-off point
23
Condition Action
may require local validation
5.1.5. Interventions
Iron and Folate supplement to all women
Give one tablet of 60 mg elemental iron and 250 micrograms folate one-two times per day. If
Hb<70 g/l: double the dose. Her haemoglobin should be determined only at 32 weeks (the third
visit)unless there are clinical signs that she has severe anaemia (pale complexion, fingernails,
conjunctiva, oral mucosa, tip of tongue, and shortness of breath).
Give the first injection of Tetanus toxoid.
Advise her on breast-feeding:
- to stop breast-feeding her previous child.
- when to begin breast-feeding her expected child.
Give advice on who she should call or where to go in case of bleeding, abdominal pain,
and any other emergency, or when in need of other advice. THIS SHOULD BE
CONFIRMED IN WRITING in the Maternal and Child Book.
Discuss about safe sex. Emphasize the risk of acquiring or transmitting HIV or STI's
without the use of condoms.
Advise her to stop using tobacco (both smoking and chewing), alcohol and other harmful
substances.
Sexual activity during pregnancy

In general, normal sexual activity can continue during pregnancy. Positions may vary as the fetus
grows and the abdomen enlarges. If sexual activity causes any discomfort to the woman it should
be discontinued.
Sexual activity is not recommended in certain circumstances:

- History of premature birth or labour
- History of miscarriage
- Vaginal bleeding or fluid discharge
- Placenta previa or low-lying placenta
- Incompetent cervix
Sexual intercourse should not take place if a woman doesnt want to for any reason. She should
not be afraid to speak with her husband/partner and say no. If a woman is at risk of getting STI
or HIV (husband/partner infected with or at risk of getting an STI or HIV) she should preferably
avoid sexual activity or use a condom to prevent herself and her fetus from getting infected.
24
5.1.7.Maintain Complete Records
Complete clinic records
Complete Maternal and Child Book. Give her the Maternal and Child Bookand advise her
to bring it with her to all appointments that she may have with any health services
5.1.8 Final Notes

All women, regardless of gestational age at first enrollment in ANC, should be examined
based on the guidelines of visit one.
Factors that could lead to complications should be identified and addressed during this
visit. Some examples are:
- strenuous workload
- poverty
- young age of mother
- women suffering from domestic or gender based violence
- women living alone
5.2 The Second FANC visit

The second FANC visit takes place at 24-28 weeks of pregnancy. The purpose of this visit is to
maintain communication as well as updating her records and monitoring her health status. In
general, follow the procedures already described for the first visit. In addition:
Address any complaints and concerns of the pregnant woman and her partner.
For first-time mothers and anyone with a history of hypertension orpre-
eclampsia/eclampsia), perform the dipstick test for protein in the urine. (Clinical Pathology
Module.)
Review and if necessary modify her individualised care plan.
Give advice on any sources of social or financial support that may be available in her
community.
5.2.1 History/Elicit Information

Obtain information on:
Present pregnancy
How she is feeling since her last visit and if there are any concerns or complaints.
Record symptoms and events since first visit: e.g. pain, bleeding, vaginal discharge (amniotic
fluid?), signs and symptoms of severe anaemia.
Personal history
Note any changes since first visit.
Medical history
Review relevant issues of medical history as recorded at first visit.
25
Note intercurrent diseases, injuries, or other conditions since the first visit.
Note intake of medicines, other than iron, folate.
Iron intake: check compliance.
Note other medical consultations, hospitalization or sick-leave in present pregnancy.
Obstetric history
Review relevant issues of obstetric history as recorded at first visit.
Other specific symptoms or events

Note abnormal changes in body features or physical capacity (e.g. peripheral swelling, shortness
of breath), observed by the woman herself, by her partner, or other family members.
Fetal movements: If fetal movements have been felt, note the time of first recognition in the
medical record.
Check-up on habits: smoking, alcohol, etc.
5.2.2 Perform physical examination

Note general condition
Note for symptoms of ill health or distress: shortness of breath, coughing, other symptoms.
Do a quick check of vital signs depending on general condition: (blood pressure, body
temperature, pulse rate, respiratory rate)
- Measure blood pressure

- Weigh her body weight
- Check for generalized oedema
Obstetric physical examination at each subsequent visit:

Monitor fetal growth and development by measuring uterine fundal height, record on graph.
Table 3: Estimated uterine fundal height
Gestational age Uterine Fundal Height
By Palpation By Tape Measure

Palpable above the pubic
12 weeks
symphysis
In between the pubic
16 weeks -
symphysis and umbilicus
At the umbilicus (20 2) cm
20 weeks
(Gestational age in weeks

22-27 weeks
2) cm
26
Gestational age Uterine Fundal Height
in between the umbilicus and

28 weeks (28 2) cm
the xiphoid process
(Gestational age in weeks
29-35 weeks
2) cm
At the xiphoid process (36 2) cm

36 weeks
Figure 1: Uterine height values by weeks of gestation

Belizan, J et al American Journal of Obstetrics and Gynaecology (1978)
Leopolds Maneuvers I-IV
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
27
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 through the fetal back. It is better to assess fetal heart beat
after determining 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.
28
Figure 2
(Adapted from Pocket Book of Maternal Health Care - Draft)
Speculum examination: perform only if not done at first examination.
5.2.3 Supporting investigations/tests

Urine: repeat multiple dipstick test to detect urinary-tract infection; if stillpositive after being treated
at the first visit, refer to hospital. Repeat proteinuria test only if woman is nulliparous or if she has
a history of hypertension, pre-eclampsia or eclampsia in a previous pregnancy. Note: all women
with hypertension in the present visit should have a urine test performed to detect for proteinuria.
Blood: repeat Hb only if Hb at first visit was below 70 g/1 or signs of severe anaemia are detected
on examination.
5.2.4 Assess for referral

Reassess whether the woman can still follow the basic component of the new WHO model, based
on evidence since the first visit and observations at the present visit.
29
Table 4: Symptoms and signs and corresponding actions (second visit)
Symptoms and Signs Action
Unexpected symptoms Refer
Bleeding, spotting Refer
Hb continuously below 7.0 Grams/dl Refer
Evidence of pre-eclampsia, hypertension, Refer
proteinuria
Suspicion of fetal growth retardation Arrange referral to hospital for evaluation.
Woman does not feel fetal movement Use hand-held doptone for detection of fetal
heart sound, if negative, refer to hospital
5.2.5 Interventions:
Iron: continue, all. If Hb is <70 g/l, increase dosage of Fe. If she has clinical symptoms of
anaemia, refer.
Urine Test
Repeat multiple dipstick test to detect urinary tract infection. If urine is still positive after
beingtreated at the first visit refer her to the hospital. Repeat proteinuria test only if she has a
history of hypertension or pre-eclampsia/eclampsia.
Repeat all the advice given at the first visit.
Encourage her to ask questions, give time for free communication.
Discuss breastfeeding.
Discuss post-partum family planning. (See Section 9.3 Postpartum and Early Newborn Care)
Give advice on whom to call or where to go in case of bleeding, abdominalpain or any other
emergency, or when in need of other advice. This should be confirmed in writing (e.g. on the
antenatal card), as at first visit. Discuss the choice of a companion for birth.
Give advice on any sources of social or financial support that may be available in her community.
Schedule the next appointment: third visit, at (or close to) 32 weeks.
5.2.7 Maintain complete records

Complete clinic record.
Complete Maternal and Child Book andgive it to the woman and advise her to bring it with her to
all appointmentsshe may have with any health services.
30
5.3 The Third FANC visit
The third FANC visit should take place around 3032 weeks of gestation. If for any reason she
missed her second visit, this visit should include all of the activities of the missed visit. This
appointment lasts about 20 minutes.
Direct special attention toward signs of multiple pregnancies and refer her if you suspect
there is more than one fetus.
Review the birth and emergency preparedness plan (discussed later in this study session).
Perform the dipstick test for protein in the urine for all pregnant women (since hypertensive
disorders of pregnancy are unpredictable and late pregnancy phenomena).
Decide on the need for referral based on your updated risk assessment.
Give advice on postpartum family planning.
Encourage the woman to consider exclusive breastfeeding for her baby.
You should also emphasise the importance of the first postpartum visit to ensure that the woman
is seen either at her home or at the Health Centre as soon as possible after the birth. The most
critical postnatal period for the mother is the first 4 hours; this is when most cases of postpartum
haemorrhage (PPH) occur. (Womens Health Module)

Present pregnancy
Symptoms and events since second visit: abdominal or back pain (preterm labour?),
bleeding, vaginal discharge (or amniotic fluid).
Other specific symptoms or events: Changes in body features or physical capacity,
observed by the woman herself, her husband or other family members.
Check if she notices fetal movements.
Personal history
Note any changes or events since second visit. Check-up on habits: smoking, alcohol, substance
use, taking traditional medicine or other practices.
Medical history
Review relevant issues of medical history as recorded at first and second visits.
Note intercurrent diseases, injuries or other conditions since second visit.
Note intake of medicines other than iron and folate and compliance with iron intake.
Note other medical consultations, hospitalization or sick-leave in present pregnancy.
Obstetric history
Review relevant issues of obstetric history as recorded at first visit and as
checked at second.
31
Note for symptoms of ill health or distress: shortness of breath, coughing, other
Measure blood pressure.

Uterine height values: record on graph.
Palpate abdomen for detection of multiple fetuses.
Fetal heart sounds: hand-held Doppler required only if no fetal movementsare seen, the woman
feels less fetal movement or if she requests it.
Check for generalized oedema.

If bleeding or spotting per vaginam: refer.
5.3.3 Supporting investigations/tests

Urine: repeat multiple dispstick test to detect urinary-tract infection; if stillpositive after being
treated at a previous visit, refer to special unit in the clinic or a hospital. Repeat proteinuria test
only if the woman is nulliparous or she has a history of hypertension, pre-eclampsia or eclampsia
in a previous pregnancy.
Blood: Hb check for all women.
All women with hypertension in the present visit should have urine test performed to detect for
proteinuria.

Reassess risk based on evidence since the second visit and observations made at present visit.
Table 5: Symptoms and signs and corresponding actions (third visit)

Unexpected symptoms, Refer
Bleeding Refer
Suspicion of fetal growth retardation(uterine Refer
height values below expected or indicative of
poor growth as evidenced by the chart curve)
32
proteinuria
Suspicion of twins Refer for confirmation and arrange delivery
BP more than 130 mm Hg Make new appointment not later than 36
weeks to check for fetal growth, BP,
proteinuria, If abnormality detected at new
appointment, refer.
5.3.5 Interventions:
Iron: continue for all women.
If Hb <70 g/l, refer or if clinical symptoms of anaemia: refer.
Tetanus toxoid: 2nd injection for all patients
5.3.6Counselling, questions and answers, and scheduling the next appointment

Repeat advice given at first and second visits.
Encourage her to ask questions, give time for free communication.
Review and if necessary modify her individualised care plan.Ask her if she is practising any
traditional practices and assess if these are helpful or harmful and discuss with her accordingly.
Provide counseling on breastfeeding and post-partum family planning and the importanceof the
postpartum visit(See Section 9.3 Postpartum and Early Newborn Care).
Give advice on measures to be taken in case of onset oflabour.

Reconfirm written information on whom to call and where to go in caseof emergency or any other
need. Discuss the choice of a companion for birth.
Make plans to ensure that transport is available in case of need during labour.
Schedule appointment: fourth visit, at (or close to) 38 weeks.

Complete the Maternal and Child Bookand give it to the woman and advise her to bring it with her
to all appointments she may have with any health services.
5.4 The Fourth FANC visit
The fourth FANC visit should be the final one for women in the basic component and should
occur between weeks 36-40 of gestation. This visit should be used to evaluate the progress of the
pregnancy and the prepare the woman for delivery.All the activities already described for the third
visit should be covered. In addition:
33
The abdominal examination should confirm fetal lie and presentation. At this visit, it is
extremely important thatif a woman with a baby in breech presentation or a transverse lie is
detected and if so, to refer her to the nearest health facility for obstetric evaluation.
The individualised birth plan (Box 1) should be reviewed to check that it covers all
aspects ofbirth and emergency preparedness/birth preparedness, complication readiness
and emergency planning, as described in Section 6.
Provide the woman with advice on signs of normal labour and pregnancy-related
emergencies and how to deal with them, including where she should go for assistance.
Box 1: Individualised birth plan
An individualised birth plan is a guide for healthcare providers developed in discussion with
the individual woman and her partner or main support persons which reflects their
preferences about the planned birth. The woman and her family should be encouraged to
have her delivery at the health centre or a district hospital. However, some couples may
choose to have their baby at home with a skilled birth attendant because they see birth as
a normal part of life.
Current Pregnancy
Ask for symptoms and events since the previous visit.
Note any changes since the third visit.
Note changes in body features or physical capacity, observed by the woman herself, her
husband, or other family members.
Note details about fetal movement.
Record symptoms and events since the third visit.
abdominal or back pain (preterm labour?)
bleeding or vaginal discharge (amniotic fluid?)
other specific symptoms or events
Personal information
Note any changes or events since the third visit.
Medical history
Review relevant issues of medical history as recorded at first three visits.
Note intercurrent diseases, injuries or other conditions since third visit.
Note intake of medicines other than iron and folate.
Iron intake: compliance.
34
Note other medical consultations, hospitalization or sick-leave in present pregnancy, since the
third visit.
Obstetric history
Review obstetric history relevant to any previous delivery complications.

Note for symptoms of ill health or distress: shortness of breath, coughing, other symptoms.
Measure blood pressure.

Uterine height values: record on graph.
Check for multiple fetuses.
Check fetal lie and presentation (head, breech or transverse).
Fetal heart sound(s): use hand-held Doppler only if no fetal movementsare seen, the woman feels
less fetal movement or if she requests it.
Check for generalized oedema.

If bleeding or spotting per vaginam: refer.
5.4.3Supporting investigations/tests:
Urine: repeat multiple dispstick test to detect urinary-tract infection; if still positive after being
treated at a previous visit, refer to hospital. Repeat proteinuria test only if the woman is
nulliparous or she has a history of hypertension, pre-eclampsia or eclampsia in a previous
pregnancy.

Reassess risk based on evidence since third visit and observations made at present visit.
Table 6: Symptoms and signs and corresponding actions (fourth visit)

Unexpected symptoms Refer
bleeding Refer
Suspicion of fetal growth retardation(uterine Refer
height values below expected)
proteinuria
Suspicion of twins Refer
35
CPD suspected Refer
Breech presentation suspected Refer to evaluate external cephalic version
Hospital delivery mandatory.
5.4.5 Interventions
Iron: continue iron.
BP more than 130 mm Hg- Make new appointment not later than 36 weeks to check for fetal
growth, BP, proteinuria, If abnormalities detected at new appointment, refer.
5.4.6Counselling, questions and answers, and scheduling the next appointment

Repeat the advice given at previous visits.
Encourage her to ask questions, give time for free communication. Ask her if she is practicing any

Provide counseling on breastfeeding and post-partum family planning and the importanceof the
postpartum visit(See Section 9.3 Postpartum and Early Newborn Care).
Give advice on measures to be taken in case of the initiation of labour or leakage of amniotic fluid.
Reconfirm written information on whom to call and where to go (place of delivery) in case of
labour or any other need.
Schedule the next appointment: if not delivered by end of week 41 (state date and write it in the
ANC card), go to hospital for check-upand possible induction of labour.
Schedule appointment for postpartum visit. Counsel on lactation and contraception.

Complete Mother and Childhandbookand give it to the woman.
36
Figure 3: New WHO antenatal care model basic component checklist
Note: Mark the activities carried out as appropriate (unshaded boxes). (Use the closest
gestational age at the time of visit.)
Name of patient_________________________ Address & telephone No.
Clinic record No. _________________________
Visits
FIRST VISITfor all women at first contact with clinics, regardless of 1st 2nd 3rd 4th
gestational age. If first visit later than recommended, carry out all <12
activities up to that time wks
DATE: /
/
Classifying form which indicates eligibility for the basic component of
the programme
Clinical examination
Clinically severe anaemia? Hb test
Ob. exam: gestational age estimation, uterine height
Gyn. exam (can be postponed until second visit)
Blood pressure taken
Maternal weight / height
Rapid syphilis test performed, detection of symptomatic STIs
Urine test (multiple dipstick) performed
Blood type and Rh requested
Tetanus toxoid given
Fe / Folic acid supplementation provided
Recommendation for emergencies / hotline for emergencies
Complete antenatal card
37
SECOND VISIT and SUBSEQUENT VISITS Gestational age approx. # of weeks
DATE: / / 26wks 32wks 38wks
Clinical examination for anaemia
Ob. exam: gestational age estimation, uterine height, fetal heart rate
Blood pressure taken
Maternal weight (only women with low weight at first visit)
Urine test for protein (only nulliparous women / women with previous
pre-eclampsia)
Fe / Folic acid supplementation given
Recommendation for emergencies
Complete antenatal card
THIRD VISIT: add to second visit DATE: / /
Haemoglobin test requested

Tetanus toxoid (second dose)
Instructions for delivery/plan for birth
Recommendations for lactation / contraception
FOURTH VISIT: add to second and third visits DATE: / /
Detection of breech presentation and referral for external cephalic

version
Complete ANC card, recommend that it be brought to hospital
Staff responsible for antenatal care: Name ___________________________________

Signature
___________________________________
38
6. Birth and emergency preparedness
6.1 The Three Delays

There are three types of delay, all of which can be serious for the mother and her baby:
Delay in healthcare-seeking behaviour (delay in deciding to seek medical care),
Delay in reaching a health facility
Delay in receiving appropriate and adequate care at the health facility
These delays have many causes, including logistical and financial constraints, and lack of
knowledge about maternal and newborn health issues. For example, the woman, her family or
neighbours may feel that only the husband or another respected family member can give
permission for the woman to deliver at a health facility or to get urgent medical care at a health
facility. This delay in making a critical decision could threaten her life and that of her baby.
Delays in deciding to seek care may be caused by failure to recognise symptoms of

complications, cost considerations, previous negative experiences with the healthcare system and
transportation difficulties. Delays in reaching care may be created by the distance from a womans
home to a facility or healthcare provider, the condition of roads, or a lack of emergency
transportation.
6.2 Birth and emergency preparedness

Birth and emergency preparedness (Birth preparedness, complication readiness and emergency
planning)
Birth preparedness is the process of planning for a normal birth. Complication readiness is
anticipating the actions needed in case of an emergency. Emergency planning is the process of
identifying and agreeing all the actions that need to take place quickly in the event of an
emergency, and that the details are understood by everyone involved, and the necessary
arrangements are made. normal birth preparedness.
Focused antenatal care includes attention to preparation for childbirth by the pregnant woman
and her family, such as selecting a birth location, identifying a skilled attendant and a companion
for birth, identifying someone to care for her other children if needed, planning for costs, planning
for transportation if needed, and preparing supplies for her care and the care ofher newborn.
Antenatal care visits also provide a crucial platform for influencing a woman to select a skilled
birth attendant for birth, whether in a facility or at home, and to establish a plan for normal birth as
well as an emergency plan, in case of complications. This emergency plan should include
transportation, money, blood donors, designation of a person to make decisions on the womans
behalf and a person to care for her family while she is away. It is estimated that 15% of all
pregnant women develop a life-threatening complication, and most of these complications
cannot be predicted, every woman and her family must be ready to respond in case a problem
39
occurs.
Educate the mother and her family to recognise the normal signs of labour. Delivery may occur
days or even weeks before or after the expected due date based on the date of the last normal
menstrual period. Knowing what labour means will help the mother know what will happen, and
this in turn helps her feel comfortable and assured during the last days or weeks of her
pregnancy.
Provide clear instructions on what to do when labour starts (e.g. in the event of cramping
abdominal pain or leaking of amniotic fluid). Make sure that the woman will understand that she
should go to the health centre or a hospital or call a skilled attendant for the birth as soon as
possible. Support verbal advice with written instructions in the local language.
Birth preparedness should also cover:

Respecting her choices. All the necessary information should be givenabout safe and
clean delivery, but ultimately a womans choice of where she wants to give birth and who
she wants to be with her needs to be respected.
Helping her to identify sources of support for her and her family during the birth and the
immediate postnatal period.
Planning for any additional costs associated with the birth.
Preparing supplies for her care and the care of her newborn baby.
Birthing supplies the mother should prepare

The birthing supplies that a pregnant woman and her family should be advised to prepare
before the delivery are listed below:
Very clean cloths to put under the mother and for drying and covering the newborn
New razor blade to cut the cord
Very clean and new string to tie the cord
Soap, a scrubbing brush and (if possible) medical alcohol for disinfection
Clean water for drinking and for washing the mother and your hands
Three large buckets or bowls
Supplies for making rehydration drinks
Flashlight if there is no electricity in the area.
Emergency/complication readiness and planning

Emergency/ complication readiness is the process of anticipating the actions needed in case of
an emergency and making an emergency plan. Pregnancy-related disorders such as high blood
pressure and bleeding can begin any time between visits for antenatal check-ups, and any other
illness may occur during the pregnancy. If such conditions are suspected at any stage, the
woman should be referred immediately and counselled to seek medical care quickly if danger
symptoms are seen.
40
Make sure the woman and her husband and other family members know where to seek help.
Making a referral
When a referral sending a client for additional health services and specialised care at a higher
level health facility, is made; complete a referral form in full and sign and date it, then make sure it
goes to the health facility with the patient; it also has a space for feedback to you by the health
facility about what treatment they have given.
If you do not have the standard referral form, you should write a note to the health facility that
contains the key information (Box). Contact the district hospital/higher level health facility if
possible.
Box 2: Referral note
Date of the referral and time

Name of the health facility you are sending the patient to
Name, date of birth, ID number (if known) and address of the patient
Relevant medical history of the patient
Your findings from physical examinations and tests
Your diagnosis
Any treatment you have given to the patient
Your reason for referring the patient
Your name, date and signature.
The following table summarizes the measures to be taken at each FANC visit.
41
Table 7: Focused antenatal care (ANC): The four-visit ANC model outlined in WHO clinical guidelines
Goals
First visit Second visit Third visit Fourth visit

12 weeks 24-26 weeks 32 weeks 36-38 weeks
Confirm pregnancy and EDD, Assess maternal and fetal Assess maternal and fetal Assess maternal and fetal well-
classify women for basic ANC well-being. Exclude PIH and well-being. Exclude PIH and being. Exclude PIH and
(four visits) or more anaemia. Give preventive anaemia. Give preventive anaemia. Give preventive
specialized care. Screen, measures.Review and measures. Review and measures. Review and modify
treat and give preventive modify birth and emergency modify birth and emergency birth and emergency plan.
measures. Develop a birth plan. Advise and counsel. plan. Advise and counsel. Advise and counsel.
and emergency plan. Advise
and counsel.
Activities
Rapid assessment and management for emergency signs, give appropriate treatment, and refer to hospital if needed
History (ask, Assess significant symptoms. Assess significant symptoms. Assess significant symptoms. Assess significant symptoms.
check records) Takeobstetric, medical and Check record for previous Check record for previous Check record for previous
social history. Confirm complications and treatments complications and treatments complications and treatments
pregnancy and calculate during the pregnancy. Re- during the pregnancy. Re- during the pregnancy. Re-
EDD. Classify all women (in classification if needed classification if needed classification if needed
some cases after test results)
42
First visit Second visit Third visit Fourth visit
12 weeks 24-26 weeks 32 weeks 36-38 weeks
Examination Complete general, and Anaemia, BP, fetal growth, Anaemia, BP, fetal growth, Anaemia, BP, fetal growth and
(look, listen, obstetric examination, BP and movements multiple pregnancy movements, multiple pregnancy,
feel) malpresentation
Screening Haemoglobin, Syphilis, HIV, Bacteriuria* Bacteriuria* Bacteriuria*

andTests Proteinuria, Blood/Rh group*
Bacteriuria*
Treatment Syphilis , Refer for Antihelminthic**, Refer for Refer for confirmatory HIV Refer for confirmatory HIV test &
confirmatory HIV test & ARV, confirmatory HIV test & ARV, test & ARV, Treat bacteriuria ARV. If breech, ECV or referral
Treat bacteriuria if indicated* Treat bacteriuria if indicated* if indicated* for ECV Treat bacteriuria if
indicated*
Preventive Tetanus toxoid Iron and Tetanus toxoid, Iron and Iron and folate Iron and folate
measures folate+ folate
Health Self-care, alcohol and Birth and emergency plan, Birth and emergency plan, Birth and emergency plan, infant
education, tobacco use, nutrition, safe reinforcement of previous infant feeding, feeding, postpartum/postnatal
advice, and sex, rest, sleeping under ITN, advice postpartum/postnatal care, care, pregnancy spacing,
counselling birth and emergency plan pregnancy spacing, reinforcement of previous advice
reinforcement of previous
advice
43
Record all findings on a home-based record and/or an ANC record and plan for follow-up
Acronyms: (EDD=estimated date of delivery; BP=blood pressure; PIH=pregnancy induced hypertension; ARV=antiretroviral drugs for HIV/AIDS; ECV= external
cephalic version; ITN=insecticide treated bednet)
*Additional intervention for use in referral centres but not recommended as routine for resource-limited settings ** Should not be given in first trimester, but if
first visit occurs after 16 weeks, it can be given at first visit+Should also be prescribed as treatment if anaemia is diagnosed
(adapted from Opportunities for Africas newborns)
44
7. The Postpartum and Postnatal Visit
The benefits of the new model of antenatal care can really be seen if it is part of a comprehensive
programme for the postnatal period which includes a postpartum visit. The visit should take place
within one week of delivery and include activities aimed at:
For the mother
Prevention of future unplanned pregnancies;
Support for breast-feeding;
Complete tetanus immunization for late attendants to ANC;
Folate supplementation for women with previous neuro-tubal defective infants
Continuation of iron supplementation for women who are anaemic, or with heavy blood
loss in labour;
Prevention of infection; and
Planning any continued postnatal surveillance, if required.
For the baby

Assessment of infants wellbeing and breastfeeding;
Detection of complications and responding to maternal concerns;
Information and counselling on home care; and
Advice on immunization schedule for the baby.
History/Elicit Information
Ask the mother:
How are you feeling?
Do you have enough time to rest?
Have you had any pain or fever or bleeding since delivery?
Do you have any problem with passing urine?
Have you decided on any contraception? (if immediate postpartum methods were not used)
How do your breasts feel?
Do you have any other concerns?
How is your baby?
Is he/she feeding well and sleeping?
Do you spend time to interact/stimulate and play with the baby?
Ask her about her diet, as she may not be eating meat, fish or vegetables due to traditional
beliefs
Ask her if she is observing any traditional practices, assess if these may be helpful or harmful.
Perform physical examination

Mother
Assess her general condition
Measure blood pressure and temperature
45
Check for pallor/anaemia
Examine her breasts
Feel the uterus. Is it hard and round? Look at vulva and perineum for:any tears, swelling, pus.
Look at pad for bleeding and lochia. Does it smell?Is it profuse?
No routine vaginal examination is recommended; it should only be conducted if there are clinical
indications.
Baby
Check the babys general condition and if he/she is alert and active (if not asleep).
Measure the babys weight
Conduct a breastfeeding assessment if the mother is willing
Assess the baby for danger signs
Interventions
Continue iron and folate supplementation
Complete tetanus immunization for late attendants to ANC
Counselling, questions and answers

Provide support for breast-feeding
Discuss postpartum contraception
Encourage her to ask questions, give time for free communication. Ask her if she is practising any
Complete records
Complete Mother and Childhandbookand give it to the woman.
Refer to 9.3 Postpartum and early newborn care.
8. Late Enrollment and Late Visits
It is likely that a good number of women will not initiate ANC early enough in her pregnancy to
follow the full basic components model.
These women, particularly those who starting after 32 weeks of gestation, should have in their
first visit all of the activities recommended for the previous visit(s), as well as those that
correspond to the present visit.A late first visit will take more time!
46
9. Special Recommendations
9.1 Twins
The woman could give a history of twins or higher order pregnancy in her obstetric history or a
similar history in her mother or sister. She may have experienced hyperemesis gravidarum in the
first trimester or have early-onset pre-eclampsia.
Uterine Height is the most likely measure to raise suspicion of a twin pregnancy. As soon as
twins (or higher order) are suspected the woman should be referred to a specialist, and should no
longer follow the basic ANC model. Provisions of care may be shared between the primary care
and referral centres.
Twin pregnancies pose a serious risk to both the mother and the child. Women who are carrying
twins are more likely to develop anaemia, pre-eclampsia, hyperemsis, and polyhydramnios, and
will experience more peripartum complications. When pregnancyadvances the patient will be
increasingly burdened by physical work. Sick-leave will relieve her of undue strain and should be
considered during the third trimester. Bed rest has not been shown to be beneficial.
Advice is crucial for woman caring twins. You should make contact with the obstetric unit of the
hospital to prepare for delivery. You should also have the woman prepare for adequate and
immediate transportation in case of labour or complications. Be sure to emphasize that birth is
likely to be preterm.
For details, refer to the Womens Health Module.
9.2 Spacing between Visits

Women should be encouragedto seek ANC as early as possible, because some tests and
interventions must begin early to be fully effective.
Timing and spacing between visits are decided based upon the WHO antenatal randomized
controlled trail. Pregnancy related disorders can begin at any time. It is considered that
asymptomatic disorders that occur between scheduled appointments will not cause harm that
could otherwise be alleviated. However, if she notices unexpected symptoms, she should be
advisedto seek care and 24-hour access to help and guidanceshould be guaranteed.
In case the patient needs help outside of the clinics hours of the health facility, give her and her
family the address and telephone numbers of alternate facilities.
47
9. Specific Issues During Antenatal Care
9.1 Counselling for Nutrition
Communication skills and counseling: the counseling process, guiding principles and the factors
that can influence the counseling process will be covered in the Community Medicine Module.
Details on maternal nutrition and newborn feeding will be covered in the Nutrition Module.
Each woman should be provided with information about balanced nutrition, ideal caloric intake
and weight gain. Food should be rich in fiber, nutrients and vitamins. There are five groups of
nutritional products that compose the food pyramid.
Table 8: Nutrition advice during pregnancy

Nutritional Products Advice during pregnancy
Rice, other cereals and potatoes Eat plenty, choosing wholegrain varieties if
possible.
Fruit and vegetables Eat a variety at least five portions/day.
Milk and dairy foods Eat or drink moderate amounts (and choose
low-fat versions whenever she can).
Meat, fish and alternatives (such as beans, Eat moderate amounts and choose lower fat
lentils, eggs, soya products) meat products whenever you can.
Foods and drinks containing high amounts of Eat foods containing high amounts of fat
fat and/or sugar sparingly (choose the low-fat alternatives).
Foods and drinks containing sugar should not
be taken too often as they can contribute to
tooth decay.
Eating well means eating a variety of foods to get all the right nutrients, especially during
pregnancy and breastfeeding, and eating enough food for good health.
Education about food is not enough on its own to change eating behaviour. Even if a woman
knows the best foods for health, she may not eat them. Many families cannot afford to buy
enough food or a wide variety of foods. Some women may simply not like the taste of some
healthy foods. To help a woman eat better, suggest healthy foods that she can afford and will
choose to eat.
Refer to 9.3.1 Nutrition Counselling under Postpartum care.
48
9.2 Counselling for HIV screening
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.
Test results which are negative
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: it 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 shehad refused to be tested, you will call her back and counsel her in a weeks time.
If she had tested positive for syphilis or HIV, refer her to the district level
Explain that:
49
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 her if she has any further questions or issues that she would like to discuss.
For Syphilis
Another test will be performed and a nurse will accompany her to the district hospital for this test.
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.
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 her if she has any further questions or issues that she
would like to discuss.
50
Individual Information Session
Provider-initiated Counselling
and Testing (PICT)
Agree Disagree
HIV negative HIV positive

Confirm by Counsel & offer
nd
2 test VCT at next visit
(district hosp)
Post-test counseling, Post-test counseling,

Information & Support Information & Support
Repeat HIV at/around 34 If positive Same day or at earliest
weeks convenience CD4 TB screen
Figure 4: HIV Rapid Test Algorithm
51
9.3 Postpartum and early newborn care
9.3.1 Care of the Mother

Advise on postpartum care and hygiene
Advise and explain to the woman:
To always have someone near her for the first 24 hours to respond to any change in her
condition.
Not to insert anything into the vagina.
To have enough rest and sleep.
The importance of washing to prevent infection of the mother and her baby: wash hands
before handling baby, wash perineum daily and after fecal excretion, change perineal
pads every 4 to 6 hours, or more frequently if heavy lochia, wash used pads or dispose of
them safely, wash the body daily.
To avoid sexual intercourse until the perineal wound heals.
Counsel on nutrition
Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish,
oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong
(give examples of types of food and how much to eat).
Reassure the mother that she can eat any normal foods these will not harm the
breastfeeding baby. Spend more time on nutrition counselling with very thin women and
adolescents.
Determine if there are important taboos about foods which are nutritionally healthy.Advise the
woman against these taboos. Talk to family members such as partner and mother-in-law, to
encourage them to help ensure thewoman eats enough and avoids hard physical work.
Breast Feeding
Counsel on the importance of exclusive breastfeeding
The mother has been counselledon the importance of exclusive breastfeeding during
pregnancyand this should be reinforced after birth. Include her husband or other family
members during the counseling session, if possible.
Explain to the mother that:breast milk
contains exactly the nutrients a baby needs,
is easily digested and efficiently used by the babys body, and
protects a baby against infection.
In addition, breastfeeding helps in the babys development and mother/baby attachment. It

can help delay a new pregnancy.
52
Babiesshouldstartbreastfeedingwithin1hourofbirth.Theyshouldnothaveanyotherfoodor drink
before they start to breastfeed. Babies should be exclusively breastfed for the first 6 months
of life with introduction of appropriate complementary food after that.
Demand feeding should be encouraged because of its benefits of less weight loss in the
immediate post-partum period and increased duration of breastfeeding subsequently.
Frequent feeding is associated with less hyperbilirubinaemia during the early neonatal period.
For mothers, demand feeding helps to prevent engorgement and breastfeeding is established
more easily.
Initiate breastfeeding within 1 hour of birth, when baby is ready

The mother should be informed that breastfeeding should be initiated within 1 hour, when
baby is ready and that help will be provided. After birth, let the baby rest comfortably on the
mothers chest in skin-to-skin contact. Tell the mother to help the baby to her breast when the
baby seems to be ready, usually within thefirsthour. Signs of readiness to breastfeed are:
baby looking around/moving mouth open searching.
Discuss with the mother and her family that there is no need to give the newborn baby
additional water or fluids or syrup or soft food.
Support for the breastfeeding mother

Checkthatpositionandattachmentarecorrectatthefirstfeed.Offertohelpthemotheratanytime. Let
the baby release the breast by her/himself; then offer the second breast.
If the baby does not feed in 6 hours, examine the baby.
If healthy, leave the baby with the mothertotrylater.Assessin3hours,orearlierifthebabyissmall.

If the mother is ill and unable to breastfeed, help her to express breast milk and feed the baby
bycup. On day 1 express in a spoon and feed by spoon.
If the mother cannot breastfeed at all, use one of the following options: donated heat-treated
breast milk. If not available, then use commercial infant formula.
Support exclusive breastfeeding

Keep the mother and baby together in bed or within easy reach. DO NOT separate them.
Encourage breastfeeding on demand, day and night, as long as the baby wants.A baby
needs to feed day and night, 8 or more times in 24 hours from birth. Only on the first day, a
full term baby may sleep many hours after a good feed.
53
A small baby should be encouraged to feed, day and night, at least 8 times in 24 hours from
birth. Help the mother whenever she wants, and especially if she is a first time or adolescent
mother. Let the baby release the breast by him/herself, then offer the second breast. If the
mother must be absent, let her express breast milk and let somebody else feed the
expressed breast milk to the baby by cup.
DO NOT force the baby to take the breast.
DO NOT interrupt feed before baby stops him/herself.
DO NOT give any other feeds or water.
DO NOT use artificial teats or pacifiers.
Ensure that the mother eats nutritious food and has enough to drink.
Ensure that the mother can wash or shower daily, but tell her to avoid washing or wiping her
nipples before breastfeeding.
Advise the mother on medication and breastfeeding

Most medications given to the mother in the normal postpartum period are safe and the baby
can be breastfed.If the mother is taking cotrimoxazole or Fansidar, monitor the baby for
jaundice.
Advise and demonstrate the mother how to breastfeed

Teach correct positioning and attachment for breastfeeding.
Show the mother how to hold her baby.
She should:
- make sure the babys head and body are in a straight line and the babys abdomen is turned
toward the mother
- make sure the baby is facing the breast, the babys nose is opposite her nipple
- hold the babys body close to her body
- support the babys whole body, not just the neck and shoulders.
- The baby is brought to the nipple height.
Show the mother how to help her baby to attach.

She should:
- touch her babys lips with her nipple
- wait until her babys mouth is opened wide
- move her baby quickly onto her breast, aiming the infants lower lip well below the nipple.
Look for signs of good attachment:

- nippleandareolaaredrawnintothebabys mouth rather than only the nipple into the mouth
- moreofareolavisibleabovethebaby'smouth
- mouth wide open
54
- lower lip turned outwards
- baby's chin touching breast
Look for signs of effective suckling

- the baby takes slow, deep sucks, sometimes pausing
- you may hear swallowing
If the baby stops suckling, stimulate by touching the cheek.
If the attachment or suckling is not satisfactory, try again. Then reassess.
Mother comfort
The mother does not complain of, or appear tohave, nipple/breast pain during the breastfeed.
If she feels pain, she can insert a clean finger into the babys mouth and get the baby to
release the attachment. Then restart feeding.
Finishing the breast feed

- the baby should release the breast her/himself rather than being pulled from the breast.
- breasts are softer at the end of the feed compared to full and firm at thebeginning.
- the newborn baby looks sleepy and satisfied atthe end of a feed.
If there is breast engorgement, express a small amount of breast milk before starting
breastfeeding to soften nipple area so that it is easier for the baby to attach.
Burp the baby at the end of the feed and observe the baby for 15 minutes to ensure there is
no regurgitation.
A - Correct Attachment B - Incorrect Attachment
(Managing Newborn Problems, WHO 2003)
55
Check List for demonstration of breastfeeding
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 Yes No
Positioning 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.
Holding The mother maysupporttheweightofher breast with her
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.
Attachment Nippleandareolaaredrawnintothebabys mouth rather than

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.
You may hear swallowing.
Mother Mother does not complain of, or appear tohave,
comfort nipple/breast pain during the breastfeed.
Finishing the The newborn should release the breast her/himself rather
breast feed 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
56
Birth Spacing and Family Planning
Counsel on Birth Spacing and Family Planning
If appropriate, askthe woman 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.
The choice of a contraceptive method and when to start a method after delivery will depend on
whether the mother is breastfeeding.
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 the woman 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.
Method options for the non-breastfeeding woman

Can be used immediately postpartum
Condoms
Progestogen-only oral contraceptives: Progestogen-only injectables Implant
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (immediately following expulsion of placenta or within 48 hours)
57
Delay 3 weeks
Combined oral contraceptives
Combined injectables
Fertility awareness methods
(Refer to Womens Health Module for Contraception).
Advise on when to return

Routine postpartum care visits
First Visit - Within the first week
Second Visit - preferably within 2-3 days 4-6weeks
Advise on danger signs

Advise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any
of the following signs:
vaginal bleeding: more than 2 or 3 pads soaked in 20-30 minutes after delivery OR bleeding
increases rather than decreases after delivery.
convulsions.
fast or difficult breathing.
fever and too weak to get out of bed.
severe abdominal pain.
Go to the health centre/district hospital as soon as possible if there is any of the following signs:
fever
abdominal pain
feels ill
breasts swollen, red or tender breasts, or sore nipple
urine dribbling or pain on micturition
pain in the perineum or draining pus, foul-smelling lochia
Discuss how to prepare for an emergency in postpartum

Advise to always have someone near for at least 24 hours after delivery to respond to any
change in condition.
Discuss with the woman and her husband and family about emergency issues: where to
go if there are danger signs, how to reach the hospital, costs involved and family and
community support.
Advise the woman to ask for help from the community, if needed.
Advise the woman to bring her maternal record to the health facility, even for an
emergency visit.
58
Sexual Relations and Safer Sex
Based on the womans history and any other relevant findings or discussion, individualize the
following key messages:
- Awomanshouldavoidhavingsexualintercourseforatleast2weeksafterbirthor until:
There is no longer any lochia rubra or serosa, and
The lochia alba has diminished or ceased.
- Afterthat,thewomancandecidewhensheisreadytoresumesexualrelations.
- Healingof episiotomy/tears and type/amount of lochia may influence her level of comfort with
intercourse. Intercourse should be avoided, however, if she experiences:
Vaginal bleeding
Perineal pain
A woman is more susceptible to sexually transmitted infectionssuch as HIV, syphilis, gonorrhea,

or chlamydiaduring the postpartum period while the reproductive tract is still healing and
returning to its prepregnancy condition.
PracticingsafersexcanreducetheriskofHIVandothersexuallytransmittedinfections(STIs):
- AbstinenceormutuallymonogamoussexwithapartnerwhoisfreefromHIVorSTIsistheonly sure
protection.
- Consistentuseofcondomsisimportant,evenduringlactational amenorrhea.
Sexualpracticesthatmayfurtherincreaseriskofinfection(suchasanalsex,drysex,etc.)should be
avoided.
Insomnia
This is a common occurrence during the first week postpartum. The mother may have fear of
sleeping through newborns cry or need for her or discomfort caused by perineal trauma
Suggest that the woman s husband/family:

Ensure that the woman has time for rest and sleep.
Share some of the responsibilities of newborn care (e.g. the husband can listen for the baby
during the night).
9.3.2 Care of Newborn

Refer to the Paediatrics Module for additional details on Newborn Care.
Care and Monitoring

Thermal protection
Ensure the room is warm
Ensure the room is warm (not less than 25 degrees C and no draught). Keep the baby in the room
59
with the mother, in her bed or within easy reach. Let the mother and baby sleep under a bednet.
Support exclusive breastfeeding on demand day and night. Assess breastfeeding in every baby
before planning for discharge. DO NOT discharge if baby is not yet feeding well. If she is at home,
ask the mother to seek advice from the midwife or breastfeeding support group if she experiences
difficulty in breastfeeding.
Keep the baby warm

At Birth and within the first hour(S)
Warm delivery room: for the birth of the baby the room temperature should be 25-28
degrees C, there should be no draught.
Dry baby: immediately after birth, place the baby on the mothers abdomen or on a warm,
clean and dry surface. Dry the whole body and hair thoroughly, with a dry cloth.
Skin-to-skin contact: Leave the baby on the mothers abdomen (before cord cut) or chest
(after cord cut) after birth for at least 2 hours. Cover the baby with a soft dry cloth.
If the mother cannot keep the baby skin-to-skin because of complications, wrap the baby
in a clean, dry, warm cloth and place in a cot. Cover with a blanket.
Subsequently (First Day)

Explain to the mother that keeping the baby warm is important for the baby to remain
healthy.
Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the first few
days, especially if baby is small.
Ensure the baby is dressed or wrapped and covered with a blanket.
Keep the baby within easy reach of the mother. Do not separate them (rooming-in).
If the mother and baby must be separated, ensure baby is dressed or wrapped and
covered with a blanket.
Assess warmth every 4 hours by touching the babys feet: if feet are cold use skin-to-skin
contact, add extra blanket and reassess.
Keep the room for the mother and baby warm. If the room is not warm enough, always
cover the baby with a blanket and/or use skin-to-skin contact.
At Home
Explain to the mother that babies need one more layer of clothes than other children or
adults.
Keep the room or part of the room warm, especially in a cold climate.
During the day, dress or wrap the baby.
At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding.
Do not put the baby on any cold or wet surface.Do not bathe the baby at birth. Wait at
least 6 hours before bathing. Do not swaddle wrap too tightly. Swaddling makes them
cold. Do not leave the baby in direct sun.
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Infection prevention: general hygiene, hand washing, cord care
Inform the mother that infection prevention is an important part of care of a newborn baby.
Newborn babies are more susceptible to infections because their immune system is still
developing. Observing the infection prevention practices below will protect the baby and mother
from infections. They also will help prevent the spread of infections.
Consider every person (including the baby and family members) as potentially infectious.
Limit the number of different individuals handling the baby.
Ensure that the mother knows correct positioning and attachment for breastfeeding to prevent
mastitis and nipple damage.
Prevention of Infection/Hygiene
Based on the mothers/babys history and any other relevant findings or discussion, individualize
the following key messages:
In general, the mother, father, and other people should wash their hands before touching or
caring for the baby. Wash both hands with soap and water (or use an alcohol-based handrub)
before and after handling the baby.
They should also wash their hands after cleaning the baby or changing her/his diaper/napkin.
Whenthebabysdiaper/napkinissoiled/wet,thefollowingactions should immediately be carried out:

- Removethediaper/napkinandproperlydisposeofitinabucket,plasticbag,orothercontainerthat can
be closed.
- Washthebabysbottom,fromthegroin/genitals toward the buttocks.
- Drythebabysbottom,fromthegroin/genitals toward the buttocks.
Untilthecordfallsoff,placethecordoutsidethediaper/napkintopreventcontamination with urine and

feces.
Put no lotions, powders, or other products on the babys skin.
Put a clean diaper/napkin on the baby.
The mother shouldcare for her own baby as much as possible.

Sharingofbabyequipmentandsupplieswithotherbabies and children should be avoided.
Sickchildrenandadultsshouldbekeptawayfromthebabybecause of the risk of cross-infection.
Thebabyshouldbeprotectedfromsmoke,which can result in respiratory problems.
The mother shouldremainvigilantforsignsofinfectionandothernewborndangersigns.Ifanyofthese
signs are seen, she should immediately enact the complication readiness plan.
61
Hygiene (washing, bathing)
At Birth:
Only remove blood or meconium. DO NOT remove vernix.
DO NOT bathe the baby until at least 6 hours of age.
Later and at Home:

Wash the face, neck, underarms daily. Wash the buttocks when soiled. Dry thoroughly. Bathe
when necessary:
Ensure the room is warm, no draught
Use warm water for bathing
Thoroughly dry the baby, dress and cover after bath.
Cord care
Wash hands before and after cord care. Put nothing on the stump. Fold nappy (diaper) below
stump. Keep cord stump loosely covered with clean clothes. If stump is soiled, wash it with clean
water and soap. Dry it thoroughly with clean cloth.
If the umbilicus is red or draining pus or blood, examine the baby and manage accordingly.
Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood.
DO NOT bandage the stump or abdomen. DO NOT apply any substances or medicine to stump.
Avoid touching the stump unnecessarily.
Sleeping
Use the bednet day and night for a sleeping baby. Let the baby sleep on her/his back or on the
side. Keep the baby away from smoke or people smoking. Keep the baby, especially a small
baby, away from sick children or adults.
Immunization
Discuss and advise on immunization according to the national guidelines (BCG, HepB, OPV-0).
Danger Signs in The Newborn Period

- Breathing difficulty
- Convulsions, spasms, loss of consciousness, or arching of the back (opisthotonus)
- Cyanosis (blue lips and nails)
- Hot to touch/fever
- Cold to touch
- Bleedingfrom umbilicus, bottom and mouth
- Jaundice (yellow skin and eyes)
- Pallor
- Diarrhea (passing loose/watery stools >3 times per day)
- Persistent vomiting or abdominal distention
62
- Not feeding or poor suckling (feeding difficulties)
- Pus or redness of the umbilicus, eyes, or skin
- Swollen limb or joint
- Floppiness
- Lethargy (looking weak with poor feeding)
- Stools- not onlyloose stools but also stools mixed with blood, pale colouredstools, having dark
stools for more than a few days, delayed passage of stools (not passing meconium after 24
hours)
Discuss how to prepare for an emergency in the newborn

Discuss with woman and her husband and family about emergency issues: where to go if
danger signs how to reach the hospital.
Advise the woman to ask for help from the community, if needed.
Advise the woman to bring her maternal and delivery record and Mother and Child
booklet to the health facility.
9.4 Pre-pregnancy counselling

To have better pregnancy outcome many health care providers recommend that a woman who is
only thinking about getting pregnant should has a pre-pregnancy/preconception visit and
counseling to reduce the risk of certain problems during her pregnancy. The goals of
preconception care are to identify and treat the conditions that can affect a future pregnancy and
to provide a woman and her husband with information that can help them to make timely informed
decisions about future pregnancies.
Pre-pregnancy counseling should include identification of preconception risks and provision of

education based on identified risks through assessment of:
Family history- Diabetes mellitus, congenital abnormalities/birth defects
Medical history- Diabetes mellitus,thyroid disorders,asthma,heart disease,chronic
hypertension,deep venous thrombosis,kidney disease,epilepsy
Current medication use
Obstetrical and gynecological history -uterine or cervical abnormalities, two or more repeated first
trimester spontaneous abortions, unsafe abortions, fetal, neonatal or infant deaths, preterm
deliveries, low-births infants, infants with birth defect(s).
Risk factors for STIs
Nutrition
Assessment of socioeconomic, educational and cultural context
Family planning and birth spacing
Substance use (smoking, alcohol, drugs)
Pre-pregnancy counseling by a specialist is recommended where specific risks and diseases are
63
identified, e.g. control of diabetes mellitus, hypertension.Advice and support should be given on
healthy life styles including diet and exercise.
All women, from the moment they begin trying to conceive until 12 weeks of gestation, should
take a folic acid supplement. Women who have had a fetus diagnosed with a neural tube defect
(NTD) or have had a baby with a NTD should receive information on the risk of recurrence and be
advised on the protective effect of periconceptual folic acid supplementation. The woman and her
husband should be referred to a specialist.
9.5 Minor Disorders in Pregnancy

Hormonal and physiological changes and increased weight-bearing during pregnancy lead to
minor symptoms or disorders of pregnancy. While they are usually mild and self-limiting, some
women may experience severe symptoms which can affect their ability to cope with daily activities.
The following is a list of minor disorders in pregnancy, the details are given in the Womens
Health Module.
Gastro-intestinal symptoms:
- nausea and vomiting (morning sickness)
- gastro-oesophageal reflux (heartburn)
- constipation
Musculo-skeletal
- backache and sciatica
- carpel tunnel syndrome
- symphisis pubis dysfunction
- varicose veins
- haemorrhoids
Genito-urinary
- vaginal discharge
- urinary symptoms
- itching and rashes
Other common symptoms
- breast enlargement and pain
- mild breathlessness on exertion
- tiredness
- insomnia
- stretch marks
- labile moods
- calf cramps
64
10. Conclusion
While undertaking the FANC module, the trainee will

Become competent in takingan obstetric history and performing an obstetric examination,
Improve clinical problem-solving skills,
Enhance communication skills, and
Adapt clinical approach to women/couples from different social and cultural backgrounds
and ethnic groups.
The essential elements of Focused antenatal care (FANC) are summarized below:
1. Focused antenatal care (FANC) segregates pregnant women into those eligible to receive
routine ANC (the basic component) and those who need specialized care for specific
health conditions or risk factors.
2. FANC emphasizes targeted and individualized care planning and birth planning.
3. FANC makes the pregnant woman, with her husband and the family, participatory in
identifying pregnancy related or unrelated complications, planning and decision-making
on the future course of pregnancy.
4. Until proved otherwise, no pregnancy is to be labelled as risk-free.
5. A pregnant woman has four antenatal visits, each with specific objectives to promote
FANC the health of the mother and the fetus, assess risks, and give early detection of
complications.
6. The four visits allow an opportunity for building rapport between the woman and the
health care provider and establishing contact between the woman (and her family) and
the health facility.
th
7. The first FANC visit should be before the 16 week of pregnancy; it assesses the womans
obstetric,medical and social history. Based on the history, physical examination and test
results, her eligibility to follow the basic component can be decided.
8. The second FANC visit is at 24-28 weeks. The additional focus is on measuring blood
pressure and fundal height to determine gestational age.
9. The third FANC visit is at 3032 weeks. The additional focus is on detecting multiple
pregnancies.
10. The fourth is the final FANC visit between weeks 36 and 40. The additional focus is on
detecting breech presentation and transverse fetal lie, and signs of hypertensive
disorders. Pay extra attention to informing women about birth and
emergencypreparedness, complication readiness and emergency planning.
11. Complication readiness and emergency planning anticipates and prepares for the actions
needed in case of an emergency, including organizing transport, money, support persons
and blood donors, and reducing sources of delay in getting to the higher level health
facility.
65
12. A referral note with all relevant details of the history, diagnosis and treatment should be
given to women who need to be referred at any stage during the pregnancy or when
labour begins.
13. During FANC particular attention will be paid to counseling women on having a facility
delivery, post-partum and newborn care (breastfeeding and post-partum family planning).
Provider initiated counseling and testing for syphilis and HIV will be stressed.
66
11. 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
nd
Oxford Handbook of Obstetrics and Gynaecology (2008) 2 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
67

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Antenatal Care Module

2. Modules related to the Antenatal Care Module ................................................... 5

3. Care in pregnancy .......................................................................................................... 6

4. Focused antenatal care................................................................................................. 7

5. The Basic Component of Focused Antenatal Care ............................................ 17

6. Birth and emergency preparedness ..................................................................... 39

7. The Postpartum and Postnatal Visit ..................................................................... 45

8. Late Enrollment and Late Visits ............................................................................. 46

9. Special Recommendations ....................................................................................... 47

9. Specific Issues During Antenatal Care ................................................................. 48

11. References ................................................................................................................... 67

2. Modules related to the Antenatal Care Module

3.1 Elements of care in pregnancy

The essential elements of care in pregnancy are as follows:

4. Focused antenatal care

4.1. Focused antenatal care: concepts and principles

Underlying Principles of Provision of Care

Inclusive of a womans husband or other family member: Respect for thehousehold

4.2 Goals of Focused Antenatal care

Targeted assessment based on the womans individual situation to ensure normal

Individualized care to help maintain normal progress, including preventive measures,

Table 1: Basic differences between traditional and focused antenatal care.

Characteristics Traditional antenatal care Focused antenatal care

4 for women categorised in the basic

Integrated with PMTCT of HIV,

More frequentvisits for all and

Relies on routine risk indicators,

Shared responsibility for birth and

Communication One-way communication (health Two-way communication

education) with pregnant women (counselling) with pregnant women

Leads to complacency by the health

4.4 Evidence-based FANC

The following interventions have been recommended:

Health Promotion and Disease Prevention

Reduction of iron deficiency anemia through nutritional counseling and iron/folate

In areas of detrimental conditions, diseases or nutritional deficiencies, the following services

Counselling is covered in detail in the Community Medicine Module.

4.7 Classifying Form

Basic component of ANC

Figure 1: Focused Antenatal care model (WHO, 2001)

Criteria for classifying women in the basic component of ANC model

Name of patient: Clinic record number:

1. Previous stillbirth or neonatal loss?

2. History of 3 or more consecutive spontaneous abortions?

3. Birthweight of last baby < 2500g?

4. Birthweight of last baby > 4500g?

5. Last pregnancy: hospital admission for hypertension or pre-eclampsia/eclampsia?

6. Previous surgery on reproductive tract?

CURRENT PREGNANCY No Yes

7. Diagnosed or suspected multiple pregnancy?

8. Age less than 16 years?

9. Age more than 40 years?

10. Isoimmunization Rh (-) in current or in previous pregnancy?

11. Vaginal bleeding?

12. Pelvic mass?

13. Diastolic blood pressure 90mm Hg or more at booking?

GENERAL MEDICAL No Yes

14. Insulin-dependent diabetes mellitus?

15. Renal disease?

16. Cardiac disease?

17. Known 'substance' abuse (including heavy alcohol drinking)?

18. Any other severe medical disease or condition?

Is the woman eligible? (circle) NO YES