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UNIT SIX COMPONENT OF FOCUSED ANC (FANC) APPROACH Learning objectives     Explain steps of history taking Perform physical

examination Perform abdominal examination Calculate EDD & G.A

Introduction
 Traditional or western antenatal care model => in low risk pregnancy, the pregnant woman is seen every four weeks until 28 weeks, then every two weeks till the 36th weeks and weekly until delivery. For high – risk woman the obstetrician decide the frequency of visit according to the risk situation.  Traditional or western model was criticized for being traditional rather than scientific evidence based screening method. Studies showed that it was not effective in reducing most adverse pregnancy out comes and hence could not justify the enormous cost incurred in the process.  The only disease for which antenatal care was shown to be effective in reducing includes detection and treatment of anemia, possible prevention of eclampsia and detection of UTI.   Most complications of pregnancy were noted to be sudden in onset and unpredictable by screening procedure & hence not preventable. Based on the above findings, WHO has suggested a new model of antenatal care with fewer antenatal visits in which targeted and evidence based tests are conducted at specific phases of pregnancy.  The new antenatal care model reduces cost and leads to better time for evaluation of patients due to small number of visits. Pregnancy outcome was not adversely affected by a shift to the new component.

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In the new antenatal care model an initial assessment is made to classify pregnant mothers in to those who are eligible for the basic component and those that need specialized care.

What is Focused / Goal - Oriented Antenatal Care ? Focused antenatal care (FANC) refers to a minimum number of 4 antenatal clinic visits, each of which has item 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.

ANC provides opportunities for:

1. Promoting healthy living. 4 GOALS 2. Preventing some complications of pregnancy and child birth. 3. Early detection and prompt management of problems. 4. Birth and emergency planning.

COMPONENTS OF FANC: includes 1. Assessment of Pregnant women 2. Detection and management of complication 3. Health promotion and preventive care and support including HIV. 4. Birth planning and emergency preparedness

DEFINITION OF TERMS. GRAVIDITY - Pregnancy GRAVIDA   PARA A pregnant women.

Primigravida - A woman pregnant for the first time. Multigravida - A woman who has had two or more pregnancies. - A woman who has produced a viable infant (28 wks of gestation)

regardless of the outcome. 2

    Examples

Nullipara - a woman who has not given birth to a child. Primipara – a woman who has given birth to one child only. Multipara - a woman who has given birth to more than one child. Grandmultipara - A woman who has given birth to 5 or more children.

1. A woman with 2 abortion and 2 deliveries are  G IV P II abortion II . 2. A woman with 1 abortion, 3 deliveries and 2 stillbirth are  G VI P V abortion I 3. A woman with 1 abortion and no alive children are  G I P 0. Abortion I. 4. A pregnant woman with one abortion, 2 still birth, and two deliveries are  G VI P IV abortion I.

1. Assessment of pregnant woman 1.1.History taking (personal, social, & family history) Purpose of history taking To assess the health of the woman. To find out any condition that may affect child bearing. For statistical purpose – to record facts. 1. Personal and social history. Name, age, marital status, occupation, religion and address. Information on marital status and occupation are important in assessing socio– economic status of pregnant woman. 2. Family history. Ask history of chronic illnesses like hypertension, diabetes, and psychiatric disorders. Family history of twinning, birth defects and hereditary illnesses is very important.

3. Past medical and surgical history. Ask past episodes of acute or chronic medical illnesses, their duration, treatment outcome, follow up and current status. History of previous blood transfusions, drug hypersensitivity. History of maternal infection and treatment during pregnancy including syphilis and other sexually transmitted infections is noted. 3

Up to 25% or more may not remember their LNMP. 5. Such detailed information is important because almost all major obstetric complications have significant recurrence risks. illiteracy and repeated pregnancies. 4. EDD. History of present pregnancy begins with a summary of past reproductive history and then the first day of the last normal menstrual period (LNMP). the last cycle should have been normal and similar to previous cycle in amount and duration of flow. number of deliveries after 28 weeks ( para). GA by date). intrapartum or post partum complications. Detail information is required on number of total pregnancies (gravida). abnormal labour including prolonged and obstructed labour. abortion. These pregnancies with unknown LMP are considered high–risk pregnancies. Abortion. If there is question as to the reliability of LNMP. This section of the obstetric history includes a detailed chronological documentation of all previous pregnancies.Surgery involving the uterus resulting in uterine scars is of particular significance. This is the most important part of the obstetric history. fetal outcome. preterm labour. whether alive or dead. SB. and number of live births. fetal birth weight. In order to ascertain the reliability of the LNMP. Such scar may dehisce during pregnancy or labour. the menstrual cycle should have been regular.- A history of pelvic surgery is important. LBW). fetal presentation. It includes detailed chronological description of the pregnancy from the first missed period. Important obstetric conditions like ectopic pregnancy. and fetal congenital anomalies have significant recurrence risks. the length of gestation. post term pregnancy. Para. Present pregnancy history (LMP. mode of delivery and the presence of antepartum. the expected dates of delivery (EDD) or confinement (EDC) and the gestational age (GA) in completed weeks are documented. and hormonal contraception should not have been in use for the three months prior to the LNMP. as they are often associated with low socio – economic status. stillbirth. Past obstetric history ( Gravida. This includes year of occurrence of the pregnancy. 4 . duration of labour. confirm it by other means.

LMP 3 / 2 / 88 + 10 +9 EDD 13 / 11 / 88 4. Average duration of a human pregnancy is 280 days or 10 lunar months. If this pregnancy passes pagume we add 5 days if pagume has 5 days. 3 / 4 / 87 +5 -3 EDD 8 / 1 / 88 EDD 8 / 1 / 88 3. we can calculate the EDD and gestational age. (or adding 9 months ). 10 days are added if this pregnancy does not pass pagume. LMP 10 / 4 / 80 +7 +9 EDD 17 / 1 / 81 or 10 / 4 / 80 +7 .3 17/ 1 / 81 In the Ethiopian calendar each month has 30 days. LMP 3/ 4/ + 5 +9 87 2. eg. To count 280 days from NMP Count 9 months forward x30 = 270 days.Once LNMP is ascertained. and we add 4 days if pagume has 6 days. LMP 6 / 8 / 90 + 4 +9 EDD 10 / 5 / 91 5 . The EDD for the European (Gregorian) calendar is calculated using the Naegle’s rule that subtracts three months and adds seven days to the LNMP. 1.

pulse rate. LMP 6 / 7 / 98 211 days ÷ 7 Examination day = 30 +1 2 / 2 / 99 G.2. & temperature are important in the evaluation of the obstetric client particularly in emergency obstetric situations. Gestational age is the estimated age of the fetus expressed in weeks. Gestational age calculation is based on the assumption of a regular twenty . respiratory rate. Privacy should be maintained. examination of various organ systems. Counting from the first day of LMP up to the date when the mother comes for antenatal examination. 2. 1. eg. anthropometric measurements.2. 6 . EXAMINATION OF VITAL SIGNS Measuremement of blood pressure. abdominal examination and pelvic assessment.1. The abdominal examination should be completed in a reasonable period of time in order to avoid fainting and dizziness due to supine hypotension syndrome following vena – caval compression by the gravid uterus: 1. 1.A = ÷ 7 = 8 weeks + 6 days. PHYSICAL EXAMINATION Physical examination of the obstetric mother includes evaluation of the general appearance. A comfortable couch should be available.The length of time from conception to birth. vital signs. However a rate of more than 100 per minute (tachycardia) is abnormal during pregnancy. LMP 1 / 8 / 96 Examination day 8 +6 3 / 10 / 96 62 days G.eight days cycle with ovulation occurring on the fourteenth day.GESTATIONAL AGE Gestation . The pulse rate increased by 10-15 beats per minute during normal pregnancy.A = 30 weeks +1 day.

Arterial blood pressure (ABP) measurement is an important evaluation during pregnancy because of increased prevalence of hypertensive disorder of pregnancy and hemorrhagic shock. The patient should be sitting or at 30 degrees left lateral tilt with measurement taken from the right arm. 7 . it gradually increases as pregnancy approaches term. The last definition is said to have a sensitivity of less than 30% and is not nowadays used to diagnose hypertension during pregnancy. and acute febrile illnesses. Important causes of fever include chorioamnionitis. Another less commonly used definition is a rise of 30 mmHg and 15mmHg in the systolic and diastolic level respectively compared to the pre–pregnancy (early pregnancy) levels. febrile illness or respiratory tract infection among other possible causes. Hence the true pre pregnancy ABP can be depicted from pre-pregnancy or early pregnancy measurements only. The measuring apparatus should be at the level of the heart. Due to changes in vascular tone and blood volume alterations in cardiovascular physiology during pregnancy. However. preterm labour etc. Fever during pregnancy is a very important finding as it indicates the presence of serious illnesses lead to serious complications such as abortion. If a pregnant woman is first seen for the first time at mid pregnancy the diagnosis of chronic hypertension may be masked due to normalization of the high B/P due to the physiologic lowering of B/P at this time. Then after. Hypertension during pregnancy is defined as an ABP above 140/90mmHg measured at least twice six hours apart. Progesterone induced central respiratory stimulation during pregnancy increases respiratory rate by 1–4 breaths per minute. the ABP gradually decreases until the second trimester from the pre pregnant level. a measurement of severe hypertension of 160/110 mmHg or more only once is adequate for diagnosing hypertension. Hence correct and accurate measurement of ABP is essential.This may indicate anaemia. Blood pressure should never be taken in the supine position in a pregnant mother due to supine hypotension syndrome leading to a false lowering of the blood pressure. urinary tract infection. This is also responsible for the breathlessness and dyspnea experienced by the pregnant mother. cardiac illness.

please refer to previous note. & throat examination  Lymph glandular examination The thyroid gland volume increases by about 25% during pregnancy.B . ears. flat. Ear – any discharge Nose – any bleeding or polyp  Heads. nose. SYSTEMATIC PHYSICAL EXAMINATION Examination started as she walks in:       Any deformity Stunted growth….palpation of a breast lump is more difficult during pregnancy due to increased vascularity & fat deposition. bad teeth. Height – Previously maternal height less than 150cm was considered as a risk factor for contracted pelvis and development of cephalo-pelvic disproportion – nowadays we consider every pregnancy is at risk. However the thyroid should not be visibly enlarged.Examine chest for any breathing problem. 1. It is important to identify and treat retracted nipples during antenatal period as time will not allow this to be performed in the puerperium when breast feeding has to be initiated as soon as possible. oedema of the face etc. N.  Breasts o Size. any lump o Retracted nipples.2.2. Abdominal examination 8 .  Cardiovascular examination  Cardiovascular system should be examined. eyes. Pregnant women may have symptomatic or asymptomatic heart disease.Anthropometric measurements include: Weight . Head – clean & healthy Face – does she look healthy? Check for signs of anaemia (conjunctiva).  Chest examination .

.  Vulva Any vaginal bleeding. Pelvic assessment may be conducted at any time during pregnancy when a specific complication arises. Pelvic assessment at term. . . In routine antenatal care follow up. pelvic assessment is usually performed on two occasions.Use comfortable couch. The purpose of pelvic assessment is it help to decide on the mode of delivery. Mothers who need pelvic assessment at term include:  Primigravida Multiparous mother 9 making the procedure easier .Strict asepsis.She should not be kept in supine position for long. The purposes of this examination are to diagnose pregnancy. 1. . 2. however. Early pregnancy pelvic examination 2.At the end of the examination the woman should be placed in the lateral position first before being asked to rise from the supine position.Specific contraindications to the pelvic examination in pregnancy include vaginal bleeding after the 28th week of pregnancy and premature rupture of the membranes. Early pregnancy pelvic examination.Abdominal examination.. This is performed during the first trimester as early as possible during pregnancy when the uterine size is small and does not preclude adnexal assessment. discharge etc  Pelvic examination . to date pregnancy by assessing uterine size & to diagnose adnexal & uterine pathologies such as myoma and ovarian tumors. The assessment is performed at term because the increased secretion of estrogen and progesterone make the soft tissues of the pelvis and vagina lax to perform and less discomforting. including the obstetric palpation is the most important component of the examination of obstetric women. Pelvic assessment at term 1.

N.  Previous history of pelvic fracture.  Examination of the extremities .Varicose vein. It may be aggravated during pregnancy.head is the best pelvimeter and head fitting can be of great value. N. birth 10 . History of difficult and prolonged labour  Breech presentation. Acute pyelonephritis is a common complication of pregnancy.Deep vein thrombosis (DVT) may lead to the development of unilateral oedema.Oedema if there is generalized oedema .B The pelvic assessment is also performed for every mother in labour at admission.  Mother with previous caesarean who require decision on vaginal after caesarean ( VBAC ). B .  Mother with skeletal anomalies.  Central nervous system examination Examination of the level of consciousness and deep tendon reflexes may be important in obstetric patients with per – eclampsis . eclampsia and embolization. Pelvic assessment . The presence of varicose veins is also a risk factor for the development of DVT.Any deformity .  Genitourinary examination The presence of costovertebral and suprapubic tenderness is important in the diagnosis of UTI.

The part of the fetus coming first and felt on vaginal examination. 8%  Shoulder 4% (1 in 250)  Face 0. B . DEFINITION OF TERMS FETO – PELVIC RELATION SHIP MECHANISM .     Normal  flexion.3. N. Abnormal  Posterior ( malposition).Relationship between the long axis of the fetus and the long axis of the mother’s uterus. To diagnose the location of fetal parts. with her arms down by her side.ABDOMINAL EXAMINATION AIMS OF ABDOMINAL EXAMINATION To observe signs of pregnancy.Series of movements of the fetus in his passage through the birth canal. . To assess fetal & maternal health.The mother should be with empty bladder. Normal Abnormal  breech 2.Should lie on her back. LIE . PRESENTATION . ATTITUDE . POSITION – Relationship of the denominator to the six areas of the mother’s pelvis.2% (1 in 500)  Brow 0.Relationship of the fetal parts to one another.the part of the fetus which lies in the lower pole of the uterus.1% (1 in 1000) PRESENTING PART . Abnormal  Extension.1.5% 11 . To detect any deviation from normal. To assess fetal size and growth.   Normal  anterior or lateral.  Vertex 96.

________________ o LONGITUDINAL LIE ________________ Figs 10.  No denominator is used.DENOMINATOR – The part of the fetus which tells the position.11 Figs 10.  Mentum.      In vertex In breech In face  Occiput. In shoulder  Acromion process.when the bi – parietal pass the pelvic brim.when the bi – parietals pass the ischial spines and the head no longer recedes between contractions.10 OBLIQUE LIE Figs 10.13 12 .  Sacrum. In brow ENGAGED . CROWNED .

Right occipitolateral. Right occipitoposterior. Left occipitoposterior. Left occipitolateral.SIX POSITIONS IN VERTEX PRESENTATION Left occipitoanterior. 13 . Right occipitoanterior.

dorso-anterior presentation Shoulder.THE FIVE PRESENTATIONS Vertex presentation Face presentation Brow presentation Breech Presentation Shoulder. dorso-posterior presentation 14 .

Size . . Shape . 15 .Fundal palpation Purpose . o Multipara . 3. PALPATION The hand should be clean and warm.Any operation scar.measure distance of fundus with points on abdomen.is it round.usually ovoid with longitudinal lie. B .lineanigra.note contour . Palpation.broad.To know lie. Fundal height . any rash. 2. N. o Transverse lie . previous section. oval.Sometimes the fetus can be seen moving. Auscultation. Skin . G. INSPECTION Remember the 4” S”. see if head or breech is there. 1 .round.Is it roughly the size it should be? twins. Fundal height can be determined by the finger method. Use the whole hand with fingers together and move hands gently. irregular or pendulous? o Primigravida . Inspection.STEPS FOR ABDOMINAL EXAMINATION 1. Scar . by using landmarks on the abdominal wall and by the tape measure of symphysis – fundal height (SFH) in centimeters.A and presentation It is the first maneuver – palpate fundus. hydramnios etc. myomectomy scar.should correspond with the estimated period of gestation.

This method is believed to be less reliable than the tape measure due to individual variations in finger size and methods of measurement. the xyphoid process at 36 weeks. The fundus just palpable above the symphysis is taken as 12 wks size. and then often returns to about 4cm below the xyphoid due to “lightening” at 40 weeks. one finger breadth is taken as one week below the umbilicus and two weeks above the umbilicus due to the faster growth of the fetus in the second half of pregnancy. More than two weeks positive or negative discrepancy requires further investigation as to possible cause. Fig.- After determining the location of the fundus.2 Fundal palpation 16 . It reaches the umbilicus at 20 – 22 wks. Fundal height to gestational age discrepancy of less than plus or minus (+) two weeks is considered acceptable. 10.

17 .3 Lateral palpation. Pressure is applied alternately with each hand. The flat and straight surface n ne side signifies the back whereas the irregular soft parts indicate the side where the fetal extremities are located. It is the second Leopold maneuver is intended to determine the lie of the fetal back. transverse or oblique. The lie of the fetus implies the configuration of the longitudinal axis of the fetus in relation to the longitudinal axis of the uterus. Fig.To know lie & position. 10.2 . The lie can be longitudinal. Purpose .Lateral palpation. Hands placed at umbilical level on either side of the uterus. Identification of the back helps in auscultating the fetal heart beat. The lateral palpation is performed alternately on both sides by using one hand to stabilize the uterus at the same time using the other hand for palpation.

The higher cephalic prominence (the sincipital) will be on the side opposite to the back.Fig.5 Method of pelvic palpation used to determine position in a vertex presentation. The palpation is conducted by using both hands starting from the level of umbilicus and gradually descending downwards to the pelvis. 18 . Purpose – To know presentation and attitude It is the third Leopold palpation.Deep pelvic palpation. 10. Fig 10.4 'Walking' the finger tips across the abdomen to locate the position of the fetal back 3 . The midwife should ask the woman to bend her knees slightly in order to relax the abdominal muscles and suggest that she breaths steadily through an open mouth.

the bulk of the head is felt on the same side as the back. the occipital and sincipital prominences are located. Although it is not part of the third palpation. A floating head is taken as 5/5th above the brim. the prominences are on the same level. 19 . One should be particularly gentle in performing the third and fourth palpations in a patient with ante partum haemorrhage due to placenta praevia. In order to determine if the vertex is presenting. - If the head is deflexed. Fetal head above the brim is measured in fingers and expressed as fifth (five fingers are taken as the breadth of the fetal head). If the head is extended. the outstretched thumbs will meet at about umbilical level. The fingers are directed inwards and downwards. Fig 10. - If the head is well flexed. a hard mass with distinctive round. descent of the fetal head can be identified as fifth of fetal head felt above the brim. the sinciput will be felt on the opposite side from the back and higher than the occiput. 2/5th denotes an engaged fetal head. If the hands are in the correct position. smooth surface will be felt.6 Pelvic palpation.- The examiner faces the foot of the patient while performing the third palpation In cephalic presentation.

The lower pole of the uterus is grasped with the right hand. N. One may skip this palpation if all information is obtained from the third palpation (pelvic palpation). B . It is also used to judge the size and flexion.In some books deep pelvic palpation is taken as fourth Leopold maneuver and pawliks grip as third Leopold maneuver. 10.4 . N.To identify the fetal presentation and its mobility above the pelvic brim.7 Pawlik's manoeuvre. Fig.pawlik’s grip. Purpose . The midwife facing the woman’s head and grasps the lower pole of the uterus between the fingers and thumb which should be spread wide enough apart to accommodate the fetal head.This palpation is more discomforting than the other palpations perform gently. the midwife facing the woman's head. 20 . B .

Fig. Fetal heart can be auscultated starting from the 10thweek using doppler ultrasonography. In breech – presentation. 21 . the FH are best heard in the region of the flanks. 10. The stethoscope should be moved about until the point of maximum intensity is located where the fetal heart is heard most clearly. In occipitoposterior position.8 Auscultation of the fetal heart. Normal fetal heart beat is between 120 and 160. the FH are best heard above the umbilicus. the FH are best heard below the umbilicus.AUSCULTATION Purpose . In cephalic– presentation. It is placed in the mother’s abdomen and at right angles to it. count for a full minute. Vertex left occipito-anterior. With the fetal heart stethoscope it can be auscultated from the 20th week on wards. With ultrasound it can be auscultated from the 6th weeks. The ear must be in close. firm contact with the stethoscope but the hand should not touch it while listening because extraneous sounds are produced.To assess fetal well–being Pinard’s fetal stethoscope is commonly used to hear the fetal heart. The fetal heart sounds are heard over the area of the left scapula.

Screen all pregnant mothers for HBV using the HB surface antigen (HbsAg). For all pregnant women voluntary confidential counseling and testing (VCCT) should be done. Screening tests for syphilis like the VDRL (venereal diseases research laboratories) or RPR (rapid plasma regain) should be done at initial visit and repeated during pregnancy.4. For Rh –ve woman indirect coomb’s test is performed on first visit and repeat at 28 and 34 weeks. ABO blood grouping of the mother and the fetus is also important in rare instances of ABO incompatibility leading to hemolytic disease of the new born. Blood group and Rh status => Performed at initial assessment.5 gm / dl. 22 . Rh –ve mother is at risk for isoimmunization injury to her fetus if her partner is Rh positive. Treat syphilis before 18 wks or earlier so that congenital infection and resulting injury can be avoided.LABORATORY INVESTIGATIONS Laboratory investigations and diagnostic procedures are performed with the intention of identifying risk factors that cannot be identified from the history and physical examination. Anemia is defined as a Hgb level of less than 10. This “Physiological anemia of pregnancy” decreases the hemoglobin level up to 11gm /dl. Serology for syphilis. Hematological tests Some of the hematological tests commonly performed are:Hemoglobin => Hgb concentration level falls during normal pregnancy due to physiological hydremia following excessive plasma volume increase compared to red cells increment. Screening for the human immunodeficiency and hepatitis B virus infections.1. Determine Hgb at the first visit and repeated at 32 – 36 weeks of gestation.

glucose. It’s incidence in pregnancy is about 7%. Urine culture and sensitivity Asymptomatic bacteruria .absence of symptoms or signs of UTI. 23 . ketones and presence of WBC indicating infection. contamination by vaginal discharge or bleeding etc. It is important to perform urine culture and sensitivity for all pregnant mothers at initial visit and treat accordingly to prevent pyelonephritis. 40% of women with asymptomatic bacteruria develop acute pyelonephritis during pregnancy. Ketonuria indicates severe nausea and vomiting which has lead to starvation ketosis. During pregnancy protein excretion is increased from the non – pregnant level of less than 16 mg / dl to 300mg / dl per 24 hrs. To avoid contamination – careful specimen collection (clean catch midstream specimen). Glycosuria is detectable in up to 50% of pregnancies due to increase in the glomerular filtration rate. Proteinuria is detected in UTI. pregnancy induced hypertension. It should be investigated by blood glucose testing.Urinalysis Urine is analyzed for protein.

In the new antenatal care model an initial assessment is made to classify pregnant mothers in to those who are eligible for the basic component and those that need specialized care. Obstetric history       Previous stillbirth or neonatal loss. History of three or more consecutive spontaneous abortions. classical C/S. Studies showed that it was not effective in reducing most adverse pregnancy out comes and hence could not justify the enormous cost incurred in the process. Most complications of pregnancy were noted to be sudden in onset and unpredictable by screening procedure & hence not preventable. Last pregnancy: hospital admission for hypertension or preeclampsia / eclampsia. then every two weeks till the 36th weeks and weekly until delivery. Previous surgery on reproductive tract (myomectomy. Based on the above findings. For high – risk woman the obstetrician decide the frequency of visit according to the risk situation. The only disease for which antenatal care was shown to be effective in reducing includes detection and treatment of anemia. Pregnancy outcome was not adversely affected by a shift to the new component. removal of septum. The new antenatal care model reduces cost and leads to better time for evaluation of patients due to small number of visits. cervical cerclage). Birth weight of last baby < 2500gm. WHO has suggested a new model of antenatal care with fewer antenatal visits in which targeted and evidence based tests are conducted at specific phases of pregnancy. cone biopsy. Traditional or western model was criticized for being traditional rather than scientific evidence based screening method. the pregnant woman is seen every four weeks until 28 weeks.UNIT 7 TIMING AND FREQUENCY OF FOCUSED ANC APPROACH Traditional or western antenatal care model => in low risk pregnancy. Women with the following conditions are not eligible for the basic components of the new antenatal care model. 24 . possible prevention of eclampsia and detection of UTI. Birth weight of last baby > 4500gm.

Age less than 16 yrs. 3. education and care to ensure the prevention of or early detection and prompt management of complications. Isoimmunization in current or previous pregnancy. 25 . Age greater than 40 years. 4 GOALS 2. Promoting healthy living. A major new focus is on birth planning and emergency preparedness. each of which has item of client assessment. Any other severe medical disease or condition. Vaginal bleeding. Known substance abuse including alcohol. Cardiac disease. 4. Preventing some complications of pregnancy and child birth. Early detection and prompt management of problems. What is Focused / Goal . N.B The obstetrician decides the frequency of visits and pattern of care for mothers with the above risks on an individual basis.Current pregnancy        Diagnosed or suspected multiple pregnancy. Birth and emergency planning. Renal disease. Diastolic blood pressure > 90 mmHg at booking.Oriented Antenatal Care ? Focused antenatal care (FANC) refers to a minimum number of 4 antenatal clinic visits. Pelvic mass. ANC provides opportunities for: 1. General medical conditions      Insulin dependent diabetes mellitus.

Request relevant laboratory investigation (Hb. 4th visit : 38 weeks (36-40 weeks). VDRL. Activities to be conducted at each visit are as follows. Blood pressure measurement. 3rd visit : 32 weeks (30-32 weeks). 2. 2nd visit: 26 weeks (24-28 weeks). Educate and counsel client. 1st visit : before 12 weeks (<16 weeks).                    Classify the women for the basic and specialized component of the program. 26 . Clinical examination for anemia Obstetric examination: gestational age estimation.How frequently should women be seen in pregnancy? 1. Recommendation for emergencies. blood group and Rhesus type. Tetanus toxoid administration. urine analysis).g. 4. Blood pressure measurement. Treat syphilis. Urine test for protein (only nulliparous women / women with previous pre – eclampsia) Iron / folic acid supplementation. Complete antenatal card. uterine height. Maternal weight (only women with low weight at first visit). and fetal heart rate. First visit activities (before 12 weeks (<16 weeks). Give appointment for the 2nd visit. These activities are supported by currently available scientific evidence to have benefits that justifies the cost. Obstetric exam . uterine height. Take action on result of laboratory tests e.gestational age estimation. Initiate discussion on birth and emergency planning. Each visit should be targeted to specific tasks. 3. Iron / folic acid supplementation. Second visit: 26 weeks (24-28 weeks). Clinical examination.

Perform pelvic examination to defect any soft tissue abnormality. Check the uterine size and palpate the fetus (lie. Use the time saved to discuss the woman’s birth plan and educate her on symptoms and signs of pregnancy complications or complications in labour.      Detection of breech presentation and referral for external cephalic version. Tetanus toxoid (1month after the first TT). Instructions for delivery / plan for birth. Fourth visit 38 weeks (36-40 weeks): in addition to second and third visit activities. Third visit 32 weeks (30-32 weeks): In addition to 1st and 2nd visit. FH sound etc). Check the uterine size and palpate fetus (lie. presentation. Checking for leg oedema (except when included in generalized oedema).      Complete antenatal card. 27 . Hgb test requested. AVOID WASTING TIME ON UNPROVEN PRACTICES There is no evidence that the following procedures are of value during antenatal care:     Routine weighing of woman Measurement of woman’s height Measurement of woman’s shoe size. Recommendation for lactation / contraception. Educate and counsel about symptoms / signs of labour. engagement. presentation etc). Review Birth plans with client.

Pregnant woman should have liberal fluid intake. fruit juice. protein. Not lifting heavy loads. Bathing Diet rich in iron. Daily cleaning with particular attention to the nipples is encouraged. Rest. vitamins and minerals.0. 28 . recreation. comfortable shoes. Pull out and roll each nipple between the fingers about three times a day to make it more protractile.UNIT 8 Health promotion and preventive care and support including HIV 2. Advice on TT vaccination.          Clothing. NO SMOKING and NO ALCOHOL.ADVICE TO THE PREGNANT WOMAN The antenatal clinic is the school of the pregnant woman. Adequate intake of fluid and fruit should prevent constipation. POINTS TO BE ADVICED ON     Exercise. at least 10 hrs at night and 2 hrs in the afternoon. she is usually very willing to listen. Marital relations should be avoided if history of abortion. Breast care – teach how to take care of her breasts so as to promote successful breast feeding. milk etc. Daily fluid requirement of 2 lit could be taken in the form of water.

2.1. There is no contraindication to administration of TT.TETANUS TOXOID VACCINATION Tetanus toxoid (TT) immunizations of child bearing women in national EPI are 15 – 49 years. A five dose of TT immunization for women of child bearing age is recommended schedule. Tetanus toxoid immunization schedule for women of child bearing age DOSE WHEN TO GIVE EXPECTED DURATION OF PROTECTION TT1 TT2 TT3 TT4 TT5 At first contact or as early as possible in pregnancy At least 4 weeks after TT 1 At least 6 months after TT 2 At least one year after TT 3 or during subsequent pregnancy At least one year after TT4 or during subsequent pregnancy Lifelong 3 years 5years 10 years None 29 .

Encourage her to feel free to discuss any concerns about her current pregnancy or future delivery.ANTENATAL COUNSELING USE GATHER COUNSELING STEPS FOR ANTENATAL VISITS       Greet Ask Tell Help Explain and examine.Ensure privacy and confidentiality. . A .Birth plans. Refer / Give Return appointment.Ask the client about: .Any complaints. 30 . . . .With respect and kindness. . .Danger signals in pregnancy and during child birth.Greet the client: .Her family / home situation.Offer her a seat. .Previous pregnancies & their outcome. G .

Care of the breast & breast feeding : Danger signs in pregnancy and / or at child birth. Effects of STIs / HIV / AIDS in pregnancy and the need for VCT and PMTCT.Explain and Examine Explain about: The benefits of goal – oriented ANC.. Importance of TT vaccine. Importance of personal hygiene.What she would do if she developed an unexpected complication in pregnancy or during child birth.Tell the client about: Appropriate diet and nutrition. Need to have some laboratory tests.Help the client to make a Birth plan: When is her expected date of delivery? Where will she deliver? Who will assist her at delivery? Who will look after her other children when she is away? What transportation will she use to reach her chosen place of delivery or if complications arise? How will she raise funds for transportation and the cost of delivery? What is her preferred position for delivery? What family planning method will she like to use after delivery & where will she obtain it? E . H . The importance of having a skilled professional attends her delivery. Examine the client to: 31 . Malaria prevention as per national guide lines with ITN (insecticide treated net). Importance of compliance with medications and health advice given. Rest and exercise in pregnancy. Harmful traditional practices. T .

multiple pregnancy. For VCT. Fits or convulsions Loss of consciousness Severe headache Blurred vision Swelling of the face. 32 . R . DANGER SIGNS IN PREGNANCY                Vaginal bleeding. STIs etc.smelling vaginal discharge. Give an appointment for her return visit. - Detect abnormalities such as anaemia. Reassure (share your finding on her progress). Premature labour pains. Fever and chills. lethargy and breathlessness Decreased or absent fetal movements Dysuria and supra pubic pain. Abdominal pains. Severe vomiting Weakness. Draining of liquor from vagina without labour.- Confirm that the uterine size is compatible with the gestational age and that the baby is alive. If she requests to be referred. For laboratory investigations.Refer the client:   If she has a complication that cannot be managed at your facility. Foul . hands and legs.

Labour pain lasting more than 12 hrs without delivery. arm or leg prolapse. Convulsions / fits or loss of consciousness.        Placenta is undelivered more than 1 hour after the baby has been delivered. Draining of liquor without labour for more than 12 hrs. Fever or foul – smelling vaginal discharge.DANGER SIGNS IN LABOUR Excessive vaginal bleeding during or after delivery. Cord. 33 . Severe abdominal pains.

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