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Antenatal Care and High-risk Pregnancy
Education of the mother about: Physiology of pregnancy Nutrition Alarming signs and symptoms Infant care Breastfeeding Child spacing 1 This chapter is taken from Ministry of Health and Population. Antenatal care will help ensure: Best possible health status for mother and fetus Early detection and timely referral of high-risk pregnancy. It played a more important role in death associated with hypertensive diseases (34%). respectively.Chapter 6 Antenatal Care and High-risk Pregnancy1 ANTENATAL CARE This chapter defines antenatal care and provides information concerning the following topics: The initial visit Periodic visits Health education for pregnant women Alarming signs and symptoms Antenatal Care in Egypt Efforts are being made to strengthen those aspects of antenatal care most likely to have an effect on the outcome of pregnancy.000 live births. 173 Standards of Practice for Integrated MCH/RH Services: First Edition. In cardiac disease lack of antenatal care and poor quality antenatal dare were considered to be avoidable factors in19% and 28% of cases. The Egypt National Maternal Mortality Study 2001 reported that poor quality antenatal care was found to contribute to 15% of maternal deaths and to 13 maternal deaths per 100. Definition Antenatal care is a preventive obstetric health care program aimed at optimizing maternalfetal outcome through regular monitoring of pregnancy. families. Women. 2004). Basic Essential Obstetric Care: Protocols for Physicians (Cairo. chaps. June 2005 . Arab Republic of Egypt. 5 and 6. and traditional birth attendants (dayas) need to have enough information to recognize the danger signs of pregnancy and the puerperium so they can seek care promptly in an appropriate facility. then diagnose any problems and manage the pregnancy. It is important for the pregnant woman to be cared for by a physician who can correctly take a full history and conduct a complete physical examination.
185-187). labor. June 2005 . hypertensive disease. Booking Procedures and/or Registration Personal history: Name Age Address Occupation (both partners) Duration of marriage Consanguinity Potentially harmful habits (i. Refer to Antenatal Care Tables (pp. and puerperium of previous pregnancies Mode of delivery Number and sex of living children 174 Standards of Practice for Integrated MCH/RH Services: First Edition. The first antenatal clinic visit should include both booking procedures (registration) and a physical examination. The information should be recorded on the Antenatal Care Card. with no complications. infections and other existing conditions and diseases that lead to high-risk pregnancy. Schedule of Antenatal Care Visits Antenatal visits-area time-when women are particularly receptive to messages about pregnancy. Antenatal care can detect anemia.. Note: Accurate record keeping is indispensable for the work of antenatal clinics. Antenatal visits should take place: To 28th weeks gestation 28th-36th weeks Thereafter every week every 4 weeks every 2 weeks In a normal pregnancy. The Initial Visit The first antenatal visit should take place as early as possible during the first trimester.e. a minimum of three antenatal visits is acceptable in the first 20 weeks.Standards of Practice for Integrated MCH/RH Services Reduction of maternal and perinatal mortality and morbidity rates. smoking) Complaints: In detail and duration Menstrual history: First day of the last normal menstrual period (LNMP) Calculation of gestational age. and expected date of delivery (EDD) Obstetric history: Antepartum care.
Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Birth weights Mode of infant feeding Date of last labor and last abortion (LL and LA) Present obstetric history Symptoms of pregnancy Symptoms of pre-eclampsia Symptoms of disease in other organ systems Fetal movements Family history: Diabetes mellitus Hypertension Multiple pregnancies Congenital anomalies Medical history: Diseases: Diabetes mellitus Hypertension Urinary tract infections Heart diseases Viral infection Drugs/allergies Other: Blood transfusion Rh incompatibility X-ray exposure Surgical history: Dilation and curettage Vaginal repair Cesarean section Cerclage Non-Gynecologic operations Family planning history Immunization history Breastfeeding history Standards of Practice for Integrated MCH/RH Services: First Edition. June 2005 175 .
pallor. height. a random one-hour 50 gm oral glucose challenge test is performed. If levels are < 140 mg/dl. and jaundice Breast examination Skeletal or neurological abnormalities Chest and heart examination Abdominal (obstetric) Inspection: Contour and size of abdomen Scars of previous operations Signs of pregnancy Fetal movements Varicose veins Hernial orifices and back Edema Palpation: Fundal level (FL) Fundal grip Umbilical grip Pelvic grip Auscultation . by Sonicaid At 20 weeks. June 2005 .Fetal Heart Sounds (FHS) At 10 weeks. If test shows levels > 140mg/dl. the test should repeated at 24-28 week of gestation. by Pinard's fetal stethoscope Laboratory investigations: Urine analysis Stool analysis for ova and parasites Blood analysis: Complete blood count ABO grouping and Rh typing Hepatitis B antigen Wasserman reaction Rubella antibody For patients with risk factors for diabetes. weight. refer the patient to the higher level of health care facility. 176 Standards of Practice for Integrated MCH/RH Services: First Edition.Standards of Practice for Integrated MCH/RH Services Examination: Minimal Physical Parameters to be Evaluated General (systemic) Physical signs (vital signs.
lie. primary health care unit. district or general hospital). Examination of the Pregnant Woman At each visit the following examinations should be done. Woman’s Health Card The health care provider should check the patient’s Woman’s Health Card and fill in the data at each antenatal care visit. glucose and ketones Assessment of fetal well-being Fetal size through assessment of fundal level (FL) Fetal kick count: at least 10 movements every12 hours Fetal movements: absence precedes intrauterine fetal death (IUFD) by 48 hours Fetal heart sounds Ultrasound if it is available At 37 Weeks Assessment of fetal size.Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Pelvic ultrasound Counsel for the Place of Delivery The health care provider should encourage the woman to deliver at a health facility (maternal and chilled health center. Periodic Visits Record the information obtained at these visits on the Antenatal Care Card. If the woman and/or her family decides to defiler at home. presentation Standards of Practice for Integrated MCH/RH Services: First Edition. counsel her for home birth (see Chapter 9 Clean and Safe Home Birth). whether at home or at health facility. The health car provider should encourage the woman to bring this card to each visit and to her delivery. General: Blood pressure Body weight Abdominal: Fundal level Fetal lie Fetal presentation Fetal heart sounds (FHS) Record any new complaints Urine examination: By dipstick for protein. June 2005 177 .
beans. ferrous fumarate. Protein (85 gm/day): Animal sources: meat. June 2005 . To prevent megaloblastic anemia. It is recommended that women at high risk for neural tube defects take 5 mg of folic acid supplement daily prior to conception and for the first 12 weeks of pregnancy. ferrous sulphate Insufficient iron in the diet least do maternal iron deficiency anemia Fats If 2/3 of protein is delivered from animal sources. fat intake should be adequate. Carbohydrates Carbohydrates can be slightly reduced to compensate for the increased calorie value of the proteins and more severely restricted if weight reduction is necessary. cheese. The caloric requirement is the same as in the non-pregnant state.500 mg/day) Sources: milk. fish. yogurt. calcium carbonate Insufficient calcium in the diet may lead to: Rickets in infants Osteomalacia in mothers Iron (30 mg/day) Animal sources: liver. red meat Plant source: green vegetables Drug sources: ferrous gluconate. During pregnancy increased metabolism is compensated for by decreased activity.Standards of Practice for Integrated MCH/RH Services Health Education for Pregnant Women Adequate Nutrition Calories (2500/day) Excess calories lead to fat deposition and obesity. Folic acid (1 mg tablet/day) Megaloblastic anemia from deficiency of folic acid may occur during pregnancy. and lentils Insufficient protein in diet leads to: Fetal prematurity and intrauterine growth retardation (IUGR) Maternal anemia and edema Calcium (1. milk. cheese. it is recommended that women take 0. 178 Standards of Practice for Integrated MCH/RH Services: First Edition. and eggs Plant sources: peas.4 mg of folic acid a day.
Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Clothing Should be loose. treat by pulling out.4 kg/week (range 0. Brush teeth after meals Tooth extraction is allowed even for pregnant women with rheumatic heart disease if prophylactic antibiotics are given. treat with a mixture of glycerin and alcohol. light. belts. Avoid high heels. or antepartum hemorrhage (APH) Traveling Allowed when comfortable In patients with a history of APH or preterm lavor it is better to be avoided. preterm labor. Weight Gain (10-12 kg) First trimester 1-2 kg Average weight gain from 20 weeks onward is 0.0. is allowed. Exercise Exercise should be mild. Brassiere (light and not tight) to support heavy breasts Sexual Activity To be avoided in pregnant women with threatened abortion. and hanging from shoulders. June 2005 179 . Housework. Dental Care Have teeth examined twice during pregnancy.6 kg/week) Baths Showers are preferable over tub baths. and corsets. Breast Care Daily washes to reduce cracking Massage Express breast secretion Open lacteal ducts and sinuses Nipples If there is dry secretion. if not overtiring. Standards of Practice for Integrated MCH/RH Services: First Edition. shoes with thin soles. If retracted. No vaginal douches are allowed. preferably walking.2 .
180 Standards of Practice for Integrated MCH/RH Services: First Edition. or as soon as possible during pregnancy (better after the first trimester). by reassuring the patient.Standards of Practice for Integrated MCH/RH Services Rest and Sleep Rest eight hours at night and two hours in the afternoon. Any pregnant woman who comes in contact with rubella should be tested for rubella antibodies.1 Tetanus toxoid TT1 TT2 TT3 TT4 TT5 At first contact. Minor complaints should be managed without the use of drugs whenever possible.1) Table 6. Smoking Smoking leads to spasm of placental blood vessels which can lead to the following: Fetal anoxia Low birth weight neonates (LBW) IUGR Prematurity Premature rupture of membranes (PROM) Placental abruption Immunization Live attenuated vaccines are contraindicated. At least four weeks after TT1 At least 6 months after TT2 or during subsequent visits At least 6 months after TT3 or during subsequent visits Minimum 1 year after TT4 or during subsequent visits Rh-prophylaxis in Rh-negative women who did not produce anti Rh-D antibodies during pregnancy and who have given birth to an Rh-positive infant: such women should receive anti Rh-D 300 mcg within 24 hours or at the latest 72 hours postpartum. Increase rest and sleep towards term. June 2005 . Tetanus toxoid should be administered to prevent tetanus if the mother has not already been immunized (See Table 6. Drugs Avoid all unnecessary drugs during pregnancy. This prevents Rh-sensitization of the mother.
June 2005 181 . Common Complaints of Pregnancy Nausea and vomiting Heartburn and hyperacidity Ptyalism (excessive salivations) Constipation Hemorrhoids and varicose veins Edema Leg cramps Leukorrhea (excessive odorless. face. Generalized edema (lower limbs. including: Severe persistent headache Blurring of vision Epigastric pain. and fingers) Standards of Practice for Integrated MCH/RH Services: First Edition.Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Irradiation Avoid exposure to irradiation for its teratogenic effect on fetus. The physician should evaluate patients with such symptoms for the following: Vaginal Bleeding Pre-eclampsia. colorless vaginal discharge not associated with burning sensation or pruritis vulvae) Backache Alarming Signs and Symptoms Pregnant women should be advised to seek immediate medical care if they experience any of the following symptoms or signs: Vaginal bleeding Severe edema Escape of fluid from vagina Abnormal gain or loss of weight Decrease or cessation of fetal movements Severe headache Epigastric pain Blurred vision Fever During antenatal care the occurrence of any of these signs or symptoms necessitates further evaluation.
Standards of Practice for Integrated MCH/RH Services Abdominal pain (second half of pregnancy) Placental abruption suspected if any of the following: Trauma Pre-eclampsia Fundal level > period of arnenorrhea Fetal parts difficult to feel Hard tender uterus Intrauterine fetal death Other signs or symptoms or signs to be investigated include: Persistent vomiting Dysuria Chills or fever Escape of fluid from vagina (PROM) Abdominal size too big or too small for gestational age All these patients will need referral to a higher level of health care facility. June 2005 . Combined Management The following high-risk situations require referral to a higher level of health care facility for combined clinical management: Diabetes Heart disease Hypertension (pregnancy-induced hypertension and pre-eclampsia and/or eclampsia) 182 Standards of Practice for Integrated MCH/RH Services: First Edition.
crackers) before getting out of bed in the morning. Problem: Persistent vomiting continues and affect the general condition of the client Advice Hyperemesis gravidarum: Refer to hospital Action Problem: Constipation Advice Increase fluid intake. Wear elastic stocking if necessary. include fruits and vegetables in the diet Action Mild laxatives can be prescribed when needed. June 2005 183 . Problem: Leukorrhea (Excessive normal discharge) Advice Reassure client and advise concerning personal hygiene. Advise against vaginal douches. Problem: Heart burn Advice Action Anti acids containing magnesium hydroxide Problem: Varicose veins Advice Advise client to frequently elevate her legs and avoid standing for long periods of time. If needed: Primperan If severe vomiting: refer to hospital. only vulval wash. Action Exclude premature rupture of membrane..Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Management and Treatment of Pregnancy Related Disorders Table 6. Action Problem: Hemorrhoids Advice Action Application of stringent ointments or suppositories such as Anusol OR Scheriproct Avoid constipation or diarrhea.e.2 Management and treatment of pregnancy related disorders Problem: Nausea and vomiting Advice Action Explain to client that it’s a normal symptom during the Prescribe vitamin B1 and B6 first months and will disappear spontaneously by the end of the third month Reassure client and advise small frequent meals as well as eating light food (i. Standards of Practice for Integrated MCH/RH Services: First Edition.
or proteinuria: Advise rest. refer to hospital. blurred vision. no oedema. or generalized edema Refer to hospital. Problem: Anemia Advice Action Preventive measure: recommend food rich in vitamins. If severe anemia. 184 Standards of Practice for Integrated MCH/RH Services: First Edition. Problem: Hypertensive disorders Advice Mild: BP less than 140/90. Moderate: BP 140-160/90-100 or severe with symptoms such as headache. Refer to the nearest hospital. June 2005 . Action Problem: Vaginal bleeding during pregnancy Advice Action No vaginal examination. Prophylactic dose of iron/folic acid started early where anemia is prevalent. Pyelitis: Refer to hospital. and frequent measurement of blood pressure. iron and folic acid. avoid excessive salt in diet. Investigate for parasitic infestation. Family Planning Counseling Tell all ANC clients about the impact of FP and child spacing on women’s and child health and on the family welfare. Estimate hemoglobin and hematocrit value. Surgery is not advisable during pregnancy.Standards of Practice for Integrated MCH/RH Services Topical local anesthetics such as: Lignocaine Ointment OR Lignocaine Suppositories if associated with anal fissure. Problem: Acute urinary tract infection Advice Action Cystitis: Refer to hospital. Explain contraceptives suitable during the postpartum period (see page 157). Prescribe iron/folic acid.
4 ANC second visit Second Visit: 22-26 weeks History Taking History of any complaint Physical Weight Blood pressure Fundal level FHS Investigation Urine analysis by dipstick Screen for DM Education and Counseling When to seek medical care Adequate nutrition Personal hygiene Breastfeeding Fetal movement awareness Fill out the Woman's Health Card Schedule next appointment Immunizations Tetanus toxoid Standards of Practice for Integrated MCH/RH Services: First Edition.Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Antenatal Care Tables Table 6.3 ANC first visit booking or registration First Visit Booking or Registration: As early as possible in the first trimester before 12 weeks History Taking Personal history Obstetric history Family history Medical history Surgical history Complaints Physical Height and weight Blood pressure Fundal level FHS Investigation Urine analysis Stool analysis for ova and parasites Complete blood count ABO grouping and Rh typing Wasserman reaction Arrange for hepatitis B antigen Arrange for Rubella antibody Arrange for pelvic ultrasound Education and Counseling When to seek medical care Adequate nutrition Persoanl hygiene Dental care Breast care Exercise Smoking Counsel for Home Birth Fill out the Woman's Health Card Schedule next appointment Immunizations Tetanus toxoid Table 6. June 2005 185 .
Standards of Practice for Integrated MCH/RH Services Table 6. June 2005 .5 ANC third visit Third Visit: 30-32 weeks History Taking History of any complaint Weight Blood pressure Fundal level FHS Physical Investigation Urine analysis by dipstick Education and Counseling When to seek medical care Adequate nutrition Personal hygiene Fetal movement awareness Arrange for home visit Travel Warning symptoms of pre-eclampsia Birth preparedness and complication readiness Fill out the Woman's Health Card Schedule next appointment Table 6.6 ANC fourth visit Fourth Visit: 34-36 weeks History Taking History of any complaint Weight Blood pressure Fundal level FHS Fetal presentation Physical Investigation Urine analysis by dipstick Education and Counseling When to seek medical care Adequate nutrition Personal hygiene Fetal movement awareness Warning symptoms of pre-eclampsia Postpartum care Contraception Fill out the Woman's Health Card Schedule next appointment 186 Standards of Practice for Integrated MCH/RH Services: First Edition.
Chapter 6 Antenatal Care and High-risk Pregnancy: ANC Table 6.7 ANC fifth visit Fifth Visit: 38-40 weeks History Taking History of any complaint Physical Height and weight Blood pressure Fundal level FHS Fetal presentation Investigation Urine analysis by dipstick Education and Counseling When to seek medical care Adequate nutrition Personal hygiene Breast care Fetal movement awareness Warning symptoms of pre-eclampsia Post term management Postpartum vaccination Fill out the Woman's Health Card Schedule next appointment Standards of Practice for Integrated MCH/RH Services: First Edition. June 2005 187 .
Family health history 5. Past health history 4. Obstetrical history 3. 188 Standards of Practice for Integrated MCH/RH Services: First Edition.Standards of Practice for Integrated MCH/RH Services HIGH-RISK PREGNANCY Introduction Risk factors are conditions associated with child bearing that may jeopardize maternal or fetal welfare. Personal factors 2. Ongoing maternal and/or fetal problems The following tables describe each of these categories in detail along with the potentially adverse effects of this condition and actions to be taken in this situation. June 2005 . There are five major categories: 1.
PROM. June 2005 189 . low birth weight and placental abruption Chronic fetoplacental dysfunction Anxiety with pregnancy Multiple pregnancy Preterm labor Increased incidence of ectopic pregnancy Actions to be Taken Intensive and repetitive health education during pregnancy Prevention and early diagnosis of such adverse effects Referral to a higher level health care facility when indicated More than 35 years old Refer to a higher level health care facility Lives far from hospital or health facility Schedule admission early in/before labor Positive consanguinity Smoking Prenatal health education Supplementary counseling Prenatal health education Assessment of fetoplacental function Long duration of marriage with infertility and use of ovulatory drugs Intensive and repetitive health education Reassurance via careful prenatal care Rule out multiple or ectopic pregnancy Ultrasound And referral to a higher level health care facility whenever indicated Standards of Practice for Integrated MCH/RH Services: First Edition. prematurity.8 Personal factors and high-risk pregnancy Personal Factors Less than 18 years old Potentially Adverse Effects on Pregnancy Unplanned pregnancy Poor clinic attendance Increased incidence of: Abortion IUGR Preterm labor Pre-eclampsia Down syndrome Increased incidence of: Pre-eclampsia IUGR Fetoplacental dysfunction Prolonged labor Incidence of obstructed labor Delivery on the way to the hospital Birth trauma Neonatal asphyxia or hypothermia Congenital malformations Repeated/habitual abortion Increased incidence of spontaneous abortion.Chapter 6 Antenatal Care and High-risk Pregnancy: HRP Personal Factors and High-risk Pregnancy Table 6.
9 Obstetrical history and high-risk pregnancy Obstetrical History Parity ≥ 5 Potential Adverse Effects on the Current Pregnancy Prolonged or obstructed labor Uterine rupture Postpartum hemorrhage Chronic fetoplacental dysfunction Nutritional deficiencies Weak general health Dependent on the cause of death Prematurity IUGR Fetal malformation Chronic fetoplacental dysfunction Recurrence of risk factors Actions to be Taken Refer to a higher level of health care facility No spacing Previous IUFD or neonatal death Improve nutrition Contraceptive advice Refer to a higher level of health care facility Previous small for gestational age IUGR Chronic fetoplacental dysfunction Fetal demise Recurrence of risk factors Gestational diabetes Diabetes mellitus Recurrence of risk factors Dystocia Birth trauma Excessive weight gain Polyhydramnios Congenital anomalies Hereditary disorders Refer to a higher level of health care facility Previous large for gestational age Prenatal health education Screen for diabetes Serial measurement of fetal weight by ultrasound Refer to a higher level health care facility when indicated Previous fetal malformation Refer to a higher level of health care facility Previous spontaneous second (2nd) trimester abortion or preterm labor Persistence of risk factors Preterm delivery Incompetent cervix Recurrence of risk factors Pregnancy-associated hypertension Renal affection Chronic fetoplacental dysfunction IUGR Prematurity Refer to a higher level of health care facility Recurrent first trimester abortion Previous hypertensive disorders during pregnancy Refer to a higher level of health care facility Careful prenatal care Monitor protein in urine Refer to a higher level health care facility if the patient develops hypertension 190 Standards of Practice for Integrated MCH/RH Services: First Edition.Standards of Practice for Integrated MCH/RH Services Obstetrical History and High-risk Pregnancy Table 6. June 2005 .
Chapter 6 Antenatal Care and High-risk Pregnancy: HRP Obstetrical History Previous cesarean section delivery Potential Adverse Effects on the Current Pregnancy Dehiscence of the previous scar Uterine rupture Actions to be Taken Refer to a higher level of health care facility Previous retained placenta or postpartum hemorrhage Recurrence of the problem Refer to a higher level of health care facility Previous Rh isoimmunization or hydrops fetalis Stillbirth Fetomaternal incompatibility Refer to a higher level of health care facility Duration of labor < 4 hours Delivery on the way to the hospital Neonatal asphyxia and/or hypoxia Neonatal hypothermia Postpartum hemorrhage Prolonged labor Obstructed labor Uterine rupture Cephalopelvic disproportion Schedule admission early in/before labor Previous instrumental delivery (vacuum extraction or forceps) Try to detect the cause Prevention of recurrence Arrange for delivery in wellequipped hospital Standards of Practice for Integrated MCH/RH Services: First Edition. June 2005 191 .
June 2005 .Standards of Practice for Integrated MCH/RH Services Past History and High-risk Pregnancy Table 6.10 Past history and high-risk pregnancy Potential Adverse Effects on the Current Pregnancy Pregnancy exaggerated hypertension Renal affection Chronic fetoplacental dysfunction Chronic hypertension Heart failure and pulmonary edema Respiratory distress Congenital infection of the newborn Teratogenicity of antituberculous drugs Teratogenicity of antiepileptic drugs (AEDs) Traumatic seizures Past History Hypertension Actions to be Taken Refer to a higher level of health care facility Heart disease or heart murmur Tuberculosis or intake of antituberculous drugs Refer to a higher level of health care facility Refer to a higher level of health care facility Epilepsy or intake of antiepileptic drugs Preconception and prenatal health education Refer to a higher of level health care facility Refer to a higher level of health care facility Refer to a higher level of health care facility Chronic illness Uterine anomalies including uterine fibroid or other pelvic masses The illness may affect the pregnancy or vice versa Second trimester miscarriage Preterm labor IUGR Abnormal placentation Malpresentation Antepartum and/or postpartum hemorrhage Abdominal pain due to fibroid degeneration Uterine rupture Uterine rupture Abnormal placentation Antepartum and/or postpartum hemorrhage Retained placenta Incompetent cervix Increased incidence of abortion Increased incidence of preterm labor Difficult delivery Soft tissue obstruction Ruptured vagina Previous myomectomy Refer to a higher level of health care facility Previous cerclage Refer to a higher level of health care facility Previous successful classical repair Arrange for timely referral to hospital preferably 4 weeks before delivery 192 Standards of Practice for Integrated MCH/RH Services: First Edition.
Family History and High-risk Pregnancy Table 6. June 2005 193 .11 Family History and High-risk Pregnancy Potential Adverse Effects on the Current Pregnancy Fetal malformations Increased incidence of twins and multiple pregnancy Pregnancy-aggravated or induced hypertension Gestational diabetes Spontaneous abortion Congenital anomalies Macrosomic neonate Family History Fetal abnormality Twin or multiple pregnancy of mother and sister Hypertension Diabetes Actions to be Taken Refer to a higher level health care facility Ultrasound evaluation Close observation of blood pressure Screen for diabetes Prevention of excessive weight gain And referral to next level of health care facility whenever indicated Standards of Practice for Integrated MCH/RH Services: First Edition.Chapter 6 Antenatal Care and High-risk Pregnancy: HRP Past History Previous successful repair of fistula Previous blood transfusion Potential Adverse Effects on the Current Pregnancy Increased incidence of recurrence Actions to be Taken Arrange for timely referral to hospital preferably 4 weeks before delivery Indirect Coombs test Fetomaternal incompatibility And referral to next level of health care facility whenever indicated.
June 2005 .Standards of Practice for Integrated MCH/RH Services Ongoing Maternal and/or Fetal Problems and High-risk Pregnancy Table 6. safe delivery Maternal length ≤ 150 cm Marked varicosities of lower limbs 194 Standards of Practice for Integrated MCH/RH Services: First Edition. safe vaginal delivery otherwise refer to hospital Maternal weight < 45 kg Prenatal health education on diet Serial assessment of fetoplacental function Refer to a higher level of health care facility Prenatal health education to avoid prolonged standing Advise for leg elevation and elastic stocking Plan for smooth. safe vaginal delivery otherwise refer to hospital Laboratory evaluation of hemoglobin Prenatal health education about diet Iron supplementation Refer to a higher level of health care facility Color: Pallor Color: Jaundice Maternal weight > 90 kg "excessive obesity" Prenatal health education on diet Early screening for diabetes Allow smooth.12 Ongoing Maternal and/or Fetal Problems and High-risk Pregnancy Potential Adverse Effects on the Current Pregnancy Post date Failure to diagnose IUGR Cephalopelvic disproportion Obstructed labor Anemia with pregnancy IUGR Preterm labor Biliary colic Obstructive jaundice Acute cholecystitis Pancreatitis Gestational diabetes Hypertension Inadequate maternal weight gain Macrosomic infants Prolonged second stage Shoulder dystocia Primary cesarean delivery Wound/episiotomy infection IUGR Preterm labor Fetoplacental dysfunction Cephalopelvic disproportion Obstructed and/or prolonged labor Severe leg pain Increased incidence of vulval and uterovesical plexus varicosities Increased incidence of hemorrhoids Current Situation Unknown last menstrual period (LMP) Gait: "Limping" Actions to be Taken Clinical evaluation of gestational age Consider ultrasound Assess pelvic capacity Allow smooth.
sedatives. June 2005 195 .Chapter 6 Antenatal Care and High-risk Pregnancy: HRP Current Situation Hyperemesis gravidarum Potential Adverse Effects on the Current Pregnancy Hypotension Tachycardia Dehydration Weight loss Electrolyte imbalance Jaundice Bile pigments in urine Retinal changes Oliguria Tetanus neonatorum Actions to be Taken Rule out other causes of nausea and vomiting Simple dietary instructions Refer for hospitalization for fluid. emotional support and reassurance Nonimmune against tetanus neonatorum Consider giving TT1 and TT2 for the first time after third (3rd) month of pregnancy (4 weeks apart) or further dose if she is immune Ultrasound Refer to a higher level of health care facility when indicated Count fetal kick (not fewer than 10 movements in 12 hours continuously) Refer to a higher level health care facility to assess fetal well-being Consider ultrasound Refer to a higher level health care facility when indicated Absent fetal movements Molar pregnancy IUFD Fetoplacental dysfunction IUFD IUGR Inaccurate LMP IUGR IUFD Oligohydramnios Missed abortion Inaccurate LMP Diabetes mellitus Multiple pregnancy Molar pregnancy Polyhydramnios Ectopic pregnancy Threatened abortion Missed abortion Molar pregnancy Marked changes in frequency and/or intensity of fetal movements Smaller uterine size than gestational age Larger uterine size than gestational age Consider ultrasound Screen for diabetes Serial assessment of fetoplacental function Vaginal bleeding in early pregnancy Refer to hospital for ultrasound and serum beta HCG Bed rest Advise no intercourse or traveling Refer to hospital for induction of abortion Refer to hospital for suction curettage and postevacuation follow-up of HCG to zero Refer to hospital following the protocol for pre-eclampsia Blood pressure ≥ 140/90 mmHg Increased incidence of eclampsia IUGR Renal disease Placental abruption Fetoplacental dysfunction Standards of Practice for Integrated MCH/RH Services: First Edition. electrolyte replacement. antiemetics.
Standards of Practice for Integrated MCH/RH Services Current Situation Excess amniotic fluid Potential Adverse Effects on the Current Pregnancy Postpartum hemorrhage Fetal malformations Preterm labor Maternal respiratory distress Fetal macrosomia Fetal malformations (renal. pulmonary hypoplasia) IUGR Stillbirth IUFD Preterm labor Actions to be Taken Refer to a higher level health care facility Diminished amniotic fluid Refer to a higher level health care facility Preterm uterine contractions Refer for admission to hospital for tocolysis and fetal monitoring First aid management Refer to a higher level health care facility Third trimester vaginal bleeding Placenta previa Placental abruption IUGR IUFD Intrapartum hemorrhage Postpartum hemorrhage DIC Ruptured membranes prematurely (PROM) Prematurity Cord prolapse Maternal infection (chorioamnionitis) Fetal infection IUFD Stillbirth Neonatal infection Anemia in pregnancy IUGR Prematurity Anemia of the newborn Urinary tract infection Renal disease Pre-eclampsia Sudden gush of vaginal watery fluid Refer to a higher level of health care facility Hemoglobin < 11 gm Dietary instructions: iron and folic acid supplementation Refer to a higher level of health care facility if the diagnosis is doubtful Urine analysis Urine culture Uric acid Creatinine Referral to hospital when indicated Screen for diabetes Proteinuria > +1 Glucosuria Gestational diabetes 196 Standards of Practice for Integrated MCH/RH Services: First Edition. June 2005 . ureteral.
000 bacteria in urine culture) Urine culture and sensitivity Antibiotics given accordingly And referral to next level of health care facility whenever indicated Standards of Practice for Integrated MCH/RH Services: First Edition. cataract. unless woman was previously known to have rubella antibodies present Counsel on basis of severe damage to the fetus Consider termination in case of affected fetus Referral to hospital when indicated Refer to a higher level of health care facility Herpes Nonengagement of fetal head at 40 weeks gestation in primigravida Malpresentation (breechor transverse lie) Refer for delivery in well-equipped hospital and estimation of pelvic capacity Ultrasound Rule out congenital anomalies Refer to hospital if gestational age > 34 weeks Bacteriuria (> 100. mental retardation) Severe disease during the neonatal period (bleeding hepatosplenomegaly.Chapter 6 Antenatal Care and High-risk Pregnancy: HRP Current Situation Rubella exposure Potential Adverse Effects on the Current Pregnancy Severe fetal damage or death if infection occurred during the first 4 months of pregnancy Congenital fetal infection (heart damage. deafness. thrombocytopenia) Spontaneous abortion Generalized flu-like symptoms Reactivation Neonatal herpes infection Prematurity IUGR and IUFD Cephalopelvic disproportion Malposition (mainly occipitoposterior) Prematurity PROM Uterine rupture Prolonged labor Obstructed labor Cord presentation Cord prolapse Urinary tract infection Pyelonephritis Pyelitis Actions to be Taken Test for rubella IgM for any woman exposed to rubella or who has any rash similar to rubella. June 2005 197 . myocarditis.