ANTENATAL CARE.pptx

Better PowerPoint

1. ANTENATAL CARE MAJOR E TEMBO

2. OBJECTIVES General objectives Understand the management of pregnancy Specific objectives Define terms used. Outline the aims of antenatal care. Discuss the components of Focused Antenatal care.

3. MANAGEMENT OF PREGNANCY INTRODUCTION Management of pregnancy, also called antenatal care is the care given to a pregnant woman from the time of conception to beginning of labour.

4. INTRO CONT, Appropriate management would reduce the maternal mortality rate which is currently at 298/100 000 live births. To achieve this, the Ministry of Healthy promotes an updated approach to antenatal care that emphasizes quality over quantity of visits called Focused Antenatal Care.

5. INTRO CONT’ Focused Antenatal C are, has four main objectives which include: Early detection, treatment and referral of abnormalities . D isease prevention and ensure safe delivery Birth and complication preparedness and Health (IEC) promotion of pregnant women ( MoH , 2004).

6. DEFINITION OF CONCEPTS Antenatal Booking (first visit): This is the first visit a pregnant woman makes to the clinic to seek medical advice. This visit should take place as soon as the woman notices that she is pregnant. Revisit: These are subsequent or follow-up visits that the woman will make after Booking for her pregnancy.

7. To receive maximum benefits from antenatal visits, it is desirable that the woman receives at least four (4) visits spread out the entire pregnancy (Now called antenatal contacts-minimum 8 contacts or visits): . Depending on the individual needs, a woman may require additional visits. At each visit, ask about her wellbeing and that of her family. Discuss individual birth plan, do observations.

8. Do abdominal examination. From 34 weeks, the size, Lie, position and Presentation of the fetus is cardinal. Pelvic assessment should be done. Also do a Pelvic Ultrasound scan to determine these aspects. Do a repeat of Hb , RPR and take appropriate action. IEC according to needs identified. IEC on labour also to be given.

9. 3. Focused Antenatal Care (Now called antenatal contacts-minimum 8 contacts or visits): This is an updated approach to ANC where a woman has frequent routine visits that are standard and a woman is classified according to their risk of complications to determine the level of care they should receive. It emphasizes the quality of visits over quantity of visits.

10. 4. Antenatal care -refers to the care that is given to a pregnant woman from the time that conception is confirmed until the beginning of labour (Fraser & Cooper, 2003 ). Ante means before and Natal means Birth: Hence antenatal care means the care given to a pregnant woman before delivery or before birth of baby.

11. SCHEDULES OF VISITS First visit at or before or by 16 weeks (by the end of four months) Second visit at 24-28 weeks (5-7 month) Third visits at 32-34 weeks (8 months) Fourth visit at 36-40 weeks (9 months) ( MoH , 2004). NOTE: Now a pregnant woman can make an average of 8 contacts/visits/appointments to the clinic (normal pregnancy). Nulliporous =10 maximum, parous =7 maximum depending on the prenancy findings.

12. Activities that are considered at each visit First visit (before or by 16 weeks). -History taking. -counselling for HIV, -Health education on what the clinic or hospital offers, investigations done, the activities e.g comprehensive history taking, full physical examination (long palpation), observations, birth preparedness, danger signs.

13. -Screen and treat for anaemia , malaria, syphilis in pregnancy, malaria in pregnancy, nutrition in pregnancy. -Order for Pelvic Ultra sound Scan to determine Gestational Age (G/A), Expected Date of Delivery (EDD), Placental location , Viability of fetus . Any anomaly, if interested, Sex of baby.

14. -Give TT (if did not finish 5 doses), Fansida first dose (SP1) only if quickening has occurred. Also give Ferrous sulphate and Folic acid. -Establish LMP and EDD. -Full and thorough Physical examination is done (Head to Toe) i.e Long Palpation. -Give appropriate next visit.

15. ACTIVITIES cont’ S econd visits (24-28 weeks). Review what occurred on the first visit (assess and continue treatment started on first visit). Reinforce birth plan, ensuring if the woman has received: fansidar , iron supplement, deworming (if did not get on first visit) medication and tetanus toxoid. IEC e.g on importance of ANC, minor disorders of pregnant, nutrition, hygiene.

16. ACTIVITIES cont’ Second visit cont’ Women reminded on the importance of rest, danger signs, delivery, and postnatal care whether HIV and syphilis test were done. Any side effects from the drugs being taken.

17. -If Pelvic Ultra sound Scan was not done on the first visit, order to determine Gestetional Age (G/A), Expected Date of Delivery (EDD), Placental location, Any anomaly, if interested, Sex of baby. A quick Physical examination is done (Short Palpation). Give appropriate next appointment.

18. Third Visit (32-34 weeks). -Provide client with information on stage of pregnancy. -Screen for Anaemia (repeat FBC for Hb and other blood indices), also do second test for syphilis. Review with client danger signs of pregnancy.

19. -Remind client of baby and mother layette. Give fansida 3, feso4, f/acid. -Order for Pelvic Ultra sound Scan to determine the Lie, Position, Presentation and Attitude of fetus. Fetus should be cephalic. Also to assess the volume of liquor amni to rule out Polyhydramnious , Viability of fetus, Any anomaly e.g cord around the fetal neck .

20. -Give IEC on true signs of labor. -A quick Physical examination is done (Short Palpation). -Give appropriate next appointment.

21. ACTIVITIES cont’ Fourth visit (36-40 weeks). - Review of child birth, screen for anaemia, infant feeding, postnatal care and family planning and physical examination is done. -Give IEC on true signs of labour. Review date now should be in line with EDD. At least 2 weeks after EDD. Fetal head should engage by 36 weeks in G1. If not could be a case of CPD.

22. COMPONENTS OF FOCUSED ANTENATAL CARE Early detection of complications and prompt treatment: Thorough history taking, physical examination and investigation.

23. Disease prevention : Thorough IEC, after quickening, give Intermittent Presumptive Treatment with Fansidar against malaria, deworming with vermox .

24. immunization against Tetanus provision of ferrous sulphate and folic acid to prevent anaemia and mebendazole to prevent worm infestation.  

25. COMPONENTS OF FOCUSED ANTENATAL CARE... cont’ Birth preparedness and complication readiness: achieved through provision of information. Health promotion : This is achieved through discussing various health topics.

26. 1. HISTORY TAKING The history provides information that will help the medical provider ( Midwife, Nurse Military Medical Assistant or D octor), target the Physical examination and testing as well as individualize her plan of care. The History will include the following:

27. Social history Personal medical history Family medical history Surgical history Past obstetric history Present obstetric history

28. Social History Name- for identification and rapport. Age- women who are 18 – 35 years have the fewest problems in giving birth. Very young women below 18 years and older primigravida are at increased risk and maternal and perinatal mortality and morbidity due to complications such anaemia , obstructed labour etc.

29. Adolescent women may have lack of access to basic healthy care and ANC services, lack of support system, resources etc. Address/phone number- this information can be used to contact the mother. Also for follow-up. Marital status- singleness may present an added risk mostly because the family abandons them. This leads to stress.

30. Occupation (of self and partner)- knowing these details can help to understand the woman economically for financial support and also to rule out other factors, like, exposure to radiation that may affect both the mother and the baby. Religion- to identify any religious beliefs that could be detrimental to health thereby giving council to the woman.

31. Habits- e.g smoking, drinking alcohol or the use of potentially harmful substances. This information helps to individualize care and giving of IEC . Alcohol as a fact, predisposes her to malnourishment, and accidental falling due to alcohol intoxication .

32. Cultural taboos- e.g avoidance of certain nutritious foods like eggs. Educate the mother that eggs are necessary and gives both the mother and unborn child the proteins required for growth and replacement of body tissues.

33. Next of king- helps to identify the kind of support she is getting . Also for easy contact in case of an emergency. Education levels - to assess the level of understanding. Hobbies- as some of them do not promote rest, like sports

34. Social habits- if she smokes cigarettes, as it predisposes her to respiratory tract infections and placental insufficiency leading to small for dates babies. Also ask about type of accommodation, water supply, type of toilet, refuse disposal etc.

35. b. Family Medical History Is useful in identifying conditions such as cardiac disease, diabetes mellitus, asthma, hypertension, epilepsy, psychosis, pulmonary tuberculosis contact and multiple pregnancies.

36. These conditions tend to run in families and they make pregnant women prone to them if present in the family. It can also help the midwife to act timely in case of problems.

37. c. Personal Medical H istory The woman is asked about her health. Some medical conditions such as Hypertension, malaria, urinary tract infections, heart diseases, asthma, anaemia, epilepsy, diabetes mellitus, mental illness and sickle cell disease are ruled out.

38. These conditions tend to recur in pregnancy and complicate pregnancy while some can be complicated or be exaggerated by pregnancy causing permanent damage to the vital organs of the body.

39. Women with chronic illnesses may require services beyond the scope of basic care. The woman is asked about previous hospitalization and for any child hood illnesses, to rule out condition that can affect pregnancy. Ask the woman if she is taking any drugs like Anti retro viral, antihypertensive, anti Diabetics, Anti Epileptics or anti malarial.

40. Some drugs are not supposed to be taken in pregnancy because of teratogenic effects hence need to change for example if a diabetic woman is on Suphonylureas e.g Daonil , substitute and give or prescribe Insulin for her until after delivery.

41. Medication history is very important because it will help a midwife give appropriate health education on the need to continue taking the drugs or discontinue, for some dugs may be toxic to the pregnancy, or there may be need to modify the dosage.

42. Dietary habits History about the type of food she likes, number of meals per day and eating of non foods, like soil, so that appropriate health education on good dietary habits can be given .

43. d. Surgical History History about any injury or operation involving the pelvic bones, spine or the lower limbs is obtained to rule out alteration of the pelvic diameters and angle of inclination leading to cephalo - pelvic disproportion.

44. History of operation involving the lower abdomen especially the uterus is taken to exclude the possibility of uterine rupture during pregnancy or labour

45. Major abdominal operation that could lead to adhesions is also ruled out. History is obtained about blood transfusion to rule out the possibility of iso -immunization if the mother is rhesus negative and also to rule out the possibility of HIV infection.

46. e. Past Obstetric History History about the number of previous pregnancies, children and their health status, year of birth, health during pregnancy, duration of labour , weight of the babies at birth, whether the children were alive or dead. If dead, find out the cause of death and at what age.

47. Type and duration of feeding is inquired. Past history on childbearing helps to predict the likely outcome of the current pregnancy, in addition discussion of the past complications provides an opportunity to emphasize the importance of having a birth and complication readiness plan.

48. f . Present Obstetric H istory Obtain history of her first day of the last normal menstrual period, age at menarche, type of the cycle duration and the flow of her menses. Find out about the contraceptive method used, when and why it was stopped.

49. Present Obstetric History This history can assist the provider in calculating the gestational age of the pregnancy as well as the estimation (expected) of the date of delivery (EDD) and help the care provider give appropriate health education to the woman and family in terms of preparation for labour and delivery.

50. Present Obstetric History Calculation of Estimated or Expected Date of Delivery (EDD) by Using the Naegele’s Rule Find out when she last had her normal menstrual period and calculate the expected date of delivery as follows:- Add 7 days to the date Add 9 months to the month e.g If her LNMP was 10.03.2020 Add 7 to 10 and you will have 17

51. Present Obstetric History Calculation of Estimated or Expected Date of Delivery (EDD) by Using the Naegele’s Rule - contd Then add 9 to the month and you will have 12 So your EDD will be 17.12.2020. Now always consider + (plus) or – (minus) 14 days to your calculated EDD. Meaning the client can deliver 14 days before this Due date or 14 days after the Due date but still consider it to be within normal range. The client should not worry.

52. Another example to calculate EDD (Estimated or Expected date of Delivery). LMP was 27. 9. 20. Calculation: 27 . 9 +7 9 34 18 Since September ends with 30 days hence subtract 30 from 34 = 4 and a year has 12 months hence subtract 12 from 18 = 6 Now on the days we went past the month of September into October by 4 days hence add 1 month to the months therefore our EDD = 04. 07 . 2021.

53. Calculation of Gestation age (Age of pregnancy) by-date. LNMP 10.11,2020. Date of Visitation to clinic for antenatal is 28. 01. 2021 Calculation is as follows:- Month number of days weeks days November 20 2 6 December 31 4 3 January 28 4 =10 =9 Gestation Age =11 weeks, 2 days By Date.

54. Calculation of Gestation age (Age of pregnancy) by-date - cont’d When you add all the days you will have 9 days. Divide by 7 to turn them into weeks you will have 1 week 2 days Add this week to the number of weeks which is 10 weeks you will have 11 weeks 2 days So the gestational age today the 28 th January for this woman is 11weeks 2 days

55. OTHER METHODS TO CALCULATE DUE DATES AND GESTATION CALENDAR METHOD: Take the first day of the last normal menstrual period and count backwards by three (3) months, then add 7 days e.g if her LMP (bleeding) started on the 06. 05. 20. count back 3/12 ( i.e April 6, March 6 and February 6). Then add 7 days (February 6+ 7 days = February 13 is her due date i.e 13. 02. 21. NOTE: Remember also the Naegele’s rule where you add 7 days to the days and 9 to the months……to calculate EDD

56. OTHER METHODS TO CALCULATE DUE DATES AND GESTATION 2. Gestational Wheel: This is a special wheel which has three columns indicating the Month (outer column), Days of each month (middle column) and Age of pregnancy in weeks (inner most column). The Wheel has two arrows or pointers i.e the first one indicates the First day of LMP and further, the second pointer indicates the Full term of pregnancy at 40 weeks.

57. OTHER METHODS TO CALCULATE DUE DATES AND GESTATION 3. Using Tape Measure (McDonald’s Rule): The measurement is called Symphysio -Height. This is because the measurement is taken by placing the zero line of the tape measure on the superior border of the symphysis pubis and then the tape is stretched across the contour of the abdomen to the top of the fundus ( from Symphysis pubis to the fundus hence the term Symphysio -height). The tape is only used when pregnancy or height of fundus is above the ambilicus ( 22 cm or 22 weeks and above).

58. OTHER METHODS TO CALCULATE DUE DATES AND GESTATION 4. Finger breadth or width: Each finger i.e fingerbreadth (the three middle fingers) each finger is equal to 2 cm or 2 weeks. Finger breadth is only used when the pregnancy or height of fundus is 22 cm or 22 weeks and above. With the woman lying flat on the couch or bed, the measurement is always taken from the middle of the fundus to the top of the fundus hence the measurement is called Height of Fundus (HOF). Counting starts from the middle of the umbilicus which is 22cm until to the top of fundus.

59. OTHER METHODS TO CALCULATE DUE DATES AND GESTATION 5. Use of Landmarks (Bartholomew’s Rule): This method is only used in two instances to determine age of pregnancy when: -the LMP is not known or -when height of fundus is below the umbilicus. NOTE: Never use tape measure or fingerbreadth to estimate age of pregnancy when HOF is below the Umbilicus!!!!!!! Just let the woman lie on the couch or bed and use your eyes and Landmarks to estimate the age of pregnancy.

60. Inquire about her health during pregnancy and any problems, such as fatigue, drowsiness, and headache, loss of appetite, nausea, vomiting, oedema and blurred vision. Ask the woman about social support and record the main support such as husband and mother in law. Ask about availability of money for food, transportation, and baby layette and supplies (Sellers, 2009).

61. Current problems Obtain history on current problems before obtaining the whole history such as;Vaginal bleeding , Severe headache or visual changes, Shortness of breath, Fever, Draining of liquor If any of these danger signs are present, then the client should receive special attention. After history taking then conduct Physical examination.

62. 2. PHYSICAL EXAMINATION After thorough History taking, a full Physical Examination is conducted. Physical examination helps the attendant to identify special needs, abnormal signs and other potential problems as well as areas where the client is doing fine.

63. They also provide information to consider when giving health messages and counselling. A thorough physical examination is performed during the first visit and in subsequent visits, a shorter or rather a more targeted examination may be sufficient depending on the woman’s needs, unless otherwise.

64. Objectives of examination To screen the woman for any existing abnormalities or high risk factors. To have a baseline data for follow up visits. Types General examination Specific examination

65. General examination a. OBSERVATIONS Vital signs, Weight- as baseline. Total weight gain is 12.5kg. In the first 20weeks its about 2.5kg . Last 20 weeks its 10kg. In the last 20weeks, weight gain is about 0.5kg per week.

66. Height- If less than 150cm and shoe size of less than 4. Woman’s movement, gait, facial expressions and general cleanliness, Stature.

67. Specific examination b. Head to Toe examination General Appearance. Head : Texture of the hair, colour and distribution of hair to rule out malnutrition and other chronic illnesses. The general hygienic status of the hair is also assessed for appropriate individual education. The scalp is also assessed for rush and nits to rule out infections and Pediculi infestations.

68. Eyes: Check for abnormalities like discharges to rule out infection, yellow pigmentation of sclera which may indicate jaundice, pale conjunctiva which may indicate anaemia , oedema of the eyelids and surrounding areas may indicate hypertensive disorder such as pre-eclampsia and renal condition.

69. Nose: It is assess for blockage, discharges, bleeding, growths or polyps . Mouth: Examined for signs of anaemia on the lips, mucus membranes of the mouth, gums and the tongue. Fissures on the tongue, oral thrush or sores may indicate lowered immunity due to other medical condition such as HIV if present.

70. Dental status: Check for dental carries, if present give appropriate education. Ears : They are examined for any discharge, growths and enlargement of peri -auricular lymph nodes which may indicate infection.

71. Glands: Palpate for lymphadenopathy behind the ears, under the jaw (submandibular), cervical glands around the neck and thyroid gland. Lymphadenopathy suggests infection, chronic illness or may be due to the effect of oestrogen on the glands.

72. Neck: Enlargement of the cervical and submandibular lymphnodes . Enlargement of the thyroid gland. Upper limbs: Examine the hands for hygiene, signs of anaemia on the palms, poor venous return on pressure of the nail bed and examine for signs of knuckle oedema by asking the woman to make a fist

73. A feeling of tightness in the knuckles when undoing the fist in absence of pitting oedema would suggest occult oedema . At times tightness of the wedding ring will also suggest occult oedema . Symmetry: The disability of the upper limbs is also assessed. It has no obstetric importance but it would affect the mother during breast feeding or care of the baby.

74. Breast examination- It comprises of inspection and palpation of the breast: Inspection- is done to note differences in shape and size, skin dimpling, sores and rash of both breast to rule out infection and breast cancer.

75. The signs of pregnancy are also observed such as Montgomery’s tubercles at 12weeks and darkening of the primary and the secondary areola at 8 and 16weeks respectively. Inspection for orange peel appearance may be indicative of the breast cancer .

76. Nipples are also inspected for flatness, depression or inversion which may cause challenges in breast feeding. Therefore appropriate intervention should be done for instance pulling of the nipples.

77. Palpation - Lumps or tenderness are noted to rule out infection and cancer of the breasts. The findings are explained and what needs to be done. Assess the axillary lymph nodes for enlargement. The woman is also taught how to perform a self breast examination.

78. Abdominal examination The abdominal examination determines the relationship between the foetus and the uterus and the pelvis. Aims of abdominal examinations To confirm pregnancy. To assess presentation and the lie of the foetus . To assess the foetal well being .

79. The abdominal examination is divided into 4 parts: Inspection, HOF or Symhysio -height, palpation and auscultation Inspection On inspection the size of the abdomen in relation to the gestation age and shape of the abdomen is noted to ascertain the lie of the foetus . An ovoid shaped abdomen denotes a longitudinal lie while a wider than its length shape abdomen indicates a transverse lie. Abdominal scars involving the operation to the uterus are noted to rule out risk of uterine rupture and adhesion. Signs of pregnancy such as darkening of linear nigra , presence of striae gravidarum and foetal movements are noted. Foetal movements are positive signs of pregnancy .

80. HEIGHT OF FUNDUS OR SYMPHYSIO-HEIGHT If using finger breadth, the pregnant abdomen is measured from the center of the abdomen hence the name HOF. But if using the tape measure, the pregnant abdomen is measured from the Symphysis pubis hence the name Symphysio -height (SOH). On the other hand if pregnancy is below the umbilicus use the land marks.

81. Palpation Palpation uses the landmarks on the symphysis pubis, umbilicus and the xiphisternum . Palpation comprises of fundal, lateral and pelvic palpation. The presence of uterine contractions indicates labour .

82. Height of fundus(HOF): This is done to estimate the period of gestation by measuring the height of the abdomen by using finger widths in 2 nd and 3 rd trimester. It is done to assess the height of fundus in relation to the gestation of the pregnancy.

83. Number of centimeters should be approximately equal to the number of weeks of gestation after 22 nd -24 th weeks gestation. 1 finger= 2 weeks/ 2 centimeters after 22 weeks. Palpation has four aspects: fundal, two lateral and pelvic palpation. Fundal palpation, noting size, shape, consistence and mobility of what is in the fundus.

84. Lateral palpation is done to determine where the back is, which helps in determine the Lie and position of fetus after 26 weeks of gestation. Pelvic palpation is done to determine presentation and engagement (3 rd trimester). Lastly you do auscultation (late 2 nd and 3 rd trimester). This is done to assess fetal wellbeing by using fetal scope or Doppler.

85. Normal fetal heart is 120-160bpm or new World Health Organization Guideline is 110 to 180 bpm. The fetal heart sounds are heard at their maximum or loudest at the point over the fetal back. They sound like a tickling watch under the pillow.

86. Before the 12th week of pregnancy the uterus remains a pelvic organ. After this period of gestation the fundus can be palpated above the symphysis pubis. From 12-20weeks gestation the fundus rises two finger’s breadth every 2 weeks. After 20 weeks the fundus rises about one finger’s breadth every 2 weeks (Sellers, 2009).

87. Approximate height of fundus at various weeks of pregnancy. THE LAND MARKS (Bartholomew’s Rule). 12 weeks : just above the symphysis 16 weeks: half-way between the upper border of the symphysis pubis and the lower border of the umbilicus. Quickening or foetal movements can now be felt by the

88. mother. The Uterine soufflé, the sound of the maternal blood coursing through the large uterine vessels can be heard on auscultation. 20 weeks: At the lower border of the umbilicus. The foetal parts and foetal movements can be felt on palpation. 22 weeks: At the centre of the umbilicus 24 weeks: At the upper border of the umbilicus 30 weeks: half-way between the upper border of the umbilicus and the lower border of the xiphisternum . 36 weeks: the lower border of the xiphisternum . 38 weeks to the onset of labour :

89. This time the uterine ligaments and the pelvic viscera become more vascular and soften. The cervix ripens and there is partial effacement of the cervical canal, causing the presenting part to descend and may even pass through the pelvic brim into pelvic cavity. This will then cause the height of fundus to drop about 2 finger’s breadth and to reduce to the level of about 32-34weeks.This is known as lightening. It usually takes place in the primegravida but may occur in the multigravida with tight abdominal muscles (Seller, 2009 ).

90. Using a tape (McDonald’s method), the height of fundus is also measured then the duration of gestation in weeks should correspond to cms with a maximum difference of 2 weeks/ cms . Fundal palpation: Palpate shape, size, consistency and mobility. The foetal breech will feel irregular, larger or bulkier than the head and is not well outlined or readily moved or balloted

91. If it’s the head presenting, it feels round and hard and can be balloted between the hands or the thumb and finger of one hand. Palpate for the shape, size, consistency and mobility of the foetal head. Lateral palpation is done to determine the position of the back and the limbs of the foetus . The foetal back feels like a firm, curved, continuous smooth mass extending from the breech to the neck

92. The front will have feet, hands, knees and the elbows felt as being small, knobby and irregular and mobile on pressure. Pelvic palpation -determines the part of the foetus that is presenting at the pelvic brim. If it’s the head presenting, it feels round and hard and can be balloted between the hands or the thumb and finger of one hand. Palpating for the shape, size, consistency and mobility of the foetal head helps to rule out cephalo pelvic disproportion.

93. It can also determine if the head has descended into the maternal pelvis. This is calculated in fifths of the foetal head above the pelvic brim. From 36 weeks lightening takes place due to softening of the cervix. Engagement of the foetal head is also determined to rule out cephalo pelvic disproportion, this usually occurs in prime gravidae while in multiparous women engagement occurs when in labour .

94. Auscultation: Foetal heart sounds are assessed for foetal viability .This is done from the side where the foetal back was felt. The normal ranges between 120 -160 beats per minute or the new according to WHO is 110 to 180bpm. The foetal heart beat must be regular and of good volume.

95. Lower limbs – Inspect the symmetry of the limbs. The shoe size if less than four may indicate a small pelvis. The soles and the feet are inspected for pallor to rule out anaemia. Calf's are palpated to rule out deep vein thrombosis.

96. Tibial and pedal oedema is assessed by applying pressure. The woman is asked if she experiences the oedema which disappears in the morning after a good rest.

97. This will help to rule out the oedema associated with raised blood pressure and proteinuria, which is pathological. If the oedema is coupled with proteinuria, the woman should be refered to the Obstetrician for further examination and management.

98. The Vulva On Inspection: warts, sores, oedema , varicose veins, abnormal discharge etc. Anal region Check for haemorrhoids and fissures, fistulae, rectocele etc

99. The Back Ask the woman to lie on her left side. Check for the curvature, lordosis, scoliosis, kyphosis, sacral oedema . PROBLEMS IDENTIFIED From history taking, physical examination and observations.

100. PLAN OF ACTION To do investigations To give medication To give IEC To refer client to the hospital etc.

101. INVESTIGATIONS DONE -RPR -FBC -Grouping and cross-match -HIV testing. Done after counselling.

102. MEDICATION GIVEN e.g -Ferrous sulphate and rationale - Fansida and rationale - Folic acid and rationale - Mebendazole and rationale - Septrin and rationale

103. IEC given : This should be individualized to the woman’s needs at each visit and will depend on the woman’s medical, surgical , obstetric history and any other concern. Health messages and counselling should include guidance on the following topics: Birth plan/preparedness, hygiene, nutrition, medication, use of ITN, danger signs, minor disorders, signs of labour, exclusive breast feeding, family planning etc. Review date.

104. INVESTIGATIONS Haemoglobin level estimation is done to rule out anaemia at booking and repeated at 28-32 weeks when the physiological effects of haemodilution are marked. Normal values are 10.5g/dl to 16g/dl (Fraser et al, 2006).

105. INVESTIGATIONS cont’ Urinalysis is done to rule out urinary tract infections, diabetes mellitus and hypertensive disorders such as pre- eclampsia . Test for HIV infection. Rapid Plasma Reagin (RPR) is also done to rule out syphilis. Rhesus factor is also done

106. MEDICATION The following medication may be given: Fansida 1 is given at 16 weeks or when quickening has occurred, then after 1 month give SP2, and 3 rd SP to be given 1 month after SP2 to prevent malaria (IPT). Ferrous sulphate 200mg od and folic acid 5mg od will be given to boost the haemoglobin levels. Dose for Feso4 can be increased if Hb is less than 10.5g/dl.

107. Tetanus toxoid to prevent the mother and the baby from tetanus. Mebendazole 500mg p.o start is given together with SP1 (after quickening) to prevent worm infestation and malaria.

108. MEDICATION cont’ In HIV positive women the following regime is given: A woman who is HIV positive, regardless of the CD4 count, is started on Option B+. If the CD4 is below 350cells/mm3 the woman will also receive Septrin until the CD4 is above 350cells/mm3.

109. BIRTH PREPAREDNESS AND COMPLICATION READINESS It allows for time to develop a birth plan which includes making arrangements for normal childbirth, such as: Skilled provider to attend the birth. Place of birth Transportation of the pregnant woman to the skilled provider.

110. BIRTH PREPAREDNESS AND COMPLICATION READINESS Funds Support person or birth companion. Items needed for a clean and safe birth and for the newborn.

111. DANGER SIGNS IN PREGNANCY Vaginal bleeding Severe headache Fever Severe abdominal pains Reduced and caesation of foetal movements. Discharge or sores on the private part, Fatigue and pallor.

112. HEALTH PROMOTION AND COUNSELLING Information on the following topics is discussed: Importance of subsequent antenatal visits. Preparing a birth plan. Common (minor) disorders of pregnancy. Recognizing danger signs in pregnancy and during childbirth.

113. HEALTH PROMOTION cont’ Mother –To Child –Transmission of HIV Nutrition during pregnancy Exercise and rest Childbirth Infant nutrition including breastfeeding and replacement feeding Postnatal care

114. Newborn care (according to individual needs) Immunization and other preventive measures from conditions that can adversely affect the women and newborn. Prevention malaria using insecticide treated mosquitoes nets and Intermittent preventive treatment (IPT) of malaria. Personal hygiene . Family planning HEALTH PROMOTION cont ’

115. COUNSELLING Techniques for successful breastfeeding (according to individual need). Counselling on HIV and other sexually transmitted diseases is done and the use of condoms for disease prevention is done. Availability of testing services and their benefits and specific issues related to mother-to-child transmission and living with HIV (after a positive test result) is also explained.

116. ACTIVITIES DURING ANTENATAL VISIT ORIENTATION: Orient mothers on the activities of the clinic or hospital in terms of services offered e.g delivery services, theatre, blood transfusion days of antenatal Booking and revisits etc. HEALTH EDUCATION: Educate mothers on importance of antenatal clinic, birth preparedness, minor disorders of pregnancy, danger signs during pregnancy, complications during pregnancy, nutrition, hygiene & infection prevention, medication, signs of labour , mother & baby layette etc GROUP AND INDIVIDUAL COUNSELLING: Do a group counselling on HIV/AIDS and finally conduct an individual or couple counselling and observe privacy and confidentiality. Educate that this test is mandatory.

117. ACTIVITIES DURING ANTENATAL VISIT 4. INVESTIGATIONS : Do Blood pressure, height, weight, history taking, physical examination, malaria test, syphilis test (Rapid Plasma Reagen ), Full bood count, Blood group and Rhesus factor, gravidex , pelvic ultrasound scan, HIV test and if HIV positive do CD4 and CD8 count, viral load, Creatinine, Liver function tests, urea and electrolytes etc. 5. HISTORY TAKING: Conduct thorough history on First visit (Booking) and a confirmatory on the subsequent visits. Collect Social, medical ( personal & family), Surgical, Present Obstetrical and Past Obstetrical history 6. PHYSICAL EXAMINATION: Do a full physical examination on the first (Booking) visit and a Short Palpation on the subsequent visits. Do Head to Toe examination. 7. DRUGS AND OTHER SUPPLEMENTS: Give prophylactic medication against malaria and worm infestation as required or guided. Give haematinics as well. Prescribe and give antibiotics if having any bacterial infection. if HIV positive commence or continue with ARV’s.

118. Conclusion Quality management of pregnancy is essential to pregnant women as it ensures early detection and management of complications, disease prevention, birth preparedness and complication readiness and health promotion.

119. Conclusion. Antenatal services should be available and acceptable to all mothers regardless of status in society. It is therefore important to encourage women to seek professional health care as soon as they are pregnant to ensure good health.

120. REFERENCE Central Statistical Office (CSO) Zambia and Macro international Inc (2009) Zambia Demographic and Health Survey (ZDHS) Key Findings (2007), Lusaka, Zambia. Fraser M.D, Cooper M.A and Nolte A.G.W (2006) Myles Text book for midwives, African edition, Elsevier. Philadelphia.  

121. References cont’ Fraser M.D and Cooper M.A (2003) Myles Text book for midwives , 14 edition, Elsevier, Philadelphia. Ministry of Health, Integrated prevention of Mother-to-Child Transmission of HIV (2010) National protocol Guide lines, Lusaka Zambia.  Ministry of Health, Introduction to Focused Antenatal Care (2004) Lusaka, Zambia.

122. REFERENCE cont’ Sellers P.M (2010) Midwifery volume 1 , 12 th impression, Juta and Co limited, Lansdowne.