MATERNAL HEALTH

CHE 242

UNIT 1.0

TOPIC: PRE-CONCEPTION CARE

Instructional Material:

 Multimedia Projector
 White board
 Marker
 VIPP card

Teaching Methods

 Brain storming
 Lecture
 Discussion
 Line up

Types of assessment

 Assignment
 MCQ

Learning objectives: By the end of the lesson, the students should be able to

1. Define pre-conception care

2. Outline the importance of pre-conception care
3. Discuss services that constitute pre-conception care
4. State the roles of community health extension workers in pre- preconception care

1.0 Introduction

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Providing quality preconception care is the responsibility of all primary care providers, not just
those who provide maternity care or handle a high volume of women’s health. Innovative
strategies that incorporate preconception care into routine primary care visits are needed. A
comprehensive peri-natal program involves a coordinated approach to medical and psycho-social
support that optimally begins before conception. Preconception care therefore should be an
integral part of well women health care because it permits identification of those conditions or
risk factors that could affect a future pregnancy or fetus, and promotes early intervention.

1.1 Definition
Pre-conception care is the provision of biomedical, behavioral and social health interventions to
women and couples before conception occurs. (WHO, 2013)

1.2 Importance of pre-conception care

It improves pregnancy out come and women’s health in general through prevention of diseases
and management of risk factors that affect pregnancy outcome and the health of future
generations.

1.3 Components of Preconception Care

Risk Assessment

Health Promotion

Medical Intervention

Psychological
intervention

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These components contains packages that addresses the following areas

1.3.1 Preconception Services for Women

Interventions Care Considerations:

Reproductive Planning Discuss reproductive goals and issues at each visit

When pregnancy is desired, discuss medications, health

conditions, and activities that may affect fertility

Folic Acid Supplementation All women of reproductive age should be advised to take
folic acid and to consume a balanced, healthy diet of folate-
rich foods. Women at high risk for NTDs should take higher
levels of folic acid

Contraception Counseling When pregnancy is not desired, discuss safe sex and effective
contraceptive methods

Offer a full range of contraceptive methods and provide

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 appropriate contraceptive counseling that is tailored to each
patient’s preference

Counsel women on the importance of Healthy Timing and

Spacing of Pregnancy

Family and Genetic History Assess pregnancy risks on the basis of maternal age, maternal
and paternal health, and obstetric history of past pregnancies /
complications. Take a thorough family history to identify risk
factors for genetic condition;
cystic fibrosis
Sickle cell,
Haemophilia etc.

Physical Assessment To exclude;

Anaemia,
physical defects that may complicate pregnancy
Signs of physical violence

Healthy Body Weight All women with a BMI greater than or equal to 30 kg/m 2 or
less than 18.5 kg/m2 should be counseled about infertility risk
and risks during and after pregnancy.

Supplementing energy- and nutrient-dense food

Promoting exercise

Chronic Disease Management Hypertension: Women of reproductive age should have blood
pressure checks during routine care. If diagnosed with
hypertension, they should be counseled on lifestyle changes
and medications that are safe in pregnancy.

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 Diabetes: Women who have diabetes should be counseled
about the importance of glycemzic control.

Depression/Anxiety Disorders: Women of reproductive age

should be screened for depression and anxiety disorders and
counseled about potential risks of untreated illness.
Medications should be prescribed/adjusted prior to
conception, if appropriate.

Assess for use of teratogenic medications and optimize risk

profile of medications

Social and Behavioral History Assess social history, lifestyle, and behavioral issues that may
affect pregnancy

All women of childbearing age should be screened for alcohol

consumption, tobacco use, and drug use at all clinical visits
using “5 As” (ask, advise, assess, assist, arrange)

Advise Non-smokers about harm of second-hand smoke and

harmful effects on pregnant women and unborn children

Immunizations Immunization status should be reviewed annually and

updated as indicated. Check record for – Rubella, HPV,
TT/TD vaccine etc.

STIs/HIV prevention and For all women of childbearing age and their partners, assess
Management STI risk, provide counseling and immunizations as indicated
to prevent acquisition of STIs, and provide indicated STI
testing and treatment.

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Physical/Sexual/Emotional All women of reproductive age should be screened for
abuse current, recent past, or childhood physical, sexual, or
emotional interpersonal violence.

Identification and assistance for victims of current domestic

violence

Psychological screening Psychological screening for parenting readiness.

Assessing psychosocial problems

Providing educational and psychosocial counseling before

and during pregnancy

Female Genital Mutilation Discussing and discouraging the practice with the girl and her
parents and/or partner

Screening women and girls for FGM to detect complications

Informing women and couples about complications of FGM

and about access to treatment

Carrying out defibulation of infibulated or sealed girls and

women before or early in pregnancy

Removing cysts and treating other complications

1.3.2 Preconception Care for Men

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 - fathering children when he and his partner choose to do so

- Counseling on the timing of pregnancy

- overcoming fertility issues

- ensuring healthy pregnancy for his partner and

- optimal post-partum outcomes for both his partner and their child or children

1.4 The Roles of CHEW’S in Pre-Conception Care

1. Health Education

 Information, education and counseling on Lifestyle and behavior changes e.g.

dangers of smoking, alcohol use and drugs abuse
 Folic acid supplement as a standard care
 Creating awareness and understanding of fertility and infertility and their preventable
and unpreventable causes
 Providing age-appropriate comprehensive sexuality education and services
 Providing guidance and information on environmental hazards and prevention

2. Counselling
 STI /HIV prevention and management
 Importance of Family Planning /HTSP
 Healthy body weight and adequate diet
 Importance of personal hygiene/ oral hygiene
 Avoidance of toxic substance and environment contaminant such as lead occupational
exposure to toxins etc

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3. Assessment
 Physical assessment including physical examination
 Taking a thorough family history to identify risk factors for genetic conditions
 Screening for anaemia , diabetes, high blood pressure and other chronic diseases
 Carrier screening - cystic fibrosis, sickle cell etc.
 Immunization record – e.g. Rubella, HPV vaccine etc.
 Complications with past pregnancies
 Identification and assistance for victims of domestic violence
 Psychological screening for parent readiness
 Chronic diseases e.g. asthma, diabetes, heart disease, obesity etc.

Test item – Describe the various services that constitute preconception care

STUDENTS’ ACTIVITY
Topic: PRECONCEPTION CARE

Learning outcome: The student will be able to

1. Define pre-conception care

2. Mention the importance of pre-conception care
3. Describe the services that constitute pre-conception care
4. Identify the roles of community health extension workers in pre- preconception care

Task: In groups, brainstorm on how to involve the community members in ensuring effective
preconception care

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UNIT 2.0

TOPIC: PREGNANCY

Instructional Materials:

- White board & Marker

- Videos
- Pictures

Teaching Method:

- Lecture
- Discussion
- Brainstorming

Types of Assessment:

- Q&A,
- Assignment
- MCQ

Learning Objectives: At the end of the lesson the students will be able to;

1. Define Pregnancy
2. Explain the Process of fertilization to pregnancy
3. Enumerate the signs and symptoms of Pregnancy
4. Describe the Physiological, social, and psychological changes in pregnancy
5. List minor disorders of Pregnancy

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2.0 Introduction

Pregnancy also known as gestation, is the duration which a woman bears one or more offspring’s
as it develops inside her. Pregnancy usually occurs by sexual intercourse but may also results
from assisted reproductive technology procedures. It typically takes a duration of 40 weeks from
the last menstrual period to childbirth. A pregnancy may end up in a live birth, a spontaneous
abortion, an induced abortion, or a still birth. Pregnancy is divided into 3 trimesters, each lasting
approximately 3 months.

2.1 Definition of Pregnancy:

Pregnancy is the state of carrying a developing embryo or fetus within the female body. It is
indicated by the cessation of menses after fertilization has occurred.

Pregnancy is a state of being with a child, from the conception to the expulsion of the fetus that
normally takes a period of 280 days or 40 weeks from the last menstrual period.

2.2 Process of fertilization to pregnancy

After ovulation, the ovum passes into the uterine tube. It is propelled along the tube by the cilia
and peristaltic muscular contraction of the tube. If not fertilized within 24-36hrs, the ova will
degenerate. During intercourse about 200 million sperm cells per ml of semen are ejaculated into
the vagina (posterior fornix). The sperm travels upward fast; those that reach the loose cervical
mucus survive to propel themselves toward the uterine tube while the rest are destroyed by the
acid medium of the vagina. More sperm dies on the way to the ovum, by the time they reach the
uterine tube only few will survive. If the condition is favorable in the uterine tube, sperm may
survive for up to 72hrs.

Only 1 sperm penetrates the ovum. An enzyme called hyaluronidase is released which allows the
penetration of the zona pellucida and the cell membrane surrounding the ovum. The cell wall
immediately hardens, preventing other sperm from entering, and the nuclei of the two cells fuse

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together to form the zygote. Both the sperm and ovum contribute half the complement of
chromosomes each to make a total of 46.

After the formation of the Zygote which normally takes place in the ampulla of the uterine tube,
it continues its journey to the uterus which takes about 3 or 4 days. During this time cell division
takes place and the zygote divides into 2, then 4, 8, 16 and so on until a cluster of cells is form
called the Morula. Then, a cavity filled with fluid is form known as the blastocyst. Surrounding
the blastocyst is single layer of cells called the trophoblast while the remaining cells are clumped
together at one end of the blastocyst forming the inner cell mass. The trophoblast later forms the
placenta and the chorion, while the inner cell mass will become the fetus and amnion.

As these formations continue its journey to the uterus, it receives nourishment in form of
glycogen from the goblet cells of the uterine tubes and later from the secretary glands of the
uterus. In the uterus it lies free for another 2-3 days, and then the trophoblasts adheres to the
endometrium and begin to secrete substances which digest the endomtrum cells allowing the
blastocyst to become embedded. Once this happens the endometrium layer is known as the
decidua.

The decidua is about 4 times thicker than the endometrium due to increase secretion of
oestrogen. The corpus luteum also produces large amount of progesterone which stimulate the
secretory activity of the endometrial gland and increase the size of the blood vessels. This
accounts for the soft, vascular, spongy bed in which the fertilized ovum implants

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 Signs and symptoms of pregnancy

presumptive Probable Positive

(possible)

The table below describes the signs under the 3 headings and their differential diagnosis
Presumptive (Possible)
Signs Time of Occurrence Differential diagnosis
(Gestational Age)

1.Early Breast Changes 3-4 weeks + Contraceptive pills.

2. Amenorrhoea 4 weeks + Hormonal imbalance, emotional stress,

illness

3. Morning Sickness 4-14 weeks Gastrointestinal disorders, fever,

cerebral irritation etc

4.Bladder Irritability 6-12weeks Urinary tract infection, pelvic tumor

(Frequency of Micturation)

5. Quickening 16-20 weeks + Intestinal movement, wind

6. Skin Changes 8 weeks + Hormonal changes, illness.

7. Enlargement of Abdomen 12 weeks + Weight gain, Intra or extra uterine

tumors, cyst or fibroid.

Probable Signs

Signs Time of Occurrence Differential diagnosis

(Gestational Age)

1. Presence of HCG in 4-12 weeks Hydatidiform mole,choricarcinoma

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 blood or urine

2. Hegar’s sign (softened 6-12 weeks “

isthmus)
3. Jacqueline’s sign 8 weeks Pelvic congestion
(bluing of vagina)
4. Pulsation of fornices 8 weeks Pelvic congestion
(Osiander’s sign)
5. Braxton Hicks 16 weeks Tumor
contractions
6. Ballottement of fetus 16-28 weeks Tumor

7. Uterine growth 8 weeks Tumor

Positive Signs

Signs Time of Occurrence Differential diagnosis

(Gestational Age)

1.Sighting the fetus by:

- Ultrasound 6 weeks+
- X-ray 16 weeks+
Detection of Fetal heart sound by: No alternative diagnosis
- ultrasound scan 6weeks
- fetuscope 20-24weeks
Fetal movements:

22 weeks+
- Palpable
Late pregnancy
- Visible
Palpating fetal parts +

2.4 Physiological and Anatomical changes associated with pregnancy

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Pregnancy is associated with normal physiological changes that assist fetal survival as well as
preparation for labour. Many of these changes are regarded as signs and symptoms of pregnancy.
The changes are not confined to the reproductive organs alone, every tissue and organ react to
stimulus of pregnancy and the metabolic, chemical and endocrine balance of the body is also
altered.

 Changes in Reproductive system:

Uterus: changes occur in the size, it enlarges to give nourishment and protection to the growing
fetus. It also has the responsibility of expelling the fetus at a viable age, so the muscles coat
develop in a remarkable degree.

 Weight – from 60gm to 900-1000gm.

 Size – from 7.5cm to 35cm (height) 5cm to 23cm(width), 2.5cm to 20cm (thickness)
(7.5 x 5 x 2.5 to 35 x 23 x 20)
 Shape – from pear shaped to globular
 Layers of the uterus -
a). Endometrium – becomes deciduas which is more thicker, richer and vascular at the fundus
and upper body of the uterus due to the effect of progesterone and oestrogen produced by the
corpus luteum. These areas are the usual site for implantation, thus the decidua is less vascular
and thinner in the lower uterine segment.

b). Myometrium – it consist of bundles of smooth muscle fibres held together by connective
tissue. In pregnancy the muscles fibre grow up to 15-20 times more than the non-gravid length.
The increase in size and number of the uterine muscle fibre (hypertrophy and hyperplasia) is due
to the effect of oestrogen.

A slight irregular painless contraction starts from the first trimester, known as Braxton Hicks
contraction which facilitates the formation of the lower uterine segment. Although progesterone
suppresses myometrial activity throughout most of the pregnancy, by the 36 th weeks, the
contractions increases which eventually leads to ripening of the cervix and labour.

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Cervix:

 The cervical cells secretes thick and viscous mucus which forms a cervical plug called
the opeculumthat provides protection against infection by occluding the os. The cervix
looks bluish due to increased vascularity.
 The cervix contains more fibrous tissue and less muscle when compared to the body of
uterus that is why it remains firmly closed and resist pressure from above when the
mother is in upright position.
 The cervix softens (ripens) in late pregnancy due to the action of prostaglandins.
Effacement occurs in the primigravida during the last 2 weeks of pregnancy, but it
usually occurs when labour begins in the multigravida.

Vagina:

 There is hypertrophy and the capacity of the vagina increases.

 Changes in the connective tissue make it more elastic.
 The increased blood supply leads to bluish discoloration and
 There is usually a marked increase in the normal whitish vaginal discharge known as
leucorrhoea.

Breast:

 There is weight increase of about 450g,

 The nipples become darker and erectile.
 Primary areola and Montgomery’s tubercles appears (about 12-30 small nodules).

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  Changes in the cardiovascular system

Heart:

 The workload of the heart increases during pregnancy and the muscles hypertrophies
leading to the enlargement of the heart. The gravid uterus pushes the diaphragm which in
turn pushes the heart upward.
 The heart rate increases and the amount of blood pumped by the heart also increase
resulting in a raised cardiac output. The heart rate increase by about 15 beats per minute’s
i.e. from 70 to about 85 beats per minutes.
 Although the cardiac output increases, the blood pressure does not due to the effect of
progesterone on smooth muscles, causing the arterial walls to relax and dilate.
 There’s more increase blood flow to the uterus, kidneys, breast and skin.

Blood:

 There is increase in the blood volume of about 20-100% depending on the body size,
parity, and no of fetus she is carrying.
 The increase in plasma level is greater than the increase in Red blood cells; this is
referred to as Haemodilution.
 It is characterized by low haemoglobin level of around 11-12 g/dl or pcv of 29% and the
effect is known as Physiological anaemia.

 Changes in the respiratory system

The effect of pregnancy is minimal.

 The lungs are displaced slightly upward when the uterus encroaches the thorax.
 There is an increase of about 20% in the O2 consumption rate due to increase metabolic
need of the mother and fetus.
 The shape of the chest changes and the circumference increase, and may not recover their
original position after pregnancy.

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  Changes in the urinary system
 Due to the influence of progesterone the ureters become relaxed and dilated, they become
elongated and curved around the brim of the pelvis.
 It usually results to statics of urine in the ureters which results to bacteriuria and infection
of the urinary system.
 Due to reduction in the capacity of the bladder in early and late pregnancy, the pregnant
women constantly pass urine.

 Changes in the gastrointestinal system

 There is increased salivation due to inability to swallow the saliva as a result of nausea in
some women.
 The gums are oedematoes and soft due to the effect of oestrogen. Nausea and vomiting is
common.
 A craving for certain food can develop or an increase in appetite in some women, also a
change in the sense of taste can occur.
 The growing uterus displays the stomach and intestines.
 The cardiac sphincter becomes relaxed leading to the reflux of acid to the oesophagus
which results to heartburn.
 Gastric tone, peristalsis and HCL secretion reduces and gastric emptying time is
decreased.
 The delay in the movement of food through the intestines leads to increased absorption of
water, thereby predisposing the pregnant woman to constipation.
 Obstruction of the intestine by the uterus and the effect of progesterone on smooth
muscles can also causes constipation.

 Changes in maternal weight

Weight gain during pregnancy is indicative of maternal adaptation and fetal growth. The
following is the expected weight gain;

 4kg in the 1st 20wks

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  8.5kg in the 2nd 20wks (0.4kg/week)

Approximately 12.5kg total.

- Fetus- 3.4kg
- Placenta- 0.6kg
- Amniotic fluid – 0.8kg
- Increase in weight of uterus – 0.4kg
- Increase in weight of blood volume - 1.5kg
- Extracellular fluid – 1.4kg
- Fat- 3.5kg

 Changes in the skin

The skin stretches on the abdomen to accommodate the uterus and extra fat deposit thus tears
occurs in deeper layers of the skin;

 Striae gravidarum: scars from the tears are seen as irregular marks called striae
gravidarum. Similar scars may occur on breasts and thighs. They are more marked when
there is excessive stretching like in multiple pregnancy.
 Chloasma: or mark of pregnancy – it is a skin pigmentation which occurs on the face. It
is not common in African women.
 Lineanigra: it is the line extending from the pubis to the xiphisternum which has become
darker.

 Changes in Muscular Skeletal system

The hormone relaxin which is secreted towards the end of pregnancy softens the soft tissue
structures of the pelvis, e.g ligaments, cartilage in between joints (Symphysis pubis,
sacroilliac joints, pelvic floor muscles, etc.

2.5 Psychological changes associated with Pregnancy

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The psychological changes that affect the pregnant women are essentially due to the
physiological changes. Interactions between the body and the mind occur throughout pregnancy
e.g. a high level of stress or a negative feeling about being pregnant may contribute to some of
the nausea that occurs in the first trimester and the nausea/vomiting may make you feel less
enthusiastic about pregnancy. These psychological feelings, includes:

 Anxiety
 Lowself-esteem/self-doubt
 Panic attacks/worries
 Mood swings
 Difficulty in concentration at the task in hand.
 feeling irritable and snappish

2.6 Minor Disorders of Pregnancy

Minor disorders of pregnancy are mild ailments caused by the pregnancy as a result of the
physiological changes due to hormones of pregnancy. They include:

 Morning sickness
 Heart burn
 Varicose veins
 Constipation
 Pruritus vulvae (as a result of thrush, diabetes, poor hygiene).
 Stress inconsistency
 Skin rashes
 Back pain
 Hemorrhoids etc.

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The treatments of these conditions are mainly health education, counselling and simple
palliative remedies that are safe and help to relieve symptoms

Test item- Group the Preconception care packages, using the 4 components as headings.
STUDENTS’ ACTIVITY
Topic: Pregnancy

Learning outcome: The students will be able to

1. Define pregnancy,
2. Describe the process of fertilization,
3. State the signs and symptoms of pregnancy and differential diagnosis
4. Discuss the physiological and psychological changes during pregnancy
5. Identify minor disorders in pregnancy

Task; In small groups, discuss how minor disorders affects pregnancy and the possible
management of each disorder.

UNIT 3.0

TOPIC: ANTENATAL CARE

Instructional Materials:

- White board & Marker

- Posters
- Pictures
- Measuring tape
- Weighing scale
- Multi dip stick/Combi 2

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Teaching Method:

- Lectures
- Discussions
- Brainstorming
- Demonstration

Types of Assessment:

- Q&A,
- Assignment
- MCQ
- Return demonstration

Learning Objectives: At the end of the lesson the students will be able to;

 Describe Focused Antenatal care (FANC)

 Describe the 2016 WHO ANC model
 Identify the general services provided during ANC clinics
 Describe the ANC contacts and what they entails
 Discuss the danger signs in pregnancy and how to manage them
 Discuss the Elimination of Mother to Child Transmission of HIV Infection

3.0 Introduction

Antenatal Care (ANC) is the advice, supervision and attention given to pregnant women. The
care given to women is specialized in order to obtain and maintain a state of good health
throughout pregnancy and improve chances of having safe delivery of a healthy live baby at
term. ANC entails a number of interactions, activities, procedures which are systematically
carried out in order to maintain both maternal and fetal wellbeing.

3.1 FOCUSED ANTENATAL CARE (FANC)

- FANC is defined as an evidence-based, client centered and goal directed care provided
by skilled health providers with emphasis on quality rather than frequency of visit.

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 - FANC entails a minimum number of 4 ANC clinical visits, each of which has specific
items of client assessment, education, and care to ensure the prevention of or early
detection and prompt management of complications. A major new focus is on birth
planning and emergency preparedness.

The traditional approach to ANC, assumes that more visits means better outcome for mother and
baby these visits includes about 12 clinic visits and women are classified by risk category to
determine their chances of complications and the level of care they need.

However, recent evidence suggests that the focused antenatal care (FANC) model, which was
developed in the 1990s, is associated with more perinatal deaths than ANC models that comprise
at least eight contacts between the pregnant woman or adolescent girl and the health care
provider. A secondary analysis of the World Health Organization’s (WHO’s) ANC Trial
suggests that the increase in perinatal mortality rate is more likely due to an increase in
stillbirths. These findings and other evidence informed the development of WHO’s 2016 ANC
recommendations.

The Goals of FANC

 Health Promotion

It is the process of promoting and maintaining the physical, mental and social health of a mother
and her baby by providing education on key issues related to pregnancy, childbirth, and
encourages an appropriate health seeking behaviour. It addresses individual needs, gestational
age and most prevalent health issue. It includes education and counselling the following:-

1. Danger signs of complications during pregnancy and labour:

2. Nutrition
3. Infection Prevention
4. Importance of Exercise.
5. Family Planning
6. Prevention of HIV/STI
7. HIV Counseling and Testing
8. Immunizations
9. Malaria Control and Prevention in Pregnancy

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  Prevention of Complications of Pregnancy and Childbirth

Two simple preventive measures have proven to be effective in reducing maternal and neonatal
death:

1. Tetanus toxoid Immunization

2. Iron and Folate Supplementation
3. IPT for malaria, and
4, other treatment for hookworm, vitamin A, and iodine supplementation.

 Early Detection and Prompt Management of Problems

This is the process of detecting and managing complications during pregnancy, whether medical,
surgical or obstetric. It is carried out through interview and proper examination by the skilled
health provider so as to detect any problem that might affects the woman’s pregnancy and
requires additional care. Conditions that could severely affect the mother or baby if left untreated
includes: HIV, STIs, TB, Anaemia, Pre-eclampsia, abnormal fetal position after 36 weeks
(indicative of a life-threatening condition), malaria.

Early treatment of these conditions can mean the difference between death and survival for
the woman and her newborn.

 Birth and Emergency Planning

It is the process of planning for safe delivery and anticipating the actions needed in case of
emergencies. If a woman is well prepared for normal childbirth and possible complications she is
more likely to receive the skilled and timely care she needs, protect her overall health and
possibly save her life and that of her baby. The health provider and the pregnant woman should
make plan for the following:

a. A Skilled Provider
b. The place for delivery
c. Transportation
d. Items needed for the birth
e. Money/Fund

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 f. Support
g. Blood Donor
h. Decision Making

Birth and emergency preparedness is important as the time required to make arrangements which
could’ve been made before in emergency situation can easily define the line between survival
and death for both mother and child.

Three (3) fatal delays have been identified in relation to obstetric management of complications;

1. Delay in decision making e.g. who, why and where,

2. Delay in reaching the appropriate health facility e.g. distance, transport, funds,
3. Delay in receiving help after reaching the service centre e.g. inability of staff to treat
condition, lack of equipment or supply, staff absent, or not motivated.
The first 2 factors relate to family/community while the third factor relate to health facility.

3.2 W.H.O’S 2016 ANC MODEL

The 2016 WHO ANC model aims to provide pregnant women with respectful, individualized,
person centered care at every contact and to ensure that each contact delivers effective,
integrated clinical practices (interventions and tests), provides relevant and timely information,
and offers psychosocial and emotional support by practitioners with good clinical and
interpersonal skills working in a well-functioning health system. WHO recommends minimum
of eight contacts for A.N.C
- One (1) contact in the first trimester,
- Two (2) contacts in the second trimester, and
- Five (5) contacts in the third trimester

The recommended interventions for the WHO 2016 Model

 Routine antenatal nutrition,

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- Provide counselling about healthy eating, and keeping physically active to stay healthy
and prevent excessive weight gain during pregnancy
- Provide daily oral iron and folic acid supplementation with 30 to 6 0 mg of elemental iron
and 400 μg (0.4 mg) of folic acid to prevent maternal anaemia, puerperal sepsis, low birth
weight, and preterm birth.
- In undernourished populations, nutrition education and counselling to increase daily
energy and protein intake is recommended to reduce risk of low-birth weight new-born.

 Maternal and fetal assessment

- Classify hyperglycemia first detected at any time during pregnancy as either gestational
diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to WHO criteria.
- Ask about tobacco use (past and present) and exposure to second-hand smoke as early as
possible in pregnancy and at every ANC visit.
- Ask about use of alcohol and other substances (past and present) as early as possible in
pregnancy and at every ANC visit.
- Provider initiated testing and counselling in ANC settings as a key component of the
effort to eliminate mother-to-child transmission of HIV;
- Integrate HIV testing with syphilis, viral, or other key tests, as relevant to setting; and
strengthen underlying maternal and child health systems.
- Provide one ultrasound scan before 24 weeks gestation (early ultrasound) to estimate
gestational age
- Improve detection of fetal anomalies and multiple pregnancies, reduce induction of
labour for post-term pregnancy, and improve pregnancy experience.
- Full blood count testing is the recommended method for diagnosing anaemia in
pregnancy.
- Replacing abdominal palpation with symphysis-fundal height (SFH) measurement for the
assessment of fetal growth is not recommended to improve perinatal outcomes.

 Preventive measures,
- Provide a 7 day antibiotic regimen for pregnant women with asymptomatic
bacteriuria (ASB) to prevent persistent bacteriuria, preterm birth, and low birth
weight.

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 - Provide tetanus toxoid vaccination for all pregnant women, depending on
previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus
- In endemic areas, preventive anthelmintic treatment is recommended for pregnant
women after the first trimester as part of worm infection reduction programmes.
- Intermittent preventive treatment with sulfadoxine pyrimethamine (IPTp-SP) for
Malaria is recommended for all pregnant women in enemic areas.

 Interventions for management of common physiologic symptoms in pregnancy,

- Nausea and vomiting:- Ginger, chamomile, vitamin B6, and/or acupuncture for
relief of nausea in early pregnancy
- Heartburn:- Advice on diet and lifestyle to prevent and relieve heartburn in
pregnancy, antacid preparations for women with troublesome symptoms not
relieved by lifestyle changes
- Leg cramps; Magnesium, calcium, or nonpharmacological treatment options for
relief of leg cramps in pregnancy
- Low back/pelvic pain:- Regular exercise throughout pregnancy to prevent low
back/pelvic pain; different treatment options can be used, such as physiotherapy,
support belts, and acupuncture
- Constipation:- Fibre supplements to relieve constipation in pregnancy if the
condition fails to respond to dietary modification
- Varicose veins and oedema:- Nonpharmacological options such as compression
stockings, leg elevation, and water immersion for management of varicose veins
and oedema in pregnancy

 Health system-level interventions to improve the utilization and quality of ANC

- It is recommended that each pregnant woman carries her own case notes during
pregnancy to improve continuity, quality of care, and pregnancy experience.
- Task shifting the promotion of health-related behaviours for maternal and newborn health
to a broad range of cadres, including Community health workers, nurses, midwives, and
doctors is recommended.

26
 - Task shifting the distribution of recommended nutritional supplements and intermittent
preventive treatment in pregnancy (IPTp) for malaria prevention to a broad range of
cadres, including CHEW, nurses, midwives, and doctors is recommended.
- ANC models with a minimum of eight contacts are recommended to reduce perinatal
mortality and improve women’s experience of care

3.3 Procedures carried out in General ANC Clinics.

1. Health Education
2. History Taking
3. Physical Examination from head to toe
4. Taking foetal heart sound
5. Taking mothers vital signs
6. Laboratory Investigations
7. Weighing
8. Tetanus Toxoid Immunization
9. Treatment of minor ailment/referral of more serious conditions.
10. HIV counseling and testing

27
A TABLE SHOWING THE NUMBER OF ANC VISITS FOR FANC & 2016 ANC
MODEL

Adopted from WHO Recommendations on Antenatal Care for a Positive Pregnancy

Experience: Summary; 2018

3.4 ANC CONTACTS AND WHAT THEY ENTAIL

FIRST TRIMESTER (UP TO 12 WEEKS, FIRST CONTACT)

1. Establish a friendly atmosphere

2. Obtain a comprehensive history on;

 Personal Information:

28
  Medical History:
 Obstetric History:
 Last Menstrual Period and Contraceptive Plans:
LMP + 7 days – 3months = EDD.
 Present Pregnancy

3. Performa “Head-to-Toe” Physical Examination.

 General Wellbeing: Girt, posture, facial expression, skin and conjunctiva for pallor or
jaundice, oedema, condition of hair
 Blood Pressure Measurement.
 Breast Inspection.
 Abdominal Examination: Surface of abdomen, fundal height.
 Genital Examination: Skin, Labia, Bartholin’s Glands, Purulent discharge (Pus-like)

4. Request Relevant Laboratory Investigations which includes;

 Urinanalysis
 Haemoglobin (Hb) or Pack Cell Volume (PCV) estimation
 Veneral Disease Research Laboratory (VDRL) or Rapid Plasma Reagen (PRP) test
 Blood Grouping/Rhesus Factor
 HIV Testing (After VCT)
 Other Appropriate Investigations as indicated by patient’s history e.g. HBs Ag, Widal,
MP, Sickling, FBS etc.

5. Provide Iron and Folate According to Guideline i.e. Folic acid 5mg daily, ferrous sulphate
200mg three times a day (All pregnant women should have iron/folate supplements for 6 months
during pregnancy).

6. Provide 1st dose of T.T. vaccine (if not immunized)

7. Provide Long Lasting Insecticide Treated Net (LLITN) if available

8. Educate and counsel client on any topic appropriate to her condition.

9. Initiate discussion on birth and emergency planning

29
10. Give appointment for the second visit, ensure all records are complete.

ROUTINE ELEMENTS OF CARE AT ALL FOLLOW-UP VISITS

i. Maintain the friendly atmosphere

ii. Ask about any complains in current pregnancy
iii. Check for anaemia
iv. Measure Blood Pressure to determine level
v. Check uterine size, and compare with gestational age
vi. Check for fetal heart sound
vii. Check urine for protein and sugar
viii. Provide iron and folate
ix. Educate and counsel client
x. Continue/conclude discussion on birth and emergency planning
xi. Give appointment for the next follow up visit

SECOND TRIMESTER (2ND & 3RD CONTACT AT 20 & 26 WEEKS)

The goal is for T.T. and first intermittent preventive treatment for malaria. It consist the
following in addition to the routine element of care.

1. Take action on result of laboratory investigations e.g. correct anaemia, treat

syphilis etc.

2. Provide 2nd dose of T.T.

3. Provide 1st dose of Sulphadoxine and Pyrimethamine for IPT of malaria

4. Provide 1 st dose of antihelminthes (Mebendazole 500mg stat) if living in

hookworm area.

THIRD TRIMESTER (5 CONTACTS)

30
The goal is to detect anaemia, give second IPT, and assess fetal growth.

4TH & 5TH CONTACTS (AT 30 & 34 WEEKS): These contacts have interval of 4 weeks
each from the 3rd contact

i. Recheck HB level and treat for anaemia, if present

ii. Check uterine size and palpate the fetal positions to exclude multiple pregnancy
and abnormal presentation.
iii. Provide second dose of anti-helminthes
iv. Provide second and third dose of SP for IPT of malaria at intervals of 4 weeks
v. Repeat ultrasound scan.
vi. Discuss lactation and contraception

6TH, 7TH & 8TH CONTACTS (36, 38, & 40 WEEKS); Interval of 2 weeks between the
contacts

The goal is to detect anaemia, educate on labour and review birth plan. The following procedures
are expected to be performed:

i. Check the uterine size and palpate fetal lie, presentation, engagement, fetal heart
sound etc.
ii. Perform pelvic examination to detect any soft tissue abnormality. Perform
obstetric maneuver if indicated.
iii. Check Hb to exclude anaemia.
iv. Educate and counsel client about signs/symptoms of labour
v. Review birth plan with client
vi. If not delivered by the end of 41 weeks advice Patient to report back and take a
decision on delivery.

3.5 IMPORTANCE OF GENERAL EXAMINATION

31
Weight: When it is taken at the initial visit (which should be early) it forms a baseline for
compares during the subsequent visits. In the first 20 weeks a gain of 2.5kg is normal, then 0.5kg
a weak in the 2nd 20weeks. A gain of about 12-12.5kg can be accounted for physiologically
during pregnancy. Static, poor, or excessive gain should be a course of concern. Obesity is
associated with an increased risk of gestational diabetes and PIH.

Blood Pressure: It is usually low in pregnancy. At every visit you compare the reading with the
initial. An initial BP of > 140/90 mmHg should be considered high. An increase of 30mmHg in
the systolic or 15mmHg in the diastolic is considered high blood pressure even when the value
does not reach 140/90mmHg. A rise in Blood pressure during the 2 nd half of pregnancy is
indicative of pre-eclampsia.

Pallor: It is indicative of anaemia. It can be detected through the conjunctiva, the palms of hand,
sole of foot, tongue etc.

Oedema: A degree of oedema is normal but when it is excessive it may be associated with PIH
and action should be taken. It may not be present at booking but occurs later in pregnancy.

Respiratory Rate: Should be assessed to rule out any underlying condition of the heart or lungs.

Breast Examination: To assess their suitability for breast feeding. The size and shape of the
nipples is noted. Examine and feel for the presence of abnormal lumps.

Abdominal Examination: It is perform to determine fetal wellbeing. It is unlikely that the uterus
will be palpable abdominally before the age of 12 weeks of gestation.

- Estimate the gestational age:

The uterus is expected to grow at a predicted rate and in early pregnancy the size will usually
equate the gestational estimate by date.Later in pregnancy the increasing uterine size may be due
to continuous fetal growth but it is less reliable as an indicator of gestational age. Factors like
multiple pregnancy increases the overall uterine size and should be diagnosed by around the
24thweeks.

In a single pregnancy the fundus is palpable just above the symphysis pubis.

32
At 16 weeks the uterus is 7.5cm above the symphisis pubis or half way between the symphisis
and the umbilicus. Quickening might be felt by the mother.

At – 22-24 weeks the fundus has reached the umbilicus

At – 30 weeks the fundus is midway between the umbilicus and the xiphisternum.

At – 36 weeks the fundus has reaches its highest level and is in contact with the xiphisternum.

At the last month of pregnancy lightening occurs and the fetus sinks down into the lower pole of
the uterus. The uterus becomes broader and the fundus lower. In the primigravida strong
abdominal muscles encourage the fetal head to enter the brim of the pelvis.

Multiple Pregnancies: It is associated with increased risk of obstetric complications. Twin

pregnancy is the commonest form of multiple pregnancies and Nigeria has the highest reported
rate in the world (45/1000 birth) predisposing factors are ethnicity, family history of twins and
assisted delivery.

Laboratory Investigation: It is important for early detection of abnormalities.

1. Full blood count, PCV or HB estimation is done to determine the level of haemoglobin which
carries oxygen for circulation. It also helps in assessing the adequacy of the iron stored.

2. Blood grouping is important to determine the ABO group and Rhesus factor, in case of any
emergency transfusion.

3. Venereal Disease Research Laboratory (VDRL) is done to detect syphilis for prompt
management to avoid fetal infection/abnormality.

4. HIV testing should be done after counseling to reduce the chances of mother-to-child
transmission through intervention.

5.Urinanalysis is carried out to exclude abnormality like bacilluria, protein due to contamination
by vaginal discharge, or disease like UTI or PIH, glucose caused by higher level in blood, or as a
result of disease, Ketones due to increased maternal metabolism caused by fetal need or due to
vomiting.

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3.6 Danger signs in Pregnancy

Danger signs are the serious signs detected in pregnancy which if not treated immediately will
impair the life of the mother and fetus. These signs include;

1. Vaginal bleeding.
2. Liquar drainage.
3. Hypertension
4. Pre-eclampsia
5. Convulsions
6. Anaemia
7. Urinary tract infection
8. Fever
9. Abdominal pains
10. Dizziness
11. Foul smelling vaginal discharge
12. Oedema of the feet, hands, and face.

1. Vaginal bleeding: - In pregnancy any bleeding from the vagina is abnormal no matter how
small, it become a cause of concern for both the woman and the health provider. Bleeding can
occur either in early pregnancy or late pregnancy.

 Bleeding before the 28th week of gestation is considered as threatening abortion.

 Bleeding after 28th weeks before delivery is ante partum hemorrhage.
I. In early pregnancy there are many causes of vaginal bleeding e.g. ectopic pregnancy,
cervical polyps (small vascular growths), or cervical cancers. But the most common
cause is spontaneous abortion.
II. In late pregnancy 28th week and above, bleeding is normally due to either placenta
praevia which is abnormal location of the placenta on the lower uterine segment,
abruptio placenta which is the premature separation of a normally situated placenta,
or incidental haemorrhage in which bleeding is not as a result of the 2 above.

34
Management – Do not perform V E.
- set IV line and refer the patient immediately.

2. Hypertensive Disorders: - Hypertension is defined as Blood pressure of > 140/90mmHg on

two occasions measured 4-6 hours apart

Hypertension is a rise in the normal values of the blood pressure to greater 30mmHg in the
systolic and 15mmHg in the diastolic even if the value does not reach 140/90mmHg.

This is why every woman’s BP must be measured at every ANC visit regardless of her
complains.

Hypertensive disorders includes: -

 Pregnancy-induced Hypertension (Gestational hypertension)

 Pre-eclampsia
Mild pre-eclampsia
Severe pre-eclampsia
 Chronic Hypertension in pregnancy
Essential Hypertension
Secondary Hypertension e.g. chronic renal disease
 Chronic Hypertension with superimposed pre-eclampsia
 Eclampsia

Chronic hypertension: When the client presents at booking (initial ANC visit) with a BP of
140/90mmHg or above with history of having similar condition even before present pregnancy.
Management: Monitor the patient closely; if at any point you feel the BP is rising refer
immediately.

Pregnancy induced hypertension: This is the development of high BP in the 2 nd half of

pregnancy (20wks) in a woman with normal BP.
Management:
 Monitor the BP closely

35
  Advice adequate rest (at least 2hrs rest in day time and 8hrs in the night)
 Advice patient to lie on the left side
 Give Diazepam tablet 5-10mg or phenobarboitone 30mg at night to ensure adequate
rest.
 Refer when BP rises above 140/90mmHg and do not subside.

Pre-eclampsia: high blood pressure in pregnancy after 20 weeks of gestation measured on two
occasions at least four hours apart and presence of proteinuria.

Mild Pre-eclampsia

 Two readings of diastolic blood pressure of 90–110 mm Hg, 4 hours apart after 20
weeks gestation
 Proteinuria up to 2+ in Dip stick urinalysis or 300mg /litre of urine (midstream clean
catch specimen)
 Usually presents without any symptoms

Severe Pre-eclampsia

 Diastolic blood pressure > 110 mm Hg

 Proteinuria > 3+
 Other signs and symptoms sometimes present:
• Epigastric tenderness
• Headache
• Dizziness
• Visual changes
• Pulmonary edema
• Oliguria
• Excessive vomiting

36
 • Pedal Oedema
• Tinnitus
• Abdominal pain
• Hypereflexia

Chronic Hypertension with Super imposed Pre-eclampsia: This condition occurs in women
with chronic hypertension before pregnancy who develop worsening high blood pressure and
protein in the urine or blood pressure related complications during pregnancy

Eclampsia: It is the occurrence of fits unrelated to other cerebral condition in pregnant woman
with Pre-eclampsia. Convulsions may occur during pregnancy, labour, puerperium. It is a
complication of Pre eclampsia but can occur suddenly without prior signs

Management:

- Monitor blood pressure, urine and fetal condition

- If blood pressure worsens, manage as mild pre-eclampsia
- If there are signs of severe fetal growth restriction or fetal compromise, arrange for
immediate referral.
- Counsel woman and family about danger signals of pre-eclampsia and eclampsia
- Encourage additional periods of rest
- Encourage woman to eat a normal diet
- Do not give anticonvulsants, antihypertensives, sedatives or tranquilizers
- Patients with mild PE do not need emergency treatment at the PHC
- They should be referred to the nearest General Hospital for further care
- In addition to the treatment of PIH, when BP is up to 160/110mmHg or more give IM
magnesium sulphate (MgSo4) 5g (10mls) + 1ml lignocaine in each buttock and refer to a
higher facility.

Women at risk of preeclampsia

- Young Mothers
- Primigravidas

37
- Past history of PIH,
- Family History of high BP,
- Multiple pregnancies,
- Molar pregnancy,
- Diabetes Mellitus,
- Renal diseases.

3. ANAEMIA: It is the reduction in quantity and quality of the RBC resulting in hemoglobin
level below 10g/dl, or PCV 30 %, thereby reducing the oxygen carrying capacity of the blood.

Anaemia is classified into: -

- Mild – 8-9.9g/dl
- Moderate – 7-7.9g/dl
- Severe - ˂ 7g/dl
It has the following effects on pregnancy: -

 Increased incidence of preterm labour

 Fetal distress
 Low birth weight
 Risk of perinatal mortality.
Signs and symptoms:

- Tiredness
- Weakness
- Dizziness
- Dyspnoea on exertion

38
 - Pallor (tongue, gums, nail beds, palms/sole)
- Liver/spleen enlargement.
Management:

- Refer any case of ˂ 7g/dl (it needs urgent blood transfusion)

- Give haematinics and vitamin C
- Treat malaria, hookworm
- Treat any obvious infection
- Avoid tea, coffee, or cola as it reduces Fe absorption
- Give nutritional counseling
- Re asses after 2 weeks, if Hb has not increased by 1g or continue to decreases refer.
4. URINARY TRACT INFECTION: Infection within the tract is one of the conditions which
complicate pregnancy. It is normally bacterial which is influenced by the anatomical and
physiological change in the urinary tract.

Signs and symptoms:

- Dysuria
- Increased frequency of micturation
- L. Abdominal pain or suprapubic discomfort
- Pus in urine
Untreated UTI i.e. cystitis eventually leads to pyelonephritis which have the following
implication on pregnancy:

 Intra uterine growth retardation

 Preterm labour
 Risk of congenital abnormality

Management:

- Do urine/HVS and ECS (endocervical swab) for culture and sensitivity.

- Advice to take plenty of water/fluid
- Give erythromycin, or Ampiclox or Amoxycillin

39
 - Septrin is a commonly used antibiotic, although effective it should not be used in
pregnancy as it is a folic acid antagonist and it may cause jaundice in the last trimester.
- Refer any re – current case to higher facility.

5. PREMATURE RUPTURE OF MEMBRANE (PROM)

It is the rupture of membranes before labor starts resulting in cervical dilatation occurring before
37wks of gestation. It is associated with infection of the reproductive tract.

Management:

Ask the time of rupture: If membrane has been ruptured for more than 12hrs

- Check and record FHS

- Check the color and odor of the liquor
- Apply clean sanitary pad
- Give broad spectrum antibiotic
Cardinal Signs: Includes temperature ˃38 degree centigrade, offensive vaginal discharge and
rapid pulse.

6. FEVER: It is a mark increase in body temperature. Fever in itself is not a disease but a
symptom. Any infection in pregnancy can cause fever e.g. STI, UTI, hepatitis, TB, Malaria etc.

The most common cause of fever in the tropics generally is malaria.

Malaria: It is a febrile condition caused by the plasmodium species which is transmitted by the
bite of infected female Anopheles Mosquitoes. It is endemic in Nigeria and a major cause of
maternal and perinatal morbidity and mortality. A positive RDT with the following
accompanying symptoms should be treated;

Symptoms:

Uncomplicated Complicated
1. Fever Any of the following in addition to signs of
2. Nausea and Vomiting uncomplicated.
3. Muscle/ Joint pains 1. Jaundice

40
 4. Shivering/Chills/rigors 2. Difficulty in breathing
5. Headache 3. Drowsiness/ sleeplessness
6. False labour pains 4. Coma
7. Mild anaemia 5. Severe anaemia
6. Severe dehydration.

For Effective Case Management:

1. Carry out malaria test using RDT

2. Encourage plenty of fluid
3. Tepid sponge if necessary
4. Assess whether uncomplicated or complicated (Refer)
5. Give Anti-malarial to those with positive RDT ( in the table below
6. Give analgesics
7. Advice on the following:
- Drug compliance and adverse reaction
- Use of ITN
- Environmental sanitation to prevent re- occurrence

Mild Malaria in Pregnancy

Medicine 1st Trimester 2nd Trimester 3rd Trimester
Quinine tablets 20mg/kg loading dose ← ←
then 10mg/kg
8hourly x 7days
ACT Not recommended. 4 tabs bd x3 days 4 tabs bd x 3 days

- Quinine is considered safe in pregnancy and can be used in all trimesters.

- ACT e.g. Artemether + Lumefantime are considered safe in 2nd and 3rd trimester only.

41
 Severe malaria in pregnancy
st
Medicine 1 Trimester 2nd Trimester 3rd Trimester
Quinine IV/IM 20mg/kg loading dose in ← ←
500ml 5% D/saline then
10mg/kg 8hrsly until patient
can tolerate oral quinine,
complete a 7 days therapy.
ACT Not recommended IM/IV for 3 days ←
then oral therapy to
complete 7 days

3.7 ELIMINATION OF MOTHER TO CHILD TRANSMISSION OF HIV

A HIV positive pregnant woman can transmit HIV to her newborn child during pregnancy,
labour, delivery, and breastfeeding. In order to prevent this, WHO introduced a set of interrelated
interventions designed to block transmission of HIV from a HIV infected mother to her child
during the period of pregnancy and breastfeeding. These interventions are offered together as a
single package of care known as Prevention of Mother to Child Transmission of HIV (PMTCT).

ARV Intervention

• Pregnancy is an absolute indication for ART.

• ART should be initiated in all HIV pregnant and breast-feeding women regardless of
WHO clinical stage and CD4+ cell count and continued for life. This is also regardless of
gestational age.

• ART should be initiated urgently in all pregnant and breastfeeding women, even if they
are identified late in pregnancy or postpartum, because the most effective way to prevent
mother-to-child HIV transmission is to reduce maternal viral load.

ARV Intervention (Recommended regimen for HIV+ Women)

42
 FIRST LINE ART PREFERRED FIRST- ALTERNATIVE FIRST-
LINE REGIMEN LINE REGIMEN

Pregnant or TDF + 3TC + EFV AZT + 3TC + EFV

Breastfeeding women AZT + 3TC + NVP

TDF + FTC + EFV TDF + 3TC + NVP

TDF + FTC + NVP

ARV prophylaxis for the HIV exposed infant

 All HIV exposed infants should receive ARV prophylaxis regardless whether they
are being breastfeed or receiving replacement feed.
 Infants born to mothers with HIV who are at high risk of acquiring HIV should
receive dual prophylaxis with AZT (bd) and NVP (od) for the first 6 weeks of life,
whether they are breastfed or formula fed.
 Infants delivered to HIV positive mothers who are stable on ART should receive
NVP prophylaxis. These infants irrespective of the type of feeding should receive
daily NVP from within 72 hours of birth to 6 weeks of age.
 If infants are receiving replacement feeding, they should be given 4 to 6 weeks of
infant prophylaxis with daily NVP (or AZT bd). (When NVP is not available and
AZT has to be used, HB should be monitored closely for early detection of
anaemia.)
 For babies with weight <2,5kg, give NVP 10mg or 1ml once daily
 For babies with weight ≥2, 5kg, give NVP 15mg or 1.5ml once daily.

Special situations for extended ARV prophylaxis for HIV exposed Infants at High Risk of
MTCT

43
 • Breastfed infants who are at high risk of acquiring HIV should continue infant
prophylaxis for an additional 6 weeks (total of 12 weeks of infant prophylaxis) using
AZT (twice daily) and NVP (once daily).

• High-risk infants are defined as those:

 Born to women with established HIV infection who have received less than four weeks of
ART at the time of delivery

OR

 Born to women with established HIV infection with viral load >1000 copies/mL in the
four weeks before delivery, if viral load measurement available;

OR

 Born to women with incident HIV infection during pregnancy or breastfeeding;

OR

 Identified for the first time during the postpartum period, with or without a negative HIV
test prenatally.

Test Item – Discuss the causes and management of Danger signs during Pregnancy

STUDENTS’ ACTIVITY
Topic: Antenatal Care (ANC)

Learning outcome

 Describe the 2 ANC models

 Identify the procedures carried out in the general ANC clinic
 Describe the ANC contacts and what they entails
 Discuss the danger signs in pregnancy and how to manage them
 Discuss the Elimination of Mother to Child Transmission of HIV Infection

44
Task: Use role play to demonstrate how to provide routine ANC services for a well pregnant
woman and a pregnant woman with danger signs

UNIT4.0

TOPIC: LABOUR AND DELIVERY

Instructional Materials:

- White board & Marker

- Videos
- Pictures
- Partograph
- Mama and Neonatalie model
- Pelvic bone

Teaching Method:

45
 - Lecture
- Discussion
- Brainstorming
- Demonstration

Types of Assessment:

- Q&A,
- Assignment
- MCQ

Learning Objectives: At the end of the lesson the students will be able to;

 Define Labour
 Identify False and True labour
 Describe the Stages of labour
 Describe Good practices and supportive care during labour
 Describe the management of labour
 Identify the danger signs during labour

4.0 INTRODUCTION

Intra-partum care is the care provided during labour, between the onset of regular uterine
contractions to the delivery of fetus, the placenta and its membranes. The period could be normal
or complicated.

4.1 DEFINITION OF LABOUR

It is described as the process by which the fetus, the placenta and membranes are expelled
through the birth canal. The term labour is only used when the pregnancy has exceeded 28 weeks
otherwise it is called abortion.

4.2 NORMAL LABOUR

46
It is described as the spontaneous and progressive contraction of the uterus at term with the fetus
presenting by the vertex. The process ends naturally with the sole effort of the mother and no
complications to the mother or child. A normal labour is said to occur when the mother by her
own efforts delivers a live healthy baby as a vertex presentation within 24hrs. The active phase
should not exceed 12 hours.

4.2.1 Signs of True Labour

1. Regular and Progressively (Intermittent) Strong uterine contractions after 28

weeks of gestation.
2. Blood stained mucus discharge (show)
3. Sudden gush of water (Breaking of membranes)
4. Progressive thinning and opening of the cervix (cervical effacement and
dilatation).

4.2.2 Signs of False Labour

1. No cervical dilatation and effacement.

2. No show.
3. No accompanying backache after contractions.
4. Contractions are erratic and no muscle (uterine) retraction.

4.3 STAGES OF LABOUR

First stage: It begins with the regular uterine contractions until the full dilation of the cervix.

 The latent phase: Is the period of cervical effacement which begins with the onset of
labor and ends when the cervix is 4cm dilated. In a primigravida this phase lasts for about
6-8hrs.
 The Active phase: It started when the cervix reaches 5cm. Progress is more rapid with the
cervix dilation at a rate of 1cm per hour

47
Second stage: It starts from the full dilation of the cervix to the complete expulsion of the baby.

Third stage: It starts from the birth of the baby to the complete expulsion of the placenta and
membranes; it also involves the control of bleeding.

Fourth stage: It is the few hours after delivery, in which both mother and child are allowed to
rest and be observe closely.

4.4 GOOD PRACTICES AND SUPPORTIVE CARE DURING LABOUR

1. Explain all procedures, seek permission for examination and carry out procedures e.g.
abdominal examination.
2. Keep the woman informed about the progress of labour by discussing the findings with
her.
3. Praise the woman, encourage and reassure her that things are going well.
4. Ensure and respect the privacy of the woman during examinations and discussions.
5. Encourage the woman to bathe or wash herself and her genitals at the onset of labour
6. Always wash your hands with soap and water before examining the woman.
7. Ensure cleanliness of the delivery suite or area.
8. ENEMA should NOT be routinely given during labour. It should only be given if there is
an indication e.g. when there is complain of constipation on admission or at the onset of
labour or if the woman wishes to have it.
Therefore encourage the woman to eat and drink as she wishes throughout labour.

9. Allow the woman to be mobile during first stage of labour

10. Changing position can also help in relieving pain and discomfort.
11. Other methods of relieving pain includes:-
i. Calm and gentle voice of the birth attendant

48
 ii. Giving encouragement, reassurance and praises
iii. Relaxing techniques like deep breathing exercise,
iv. Massages, placing a cool cloth on the forehead.
12. Encourage and assist the woman to pass urine

4.4 MANAGEMENT OF LABOUR

Vaginal Examination (VE) is carried out to decide the stage of labour:

During the examination determine the following:

 Cervical effacement
 Cervical dilatation in centimeters
 Presenting part (head or buttock, by judging the hardness, smoothness or roundness).

49
4.4.1 Managing the first stage of labour (shouldn’t exceed 12hrs)

In the latent phase the cervix is 0-4cm dilated and contractions are weak, less than 2 in
10minutes.

1. Monitor the following every 1 hour:

Contractions:

 Frequency (once in how many minutes)

 Intensity (how strong)
 Duration (How long does it last in seconds)

Fetal Heart Rate: The normal FHR is 120 – 160 beats per minutes.

Any Sign of Emergency: E.g. difficulty in breathing, vaginal bleeding, convulsions or

unconsciousness (Refer)

2. Monitor the following every 4 hours:

- Cervical dilatation in cm: - Unless indicated, do not do a VE more than once every 4 hrs.
- Temperature
- Pulse
- Blood Pressure

3. Record the time of rupture of the membranes and the colour of the amniotic fluid.

4. If after 8 hours the contractions are stronger and more frequent, but there is no progress
in cervical dilatation with or without rapture of the membranes, refer immediately to a
General Hospital. It is a case of non – progressive labour.

50
 5. On the other hand, if after 8 hours, there is no increase in the intensity/frequency/duration
contractions, and the membranes have not ruptured and there is no progress in cervical
dilatation, ask the woman to relax. Advise her to send for you again when the
pain/discomfort increase and/or there is vaginal bleeding, and/or the membranes ruptur

In the active phase: when the cervix is 5cm or more dilated. Start plotting on the
PARTOGRAPH

1. Monitor the following every 30min.

- Frequency, intensity and duration of the contractions
- FHR
- Presence of any emergency sign

2. Monitor the following every 4hrs

- Cervical dilatation
- Temperature
- Pulse
- Blood Pressure

4.4.2 Managing the Second Stage of Labour (Shouldn’t exceed 1hrs)

The following are signs of second stage of labour:-

i. Full dilatation of cervix

ii. Bulging of the perineum
iii. Gaping of the anus
iv. Presenting part appears
v. Expulsive uterine contractions
vi. Retching and vomiting

1. Monitor the following every 5 minutes

- Frequency, duration and intensity of contractions

51
- FHR
- Perineal thinning and bulging
- Visible descent of foetal head during contractions
2. The upright positions such as standing, sitting, squatting and being on all fours makes
pushing easier, therefore, if the woman finds it difficult to push, or there is slow descent
of the head, you should help her to change position.
3. During the 2nd stage, the woman should be allowed to push down with contractions if she
has the urge.
4. Do not ask the woman to hold her breath and bear down as this can be harmful by
reducing the blood flow through the uterus and placenta, hence reducing the oxygen
supply to the fetus.
5. Bearing down efforts are not required until the head has descended into the perineum.
Therefore, the woman should not be advised to push actively until the fetal head is
distending the perineum. Occasionally, the woman feels the urge to push before the
cervix is fully dilated. This should be discouraged as it can result in oedema of the cervix
which may delay the progress of labour.
6. To prevent pushing at the end of the first stage of labour (before full dilation), teach the
woman to pant, i.e. to breath with an open mouth, take in 2 short breaths followed by a
long breath out
7. Teach the woman to be aware of her normal breathing encourage her to breath out more
slowly, making a sighing noise, and to relax with each breath.
8. It is not advisable to give the woman oxytocics to shorten the second stage
9. Ensure a controlled delivery of the head by taking the following precautions:
- Keep one hand gently on the head as it advances with the contractions.
- Support the perineum with the other hand during delivery and cover the anus with a pad
held in position by the side of the hand.
- Leave the perineum visible (between the thumb and the index finger)
- Ask the mother to breathe deeply and steadily with her mouth open, and not to push
during delivery of the head. Wipe the mouth and nose with sterile swab.

10. Feel gently around the baby’s neck for the presence of the umbilical cord around the
neck. If cord is presence:

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- If it is loose around the neck, deliver the baby through the loop of the cord, or slip the
cord over the baby’s head.
- If tight, clamp it and cut the cord, and then unwind it from around the neck.

11. To deliver the shoulders and rest of the body:

- Wait for spontaneous rotation which usually happens within 1-2 minutes
- Apply a gentle pressure downwards to deliver the anterior shoulder.
- Then lift the baby up, towards the mother’s abdomen, to deliver the posterior shoulder.
The rest of the baby’s body follows smoothly.
- Place the baby on the mother’s abdomen.

12. Note the time of delivery

13. Give immediate newborn care
14. Rule out the presence of another baby by palpating the abdomen and trying to feel for
fetal parts.

15. Follow these steps to cut the cord:

- Tie and cut the cord after 2-3 minutes during which time the cord will normally stop
pulsating. It results in an increased amount of blood being transfused into the
foetalcirculation and this help in avoiding neonatal anaemia.
- Put ties tightly around the cord at 2cm and 5cm from the baby’s abdomen.
- Cut between the ties with a sterile blade
- Look for oozing of blood from the stump. If there is oozing, place a second tie between
the baby’s skin and the first tie. Leave the stump dry.

16. Place the baby on the mother’s chest for skin-to-skin contact.
17. Cover the baby to prevent loss of body heat. If the room is cool, use additional blankets
to cover the mother and the baby.
18. Encourage the mother to initiate breastfeeding.

4.4.3 Active Management of the third stage of labour (Not More than 30min

3. Massage 53 1. Give 10
the units of
Uterus Oxytocin IM
4.5 WARNING SIGNS DURING LABOUR

1. Vaginal bleeding
2. Convulsion
3. Unconsciousness
4. Difficulty in breathing
5. Obstructed labour (lack of progress in cervical dilatation for 8hrs)
6. Preterm labour
7. Cord prolapsed
8. Foetal distress
9. Retained placenta or fragment
10. Perineal tear.

Test Item:
i. Identify the signs of second stage of labour
ii. Differentiate between True and False labour
iii. Discuss the management of the second stage of labour
iv. Describe Active management of the third stage of labour

STUDENTS’ ACTIVITY;

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Topic: Labour and Delivery

Learning outcome; the students will be able to

 Define Labour
 Differentiate True labour from False labour
 Itemize good practices and supportive care during labour
 Describe the management of the stages of labour
 Identify the danger signs during labour

Task; Using different sheets of Partograph, record the progress of labour for Mrs “A” and Mrs
“B” as provided in their case scenarios.
UNIT 5.0
TOPIC: SKILLS IN MANAGING LABOUR AND DELIVERY

Instructional Materials:

- Partograph
- Mama and Neonatalie model
- Pelvic bone

Teaching Method:

- Discussion
- Demonstration

Types of Assessment:

- Q&A,

Learning Objectives: At the end of the lesson the students will be able to;

 Demonstrate how to use the Partograph to monitor labour

 Demonstrate how to conduct normal vaginal delivery using the Mamanatalie model

Guide for Facilitator –

- Facilitator to group the participants,

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 - Guide them on how to manipulate the model
- Observe how they use the model.
- Ensure they take turn in demonstration while observations and corrections are made after
each trial
- Praise or correct each perform task appropriately

STUDENTS’ ACTIVITY

Topic – Skills in Managing labour and delivery using Models and Partograph

Learning outcome; the students will be able to

 Skillfully demonstrate how to fill the Partograph

 Skillfully demonstrate how conduct normal delivery using the model

Task; In Pairs, students take turn to demonstrate using the model

UNIT 6.0

TOPIC; POST PARTUM CARE

Instructional Materials:

- White board & marker

- flip charts
- VIPPs cards

Teaching Method:

- Discussion
- Demonstration

Types of Assessment:

- Q&A,

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Learning Objectives: At the end of the lesson the students will be able to;

 Define Postpartum
 State the objectives for postpartum care
 Describe the care during postpartum
 Discuss the Postpartum complications
 Identify Danger signs in the Newborn

6.0 INTRODUCTION

The postpartum/ post natal period is a critical phase in the lives of mothers and newborn babies.
Most maternal and infant deaths occur during this time. Yet it is the most neglected period for
the provision of quality care.

6.1 DEFINITION OF POSTPARTUM

Postpartum is the period starting after the delivery of the baby and placenta to six weeks after
delivery. It is also called post natal or Puerperial period. Post natal care: is the care given to
mother and child during the puerperium.

6.2 Objectives of post-partum care

- Early detection of complications and abnormalities

- Ensure the initiation of exclusive breastfeeding
- To motivate Mothers for family planning
- To initiates routine immunization for baby
- Appropriate referral when the need arises.

6.3 POSTPARTUM CARE

1. Establish mother to baby contact which encourage bonding, by placing the baby on the
mother’s chest
2. Clean the mother by:
- Swab the vulva.
- Check for abnormalities like prolapsed, growth

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 - Check for lacerations, tears and bruises
- Check for bleeding, note the color, quantity and odor
- Apply sanitary pad
- Educate on vulval hygiene
3. Examine the uterus for firmness to ensure good contraction
4. Estimate blood loss (Average 150-300mls) Control haemorrhage through:
- Rubbing the uterus for contractions every 15 minutes for 2 hrs
- Check placenta and membranes for completion.
- Repair any tear, laceration or episiotomy immediately
5. Check the vital signs
6. Encourage emptying the bladder
7. Encourage Mother to take warm food
8. Give the mother and baby time to rest
9. Observe mother’s attitude toward her baby
10. Initiate breastfeeding at least 30 minutes - 1 hour after delivery
11. Educate on proper nutrition with plenty of fruits and vegetables for mother
12. Place on oral medication of Antibiotics, Analgesics and haematinics/ vitamin C

6.3.1 Post Natal Visit

The first 48 hours following delivery is very crucial to the survival of both mother and child
during the postpartum period.

 The first visits is therefore scheduled within the 1st 48hrs

 The second visit is carried out after the 1st week of delivery.
 The third visit is carried out by the 6th week of delivery.

6.3.2 Post Natal Check Ups

1. Observe the general wellbeing/ physical appearance.

- Excess tiredness and unwell looking may indicative of anaemia, hypoglycaemia or
developing infection.
- Encourage adequate rest as excess fatigue can lead to depression.

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 2. Examine the abdomen for contraction of the uterus
- Check if uterus is hard,well contracted
- If it is soft- think of uterine atony
- If tender and soft-infection is likely present
- Check for involution- the uterus weigh 1kg after labour and can be felt just below the
umbilicus, by the end of puerperium it goes back to its pre- gravid stage
3. Examine the breast for cracks and soreness of nipples.
- Advice on proper positioning during breastfeeding,
- Advice on breast hygiene (no soap should be used in cleaning the breast before breast
feeding)
4. Examine the perineum for any tear, nature of healing, amount of bleeding, nature of
lochia- normal or foul smelling?
5. Check the vital signs – BP, temp, pulse, respiration. High temp and pulse rate is a
cardinal sign of sepsis.
6. Advice on diet and give Vitamin A supplement (200,000 iu) to mothers.
7. Give third dose of T.T immunization.
8. Provide child spacing options
9. Counsel on:
- Exclusive breastfeeding,
- Complimentary feeding,
- Routine immunization.

6.4 POST PARTUM COMPLICATIONS

1. POST PARTUM HAEMORRHAGE (PPH)

It is a blood loss of 500mls or more from the reproductive organs after delivery, or any amount
sufficient enough to cause symptoms. Any amount of bleeding can cause shock in a woman who
is unready anaemic.

 Primary PPH – it is the blood loss that occurs during the 3 rd stage of labour and within
the first 24hours of delivery.

59
  Secondary PPH – it is the excessive bleeding which occurs after 24hours and within
the 6 weeks of delivery. Commonly caused by infection.
Causes

1. Uterine inertia (atony)

2. Retained placenta or fragment of membranes
3. Ruptured uterus.
4. Uterine inversion
5. Disseminated intravascular coagulopathy (DIC)

Signs
1. There is uterine atony
2. Heavy bleeding occurs few minutes after delivery
3. The blood gushes out
4. The uterus is big and soft
5. The uterus rises above the umbilicus
6. There is low BP (systolic of less than 90mmHg), weak and rapid pulse (above 110/min.)
7. The skin is cold and clammy
8. There will be shock or fainting
9. Rapid breathing (greater than 30/min.)
10. Scanty urine less than 30mls/hr.

Risk factors
1. Over distended uterus e.g. in twins, big baby, polyhydramnious.
2. Prolonged labour.
3. Severe pre eclampsia/eclampsia.
4. Prolonged labour.
5. APH - it weakens the uterus.
6. Anaemia.
7. General anesthesia.

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Prevention of PPH
1. Prevent prolong labour (use partogrph).
2. Practice active management of third stage of labour.
3. Avoid perineal/vaginal tear.
4. Monitor woman closely after childbirth.
5. Ensure that you are prepared for any emergency.

2. PUERPERAL SEPSIS
It is a bacterial infection originating in the reproductive tract during labour or the puerperium.

Signs and symptoms

1. Fever
2. Tachycardia
3. Offensive vaginal discharge
4. Bulky uterus
5. Lower abdominal pains
6. Chills and rigors.

OTHER PUERPERAL INFECTIONS:

a. Endometriasis: it is the infection of the endomerium or deciduas with extension into the
myometrium and perimetrial tissues.

b. Pelvic abscess: It is the collection of pus within the pelvis. The cause may be septic procedure
during labour or preexisting STI.

c. Peritonitis: It is the infection of the peritoneum.

d. Tetanus: It is an infection caused by the bacteria clostridium tetani. It is common in

unsupervised septic delivery at home.

3. BREAST PROBLEMS

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These are conditions affecting the mammary glands which can interfere with breastfeeding.
a) sore/cracked nipples: it is a condition in which the nipples develop fissures and become sore
and painful.

b) Breast engorgement: it is a condition which occurs when the breast milk is not sufficiently
emptied leading to accumulation. The breast is enlarged, painful and tender.

c) Retracted/inverted nipples: it is a condition in which the nipples are below the level of the
skin surface i.e. does not protrude beyond the areola surface and breast feeding becomes
difficult.

d) Breast Abscess: it is a localized collection of pus in the breast which can be very painful and
tender. It usually follows acute mastitis.

e) Mastitis: it is the inflammation of the breast tissues, usually due to bacterial infection which
could occur in the puerperal period and can interfere with lactation.
1. OTHER MEDICAL CONDITIONS IN THE PUERPERIUM
i) Postpartum aneamia
ii) Sickle cell disease
iii) Postpartum eclampsia
iv) Postpartum depression and psychosis

6.5 DANGER SIGNS IN THE NEWBORN

1. Difficulty in breathing
2. Convulsions, spasm, loss of consciousness or arching of the back
3. Cyanosis
4. Fever
5. Hypothermia
6. Heamorrhage
7. Jaundice
8. Pallor

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9. Diarrhoea
10. Persistent vomiting or abdominal distention
11. Poor suckling or not feeding well
12. Pus or redness of the umbilicus, eye, or skin
13. Swollen limps or joints
14. Floppiness
15. Lethargy

Test Items
- Identify the time for post natal visits and describe the care provided to be provided

STUDENTS’ ACTIVITY

Topic – Postpartum Care

Learning outcome; the students will be able to;

 Define Postpartum
 State the objectives for postpartum care
 Describe the care during postpartum
 Discuss the Postpartum complications

Task; Brainstorm and make a comprehensive note on how to manage danger signs during
pregnancy, labour and delivery and complications during the postpartum period

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MedicineNet (2020) Early pregnancy symtoms and stages week by week. www.medicinenet.com

National Guideline for HIV Prevention, Treatment, and Care, (2016)

Neelofur D, et al. Alternative versus standard packages of antenatal care for lowrisk
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