2 - Antenatal Care

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Second level
Third level
Fourth level
Fifth level
7/28/2018 1
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Objectives
At the end of the module, the participant must be able to
Click
discuss the:
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Second
1. Principles of antenatal care: level
definition, objectives,
focused antenatal care Third level
Fourth level
2. Steps to follow in antenatal care
Fifth level
3. Recognition and management of pregnancy
complications
4. Preventive measures to be instituted
5. Use of the Mother and Child Book
6. Preparation of a birth and emergency plan
7. Health education and health promotion
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Click to editof
Definition Master title style
Antenatal Care
• Regular
Click
andtoperiodic
edit Master
care of texta pregnant
styles
woman and her unborn baby throughout
Second level
pregnancy Third level
Fourth level
• Regular visits to a skilledFifth
health
level
professional
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Click to edit of
Objectives Master title style
Antenatal Care
• To identify danger signs of pregnancy and manage
health problems that have an unfavorable outcome
on pregnancy Second level
Third level
• To prevent occurrence ofFourth
serious
levelcomplications
Fifth level
• To educate and counsel women for a health
pregnancy, childbirth and postnatal recovery
including care of newborn, promotion of early
breastfeeding initiation and exclusive breastfeeding
and family planning
• Formulate a birth and emergency plan
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ClickFocused
to edit Master title
Antenatal style
Care
In normal,Click to edit Master
uncomplicated textatstyles
pregnancies, least 4 antenatal
visits with a skilled health provider:
Second level
1st visit: within 3 months
Third level
2nd visit: 6 months Fourth level
3rd visit: 8 months Fifth level
4th visit: 9 months – return if undelivered within

2 weeks after the EDC
Pregnant women who do not come for prenatal care

should be visited at home
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Click to
Steps to edit Master
Follow title style
in Antenatal Care
1. QUICK CHECK for emergency signs
• Unconscious/Convulsing
Second level
• Vaginal bleeding
Third level
• Severe abdominal pain Fourth level
• Looks very ill Fifth level
• Severe headache with visual disturbance

• Severe difficulty in breathing
• Dangerous fever (looks very weak)
• Severe vomiting
Attend to a sick woman quickly
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Click to
Follow title style
in Antenatal Care
2. Make Click
the woman
to edit comfortable.
Master text styles
• Greet her, make sureSecond level
she is comfortable and ask how
she is feeling. Third level
Fourth level
• At first visit, register the woman and
Fifth level issue a Mother
and Child Book (antenatal record form)
7/28/2018 7
Click to
Follow title style
in Antenatal Care
3. AssessClick
the pregnant woman
Second history
At FIRST visit: Do a complete level
Third level
• Age
Fourth level
• Past Medical History/Alcohol/Drug/substance
Fifth level abuse?
• Obstetric History: Gravidity? LMP? AOG?
7/28/2018 8
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Follow title style
in Antenatal Care
3. AssessClick
the pregnant woman
Second history
Third level
• Ask about or check record for prior pregnancies:
Fourth level
– Preterm birth/s Fifth level
– History of breastfeeding experiences for
non- primiparas
– Stillbirth or death in the first day
– Heavy bleeding during or after delivery
– Prior cesarean section, forceps or abortion
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Click to
Follow title style
in Antenatal Care
3. AssessClick
the pregnant woman
Second history
Third level
• Ask about or check record for prior pregnancies for
Fourth level
general danger signs: Fifth level
– Severe headache
– Visual disturbance
– Convulsions
– Fever or chills
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Click to
Follow title style
in Antenatal Care
3. AssessClick
the pregnant woman
Second physical
At FIRST visit: Do a complete level examination
Third level
• Vital signs, height, weight
Fourth level
• Conjunctival and palmar pallorFifth level
• Abdominal exam – Look for any mass, scar

– In the 3rd trimester: Leopold’s exam, FHT
• Do not perform vaginal exam as a routine prenatal
care procedure
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Click to
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in Antenatal Care
4. Get baseline
Click tolaboratory information
edit Master of the
text styles
woman on the first orSecond
following
levelthe first visit.
• CBC or Hb, Hct, bloodThirdtype
level
• Urinalysis Fourth level
Fifth level
• Rapid plasma reagin
• Blood sugar screening
• HIV
If not available, refer to the nearest RHU or
hospital for the tests
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Click to
Follow title style
in Antenatal Care
ON ALL VISITS:
• Check duration of pregnancy (AOG)
Second level
• Ask for occurrence ofThird
anylevel
danger signs during this
pregnancy Fourth level
• Check record for previousFifth
treatments
level received
during this pregnancy
• Prepare birth and emergency plan
• Ask patient if she has other concerns
• Educate and counsel on family planning and
breastfeeding
7/28/2018 13
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in Antenatal Care
ON ALL VISITS:
On the Third Trimester:
Seconddolevel
also
• Leopold’s examination
Third level
Fourth level
• Check fetal heartbeat Fifth level
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Recognition and Management
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Pregnancy Complications
Click to edit Master
1.Check for pallor or anemia
text styles
Second
• Ask about getting tired easilylevel
or shortness of breath
during routine work Third level
• Look for conjunctival or palmar pallor
Fourth level
Fifth level
• Count number of breaths in one minute
• Measure Hb & Hct on 1st visit or following visit :
hemoglobin & blood type
– The normal hemoglobin
cut-off level for a pregnant
woman is 11g/dl.
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Management title style
of Anemia
MODERATE ANEMIA SEVERE
Second level
ANEMIA
Hb 7-11 g/dL or Third levelHb < 7g/dL and/or
Palmar or conjunctival Fourth level
Tires easily
pallor Fifth level
Dizziness
+/- Dizziness HR >100/min
HR > 100/min RR = 30 breaths/minute
Give all dose of iron Refer for blood

transfusion
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2. Check for hypertension/ preeclampsia
• Measure BP in sitting Second level
position
• If diastolic BP is 90 mmThird
Hg orlevel
higher
repeat measurement after 1 hour
Fourth level rest
• If diastolic BP is still 90 mmFifth
Hg level
or higher ask the
woman if she has:
– Severe headache
– Blurred vison
– Epigastric pain
• Check urine for protein
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Hypertension in Pregnancy
Pregnant woman
with BP ≥
Second140/90
level
Third level
Before 20 weeks Fourth level After 20
AOG weeks AOG
Fifth level
No
No or stable
New or Proteinuria
↑proteinuria, dev’t proteinuria
proteinuria of increasing BP, or
HELLP syndrome
PRE- Gestational
CHRONIC PRE-ECLAMPSIA ECLAMPSIA HPN
HYPERTENSION superimposed
on chronic HPN
Source: American Society of Hypertension, 2009
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Diagnosis title style
of Preeclampsia
• A pregnancy-specific, multisystem disorder,
Click by
characterized to the
editdevelopment
Master textofstyleshypertension
and proteinuria afterSecond
20 weeks of gestation
level
–Mild: Systolic BP ≥ 140Third
mmHg level or
Diastolic BP= 90-109
FourthmmHg,
level or
Fifth level
both at least 2x 4 hours apart with
proteinuria of 1-2 g/L (++)
–Severe: Systolic BP ≥ 160mmHg or
Diastolic BP ≥ 110 mmHg, or
both with proteinuria 3 g/L (+++)
–Eclampsia: (+) convulsions
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Definition title style
of Preeclampsia
•Severe Also: BP ≥ 140/90 with any of the
Second level
following:
–Headache (increasingThird level
frequency, not relieved by
Fourth level
regular analgesics) Fifth level
–Blurred vision
–Oliguria (< 400mL of urine in 24 hours)
–Upper abdominal pain (epigastric or RUQ pain)
–Pulmonary edema
–Hyperreflexia
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Management
Click of Mild title
to edit Master Preeclampsia
style
 FollowClick
up 2xto aedit
week OSalt
Master text styles
restriction
as an outpatient*Second level
 Monitor BP, proteinuria, O Anti-hypertensive
Third level
fetal condition O Diuretic
Fourth level
 Advise on danger signals Fifth level
O Sedatives or
of severe preeclampsia/
eclampsia tranquillizers
 Encourage additional
periods of rest
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Management
Click to edit of Severetitle
Master Preeclampsia
style
•Give anticonvulsant to prevent
Click to edit Master texteclampsia
styles
•Control blood pressure
Secondwith
levelanti-hypertensives
Third level
•Deliver the baby
Fourth level
–Give antenatal steroids ifFifth
thelevel
baby is preterm
•Best managed by a physician during the

entire course of the pregnancy
REFER
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Management of Severe Preeclampsia
Administration of Magnesium Sulfate
Give Combined IV/IM
Click to editdose as Loading
Master Dose
text styles
• Insert IV line (normalSecond
saline or Ringer’s lactate) slowly
level
(1liter in 8 hrs) Third level
• Give 4 grams MgSO4 IV slowly
Fourthover
level 20 min (woman
Fifth level
may feel warm during injection)
• Give 5 grams deep IM in the
upper outer quadrant of each e
buttock (total 10 gms) or in
the ventrogluteal area
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Management of Severe Preeclampsia
Administration of Magnesium Sulfate
• Magnesium sulfate 25% vial = 250 mg /ml
– 4 grams = 16 mlSecond level
– 5 grams = 20 ml Third level
Fourth level
• Transfer to a higher level facility
Fifth level after
loading dose
• Only definitive treatment is termination of
pregnancy or delivery
7/28/2018 24
Clickofto
Levels edit Master title Prevention
Preeclampsia/Eclampsia style
LEVELClick to edit Master text DEFINITION
STRATEGY styles
1. Primary Prevention  Avoiding
Second level the development of
Thirdthe disease
level
 Avoiding
Fourth level pregnancy and
conditions
Fifth level favorable to PE
development
2. Secondary Detection, Detecting the disease before
Screening clinical symptoms of PE appear
3. Tertiary Treatment, Treating the disease early to
Management prevent complications
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2. Check for diabetes mellitus
text styles
ASK ABOUT Second level
Third level
• Family history of diabetes
Fourth level
& history of obesity Fifth level
• Past pregnancy for difficult
labor, large babies,
congenital malformations
and previous unexplained
fetal death
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text styles
Second level
LOOK FOR Third level
• Signs of maternal overweight
Fourthor obesity
level
• Polyhydramnios Fifth level
• Signs of large baby or fetal abnormality
• Vaginal infection
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text styles
Second level
LABORATORY CHECK Third level
• WHEN: Fourth level
– Low Risk: 24-28 wks Fifth level
– High Risk: Immediately, any AOG
• HOW
– 2-hour 75 gram Oral Glucose Challenge Test
– If result > 140 mg/dL, REFER
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Click to edit
3. Check for Syphilis
Master text styles
• Goal- reduce maternal Second level fetal loss and
morbidity,
neonatal mortality and Third level due to syphilis
morbidity
Fourth level
• For all pregnant women, order RPR at first prenatal
Fifth level
visit within the first trimester, again in late pregnancy
and at delivery
– If positive, REFER to the doctor for further mgt
– For women who do not have test results but with
high-risk behavior, REFER to the RHU doctor
7/28/2018 29
4. Ask for Click
otherto edit Master
illnesses or health text styles
problems
• Episodes of fever orSecond
chills level
Third level
– Take body temperature
Fourth level
– Fever may be a sign of infection
Fifth level
• Burning sensation on urination R/O UTI
• Abnormal vaginal discharge, itching at the vulva or
if partner has a urinary problem
• Cough ≥ 14 days R/O PTB, REFER for sputum exam
and further diagnosis and treatment
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4. Ask for Click
otherto edit Master
illnesses or health text styles
problems
• Tooth decay and gum Second
diseaselevel
Third
– “One tooth is lost with levelpregnancy.” NOT TRUE
every
Fourth level
– Hormones of pregnancy Fifthincrease
level
the deposition
of plaque on teeth. If this is not removed gums
become swollen and bleed easily
– Instruct the pregnant to brush teeth regularly
after each meal to prevent accumulation of
plaque on teeth
– REFER to the dentist for regular check-up
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Preventive Measures
1. Give tetanus toxoid according to the ff. schedule:
Tetanus Toxoid Immunization Schedule
Vaccine
ClickMinimum
to edit Master textDuration
Interval
stylesof Protection
Second level
TT1 at first contact with woman
ThirdNIL
15-49 yrs or at first ANC visit level
– no protection
Fourth level
TT2 at least 4 weeks after TT1 •Infants born to the mother will be protected from
Fifth level
neonatal tetanus
•3 years of protection for the mother
TT3 at least 6 months after TT2 •Infants born to the mother will be protected from
neonatal tetanus
TT4 at least 1 year after TT3 •Infants born to the mother will be protected from
neonatal tetanus
TT5 at least 1 year after TT4 •Infants born to the mother will be protected from
neonatal tetanus
•Lifetime protection for the mother
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Preventive Measures
2. Give iron and folic acid supplementation to prevent
maternal Click toand
anemia editfetal
Master
neuraltexttubestyles
defects
• Ferrous sulfate 320 Second
mg (60 mglevelelemental iron)
• Folic acid 400 mcgram Third level
Fourth level
• Can be given as a tablet with 60 mg elemental iron
Fifth level
with 400 mcgrams of folic acid
• Give 1 tablet as soon as pregnancy is confirmed
• Give at least 180 tablets administered once a day
for the whole duration of pregnancy
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Preventive Measures
3. Iodine supplementation
Preparation is a capsule with 200 mg elemental iodine.
• Give twoClick to editonce
(2) capsules Master
a year text
in anystyles
of the following
situations: Second level
– Iodine Deficiency Disorder
Third(IDD)
levelis classified as
moderate or severe cretinism
Fourthand
level neonatal
hypothyroidism are presentFifth level
– Area where the patient resides has 90% of the
households using iodized salt and median urinary
iodine is 100 mcgrams among school children
• Give iodine supplementation during the first trimester, but
no later than the second trimester
• This has been shown to prevent cretinism and other
abnormalities
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Preventive Measures
4. Deworming
• Click to edit
Give Mebendazole 500mg Master textonce
single dose styles
in 6 months
after the first trimester (from 4-9 months of pregnancy)
Second level
• Give if none was given in the past
Third six (6) months
level
UPON THE PRESCRIPTION OFFourthTHE DOCTOR
level
• Do NOT give mebendazole in the first
Fifth 1-3 months of
level
pregnancy (might cause congenital problems in the baby)
- proven to be safe during pregnancy
- not absorbed in the bloodstream (remains only in GIT)
- paralyzes and kills intestinal parasites
- global standards in drug safety advise to avoid giving
during the first trimester
7/28/2018 35
Preventive Measures
5. Antimalarial
Click tointermittent
edit Masterpreventive
text styles treatment
and promotion of insecticide-treated nets
Second level
(in endemic areas) Third level
• All pregnant women should sleep under an
Fourth level
Fifth level
insecticide-treated bednet (ITN)
• Dip net every 6 months
• In areas of stable transmission of falciparum
malaria, all pregnant women should be given
intermittent preventive treatment (IPT)
7/28/2018 36
ClickBirth
to edit
and Master titlePlan
Emergency style
• ConferClick
withto edit
the Master
mother andtext styles
her family
Second level
regarding the preparation of her
Birth and EmergencyThird
Planlevel
Fourth level
• A written document prepared during
Fifth level the
first prenatal consultation
• Reviewed every visit
• May change anytime during pregnancy if
a problem is detected
7/28/2018 37
ClickBirth
to edit
and Master titlePlan
Emergency style
• Important
ClickInformation included
– Woman’s condition during
Second levelpregnancy
– Preferred birth attendant
Third level
– Desired place of birthFourth level
– Transportation to health Fifth level
facility
– Available resources for her childbirth and
newborn baby and emergency expenses
– Birth companion of her choice
– Preparations needed should an emergency
situation arise like blood donors
7/28/2018 38
Second level
Third level
Fourth level
MOTHER AND C B
HILDFifth level
OOK
7/28/2018 39
Health
Click Education
to edit Masterand Health
title style
Promotion
• Click to edit Master text styles
Give nutrition education and counseling
Second level
• Counsel on self-care during pregnancy
Third level
• Advise adherence toFourth
prophylactic
level treatments
• Counsel against unhealthy lifestyle
Fifth level
– Advise the pregnant woman not to smoke,

avoid others who smoke and not allow smoking
inside the house and work areas
– Caution the woman against taking alcoholic
drinks
7/28/2018 40
Health
Click Education
to edit Masterand Health
title style
Promotion
• Advise on danger signs of pregnancy and
where to go duringSecond level
emergency
– Severe headache Third level
Fourth level
– Blurring of vision Fifth level
– Fever
– Fast or difficult breathing
– Severe abdominal pain
– Vaginal bleeding
– Convulsions
7/28/2018 41
Click to edit
KeyMaster title style
Messages
• ANC is Click
the 1to edittowards
st step Masterpreventing
text stylesmaternal
and newborn death. Encourage
Second level early and
continued antenatal visits throughout the
Third level
pregnancy. Fourth level
Fifth level
• Focused ANC means at least 4 quality visits for
health education and promotion, prevention,
recognition and management of pregnancy
complications and timely referral to higher
facilities when needed.
7/28/2018 42
Click to edit
KeyMaster title style
Messages
• Mother and her family should prepare a Birth
Second level
Plan for birth preparedness and complication
Third level
readiness together with the
Fourth health care
level
attendant. Fifth level
• Counsel the woman to deliver in a health

facility with a skilled health worker as the
birth attendant.
7/28/2018 43
Second level
Third level
Fourth level
Fifth level
Because giving birth should be about

giving life, not giving up a life.
7/28/2018 44

2 - Antenatal Care

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Click to edit Master title style

Click to edit Master text styles

4th visit: 9 months – return if undelivered within

Pregnant women who do not come for prenatal care

• Severe headache with visual disturbance

• Abdominal exam – Look for any mass, scar

Give all dose of iron Refer for blood

•Best managed by a physician during the

– Advise the pregnant woman not to smoke,

• Counsel the woman to deliver in a health

Because giving birth should be about

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