Focus antenatal care

The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation

1. ANTENATAL RISK ASSESSMENT TOOLS BY HAJ. SHAFA’ATU UMAR FOCUS ANTENATAL CARE:

2. Introduction All pregnancies and deliveries are potentially at risk. However, there are certain categories of pregnancies where the mother, the fetus or the neonate is in a state of increased jeopardy . Early identification and management of the risks associated with pregnancy is essential to providing optimal treatment to pregnant women.

3. FOCUS ANTENATAL CARE This model developed in 2002 was a goal-oriented approach to delivering evidence-based interventions at four critical times during pregnancy. This approach achieved an increase in ANC in low-and middle-income countries (LMICs ). This 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 and was reviewed in 2016

4. FOCUS ANTENATAL CARE…, It emphasizes contact rather than visit and recommends a total of 8-contacts instead of current 4-visits and the provision of quality care at each contact.

5. FOCUS ANTENATAL CARE FANC (4 visits) 1st visit around 12 weeks or anytime feels she is pregnant 2nd visit between 24-28 weeks 3rd visit at 32 weeks 4th visit at 36 weeks W.H.O.2016 ANC MODEL (8visits) 1 visit in the 1st trimester (up to 12 weeks of gestation), 2 visits in the second trimester (at 20 and 26 weeks of gestation) 5 visits in the third trimester (at 30, 34, 36, 38 and 40 weeks)

6. ANTENATAL RISK ASSESSMENT is an assessment carried out on all pregnant women at each antenatal visit using It is done to know the general status of a pregnant woman at present . Risk assessment is done to identify the risks and manage it.

7. Identification and management

8. Anaemia Commonest medical disorder in pregnancy. 18-20 pregnant women are anaemic in developed countries as compared to 40-75% in developing countries. It is responsible for significant high maternal and fetal mortality rate worldwide

9. definition ANAEMIA: generally refers to as reduction in the number of circulating blood cells and haemoglobin level resulting in to reduction of oxygen carrying capacity of the blood. ANAEMIA IN PREGNANCY: The WHO and American college of Obstetricians and Gynecologist define anaemia in pregnancy as follows: 1 st trimester: Hb <11g/dl 2 nd trimester: Hb <10.5g/dl 3 rd trimester: Hb <11g/dl However, most of the physician begin a work up of anaemia in pregnancy until Hb is less than 10g/gl.

10. CAUSES Decrease erythropoiesis Excessive destruction of red blood cell Haemorrhage Severe hookworm infestation Deficiency of iron, vitamin B12, folic acid necessary for production

11. RISK FACTORS FOR ANAEMIA IN PREGNANCY Multiple pregnancy Excessive vomiting during pregnancy Teenage pregnancy Previous anaemia in pregnancy No child spacing Lack of iron in diet NOTE: the most common cause of anaemia in pregnancy is as a result of Iron deficiency Folate deficient Which is occur in one third of pregnant woman during the 3 rd trimester.

12. CLASSIFICATION Physiological Anemia Pathological Anemia Iron deficiency Folic acid deficiency Vitamin B12 deficiency Hemorrhagic Anemia Acute—following bleeding in early months of pregnancy or APH Chronic—hookworm infestation, bleeding piles, etc. Hemolytic anemia Familial—congenital jaundice, sickel cell anemia, etc. Acquired—malaria , severe infection, etc Bone marrow insufficiency hypoplasia or aplasia due to radiation, drugs or severe infection. Hemoglobinopathies Abnormal structure of one of the globin chains of the hemoglobin molecule of globin chains of the hemoglobin molecule ex- sickle cell disease

13. SIGNS AND SYPTOMS Weakness/tiredness Dizziness Breathlessness and mild exertion Pedal oedema ( swelling of legs) Prominent neck vein in severe anaemia Pallor of conjunctiva, gum, tongue, nail beds, and or palms and soles of the feet Hepatomegaly Splenomegaly

14. DIAGNOSIS Screening of patient for anaemia Ask and listen: ask if she eats non nutritive foods and not pica If her pregnancy has been closely spaced If she bruises easily If she had haemorrhage with any pregnancy Social and dietary history taking including date of last menstrual period

15. DIAGNOSIS CON’T Physical examination- examine the conjunctiva, tongue, lips, palms of the hand nail beds and sole of the feet for pallor Blood specimen is obtained for sickling cells, malaria parasites, haemoglobin if 8gms or below. Estimation of the packed cell volume of blood (PCV). Stool examination for ova of worms and parasites especially for hook worm.

16. EFFECTS OF ANEMIA ON THE MOTHER Reduced resistance to infection caused by impaired cell-mediated immunity Increase risk of post partum haemorrhage Predisposition to PIH and preterm labor due to associated malnutrition Worsen existing maternal condition

17. EFFECTS TO FETUS Intrauterine hypoxia and growth retardation Prematurity Low Birth Weight Increased risk of perinatal morbidity and mortality

18. DEGREES OF ANAEMIA Mild Moderate and Severe.

19. MANAGEMENT  Avoidance of frequent childbirths Supplementary iron therapy Dietary advice Adequate treatments to eradicate illnesses likely to cause anemia Early detection of falling hemoglobin level

20. MILD ANAEMIA The haemoglobin level is below 10.4 -11.9gm/dl i.e. above 8.1g/dl MANAGEMENT: She is better manage as outpatient Dietary advice is given on source of iron e.g increased consumption of dark green vegetables e.g ugu vegetable, intake of food rich in protein, and vitamin Iron supplement e.g ferrous sulphate tablet 200mg tds plus folic acid tablet 5mg daily . Treatment of malaria and worm infestation if identified during investigation of blood and stool.

21. MODERATE ANAEMIA This is when the haemoglobin estimate is or below 8.1gm/dl (i.e. between 7g/dl to 8.1g/dl) MANAGEMENT Double doses of iron supplement of ferrous sulphate 4 00mg t.d.s . , folic acid 5mg daily throughout pregnancy is given. Advice on food rich in iron, protein and vitamin c (use of locally and affordable foods). Treat malaria and worm infestation (if present after investigation). Check haemoglobin at every visit for the rest of the pregnancy.

22. SEVERE ANAEMIA This is when the haemoglobin level is 6g/dl or below Haematocrit 20% or less There is : increased incidence of preterm labour, fetal distress, low birth weight and increased risk of perinatal mortality

23. NURSING MANAGEMENT OF SEVERE ANAEMIA Admit for rest if HB is less than 6g/dl Start an iv infusion using a large bore canular or needle Infuse normal saline or Ringers lactate at the rate of 1L over 8hours Avoid given sedative Refer urgently for transfusion (if not in the hospital ).

24. NURSING MANAGEMENT OF SEVERE ANAEMIA Prop patient up in bed to allow for easy breathing and prevent congestion of the lungs Monitor maternal and fetal heart closely Check temperature 4hourly pulse and fetal heart rate half hourly Monitor intake and output charts Record any abnormal variation

25. NURSING MANAGEMENT CON’T Give high protein diet rich in green vegetables and vitamin c. Give fresh fruits and nourishing drinks to augument the diet. Treat for hookworm, if in endemic area give mebendazole. Provide iron (120mg) and folate (400mcg) by mouth daily for 6month.

26. PREVENTION OF ANAEMIA IN PREGNANCY Identification of risk factors for heamorrhage and managing them appropriate. Use of iron supplement for all pregnant woman throughout pregnancy Identification and treatment of malaria and worm infestation Prophylactic treatment and worm infestation

27. PREVENTION OF ANAEMIA IN PREGNANCY…, Check for other signs of infection or diseases Check haemoglobin Emphasize on sleeping under treated net to prevent malaria Advice on child spacing after delivery Educate on nutrition i.e diet rich in iron, folate and vitamin c and to avoid food that decrease iron absorption e.g coffee

28. MANAGEMENT DURING LABOR 1st stage Special precautions Comfortable position on bed Light analgesia Oxygenation to increase oxygenation of maternal blood and prevent fetal hypoxia Strict asepsis 2nd stage Usually no problem. 10iu of oxytocin IM given Give 20 iu oxytocin in D/S 500ml .

29. MANAGEMENT DURING LABOR…, 3rd stage Intensive observation. blood loss must be replaced by fresh pack cell and amount must not exceed loss amount to avoid overloading Puerperium Bed rest Sign of infection detected and treated. Pre delivery iron therapy must be continued until patient restores. Diet Patient and family members must be counseled for help at home regarding baby care and household chores

30. FOLLOW UP Recheck haemoglobin 48hours after transfusion. Advice on nutrition. Continue iron therapy if still pale. Explain the important of keeping ante natal appointment. ADVICE ON DISCHARGE Advise on diet rich in iron, protein and vitamins. Advice on use of iron supplements to augument diet. Educate on taking iron drugs after meals with fruit juices or vitamin c to enhance absorption. Remind her on family planning. Advice her on keeping aseptic techniques in order to avoid infection.

31. CONCLUSION Anemia in pregnancy is the most commonly occurring disorder during pregnancy, so every mother who are pregnant must screen for anemia and must take treatment as soon as possible along with diets rich in iron and also must have family support and care throughout pregnancy.

32. Malaria Malaria infection during pregnancy is a significant public health problem with substantial risks for the pregnant woman, her fetus, and the newborn child. Malaria-associated maternal illness and low birth weight is mostly the result of Plasmodium falciparum infection and occurs predominantly in Africa . Malaria infection in pregnant women is associated with high risks of both maternal and perinatal morbidity and mortality.

33. Definition Malaria is a febrile illness caused by plasmodium- a parasite transmitted through the bite of an infected female Anopheles mosquito. Malaria is more frequent and complicated during pregnancy.

34. SIGN AND SYMPTOMS Headache High-grade fever (temperature 38ºc) Muscle pain Nausea and Vomiting Shivering, chills and rigors Sweats Diarrhoea Loss of appetite Weakness

35. Clinical DIAGNOSIS Laboratory examination Blood smear test Rapid diagnostic tests (RDTs) Haemoglobin estimation may show anaemia

36. Management of malaria in pregnancy The World Health Organization (WHO) recommends a three-pronged strategy for control of malaria in pregnancy, (prompt treatment with highly effective drug ) use of insecticide-treated nets (ITNs) intermittent preventive treatment ( IPTp ), using sulphadoxine-pyrimethamine (SP) the administration of a full treatment course of an effective antimalarial at regular antenatal visits, usually a month apart.

37. Second and third trimester The following drugs are use in the treatment of uncomplicated malaria in the 2nd and 3rd trimesters of pregnancy: ACTs, namely artemether-lumefantrine amodiaquine-artesunate mefloquine-artesunate dihydroartemisinin piperaquine (DHA-PQ),

38. Conclusion Pregnant women are uniquely susceptible to malaria. Optimal malaria prevention varies with the transmission; in higher transmission areas ITNs have demonstrated benefits. In lower transmission settings, women may lack malaria immunity and are at risk of developing severe, potentially fatal disease or losing their babies to miscarriage or stillbirth; they require immediate diagnosis and treatment. ACTs are recommended in most circumstances, although quinine remains the first choice in the first trimester of pregnancy. The approach to treatment should be tailored according to pregnancy trimester and clinical severity of malaria.