Maternal Care: Skills workshop Routine use of the antenatal card

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Skills workshop Routine use of the antenatal card

  1. 1. 2A Skills workshop: Routine use of the antenatal card 3. Proteinuria or glycosuria. Objectives 4. Oedema. 5. Fetal movements from 28 weeks onwards. 6. Presenting part from 34 weeks onwards. When you have completed this skills 7. Haemoglobin concentration at 28 and 34 workshop you should be able to: weeks. • Plot the symphysis-fundus height. 8. The symphysis-fundus height from 18 • Use the symphysis-fundus height graph weeks. 9. Any additional notes. to assess whether the fetus is growing 10. Signature of the responsible midwife or adequately. doctor. • Plot the patient’s weight and assess The symphysis-fundus (s-f) height is recorded whether the weight gain is normal. on the antenatal graph while the other information is recorded in the spaces providedA. Recording information (see Figure 2A-1).on the antenatal cardThe front of the antenatal card is used B. Recording the results of the rapidto record details of the patient’s history, HIV test on the antenatal card.examination, special investigations, duration 1. If the first rapid test is negative, it isof pregnancy, planned management, and accepted that the patient is HIV negative.future family planning at the first and second In the space for special investigations onantenatal visits. The back of the antenatal card the front of the antenatal card, ‘Yes’ must beis used to record the observations made at circled as the test was done (i.e. accepted)each antenatal visit throughout pregnancy. and then ‘No’ must be circled as the resultThe following items should be recorded on was negative for RVD (i.e. precautions arethe back of the antenatal card every time the not needed). RVD is the abbreviation forpatient attends the antenatal clinic: Retro Viral Disease (see Figure 2A-2). 2. If both the first rapid test and the1. Date. confirmatory (second) test are positive, it2. Blood pressure.
  2. 2. SK ILLS WORKSHOP : ROUTINE USE OF THE ANTENATAL CARD 79 Date PROBLEM LISTSIGNATURE: 1 2DATE: 3 4GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 5 45 GESTATION EST. BY: 45 Date NOTES (essential facts only) Dates Sonar 40 40 Both S-F-measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths)GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43BLOOD- Syst.PRESSURE Diast. P PUrine S SOEDEMA RRT 2/01 Fetal movements Antenatal Haemoglobin (g/dl) card B ENGFigure 2A-1: The back of the antenatal card is accepted that the patient is HIV positive. centiles respectively (i.e. the upper and lower Circle ‘Yes’ for the test being done and limits of normal fundal growth). again ‘Yes’ for the test being positive for RVD. The test was therefore accepted and D. Plotting the symphysis-fundus height precautions are needed (see Figure 2A-3). for the first time when the patient is sure The patient must receive appropriate of the date of her last menstrual period antiretrovirals to prevent mother-to-child transmission of HIV. 1. Calculate the period of gestation in weeks.3. If, after counselling, the patient decides not The gestational age is given along the top to have an HIV test, ‘No’ must be circled as and bottom of the graph (the horizontal the test was not done. As the test was not axis). The patient’s gestational age is 24 done, a decision about precautions is not weeks. required (see Figure 2A-4). 2. Measure the s-f height. The s-f height in centimetres is given on both sides of the graph (the vertical axis). The patient’s s-fC. The significance of the lines on the graph height measures 21 cm.There are three oblique lines on the antenatal 3. Knowing the gestational age and the s-fgraph. height, the s-f height for the gestational age can be plotted on the graph and should beThe three lines represent the normal increase recorded by making a dot. A small circle isin the symphysis-fundus or s-f height (i.e. a drawn around the dot to make sure that itcentile growth chart of fundal height). The is clearly seen (Figure 2A-5).solid line in the centre is the 50th centile or 4. The date of the antenatal visit should beaverage growth line. The dotted lines above written at the top of the card in the squareand below this represent the 90th and 10th
  3. 3. 80 MATERNAL CARE RVD: Test done Yes No Precautions Yes NoFigure 2A-2: Recording of a negative HIV test on the antenatal card RVD: Test done Yes No Precautions Yes NoFigure 2A-3: Recording of a positive HIV test on the antenatal card RVD: Test done Yes No Precautions Yes NoFigure 2A-4: Recording that the patient decided not to be tested for HIV el SIGNATURE: N F. 7 DATE: / 27 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both SF-measurement 35 LW. 0. = Weight 35 = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths) GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 BLOOD- Syst. PRESSURE Diast. P P Urine S S OEDEMA RRT 2/01 Fetal movements Antenatal Haemoglobim (g/dl) card B ENGFigure 2A-5: An s-f height measurement of 21 cm at a gestational age of 24 weeks is plotted on July 27th
  4. 4. SK ILLS WORKSHOP : ROUTINE USE OF THE ANTENATAL CARD 81 el SIGNATURE: N F. 10 DATE: 4/ GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both S-F-measurement 35 LW. 0. = Weight 35 = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths) GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 BLOOD- Syst. PRESSURE Diast. P P Urine S S OEDEMA RRT 2/01 Fetal movements Antenatal Haemoglobin (g/dl) card B ENGFigure2A-6: Recording the s-f height of 27 cm on the 50th centile when a patient could not remember thedate of her last menstrual period. The patient attended the antenatal clinic on 4 October. opposite the gestational age of the patient. opposite the 27 cm on the vertical axis The person recording the observations on (figure 2A-6). the antenatal card must also write her or 2. By plotting the s-f height measurement his name next to the date. on the 50th centile you are assuming that5. The method whereby the gestational age the fetus is growing normally and that was determined must now be ticked in the measurement on the horisontal axis the appropriate block at the top left-hand represents the approximate gestational corner of the chart. In this case ‘Dates’ age. In this case the approximate should be ticked. gestational age is 28 weeks.6. Between 18 and 36 weeks the s-f height in 3. The method whereby the gestational age centimetres should be plotted on the s-f was determined must now be ticked in curve to determine the gestational age in the appropriate block at the top left-hand weeks. If the fundal height is at the level of corner of the chart. In this case ‘s-f- the umbilicus or higher, and the s-f height measurement’ should be ticked. differs from the gestational age by four weeks 4. The fundal growth must be carefully or more, the s-f height should be plotted. recorded at the following visits. If little or no growth occurs in the next four weeks, theE. Plotting the s-f height for the first diagnosis of intra-uterine growth restrictiontime when the patient does not know must be made. If excessive growth occurs,the date of her last menstrual period multiple pregnancy must be excluded. Normal growth with the s-f height between1. The patient’s s-f height measures 27 cm. the 90th and 10th centiles confirms a Plot the measurement on the 50th centile normal growing singleton pregnancy.
  5. 5. 82 MATERNAL CARE el SIGNATURE: N F. /5 DATE: 20 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both S-F measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start S-Fmeasurement SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths) GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 BLOOD- Syst. PRESSURE Diast. P P Urine S S OEDEMA RRT 2/01 Fetal movements Antenatal Haemoglobin (g/dl) card B ENGFigure 2A-7: A patient’s gestational age, according to her last menstrual period, is 31 weeks and the s-f heightmeasurement is 25 cm.F. The first recording of the s-f height at the top left-hand corner of the growthwhen the duration of pregnancy, as chart. In this case a tick should be madedetermined by her last normal menstrual opposite ‘s-f measurement’.period, differs from that determined by 4. The fundal growth must be carefullythe s-f height by four or more weeks. recorded at the following visits. If little or no growth occurs in the next four1. According to the patient’s last menstrual weeks, a diagnosis of intra-uterine growth period, she is 31 weeks pregnant. The restriction must be made. If excessive s-f height measurement is 25 cm which growth occurs, multiple pregnancy must indicates a gestational age of 26 weeks if be excluded. Normal growth with the s-f plotted on the 50th centile of the s-f curve height between the 90th and 10th centiles (Figure 2A-7). confirms a normal growing singleton2. In this case the fundal height is above pregnancy. This information also confirms the umbilicus, and the gestational age that using the s-f height to determine estimated from the mother’s last menstrual gestational age was correct. period and the s-f height differ by five weeks. The s-f height probably indicates the true gestational age. Make a mark on the G. Plotting the symphysis-fundus 50th centile opposite 25 cm. This indicates height at subsequent antenatal visits an estimated gestational age of 26 weeks. The symphysis-fundus height must be plotted3. The method by which the gestational age on the graph at every subsequent antenatal is estimated must be recorded in the box clinic visit. As before, the symphysis-fundus
  6. 6. SK ILLS WORKSHOP : ROUTINE USE OF THE ANTENATAL CARD 83 el el el SIGNATURE: N N N F. F. F. /5 /6 /7 DATE: 20 17 15 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both S-F measurement 35 LW. 0. = Weight 35 = measurement 30 30 25 25 20 20 15 15 10 10 Start S-Fmeasurement SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical Vx landmarks HEAD ABOVE PELVIS (fifths) 4 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 BLOOD- Syst. PRESSURE Diast. P P Urine S S OEDEMA RRT 2/01 Fetal movements Antenatal Haemoglobin (g/dl) card B ENGFigure 2A-8: A patient’s s-f height measurement is 30 cm, four weeks after her last visit. Four weeks later thes-f height is 32 cm.height measurement and the gestational age H. Recording the presenting part andare used to determine where the dot should the amount of fetal head palpablebe made on the graph. For example, if the above the brim of the pelvispatient’s present visit is four weeks after she From 34 weeks gestation onwards the lielast attended the antenatal clinic, the s-f height and the presenting part must be determinedmeasurement must be plotted four weeks later at every visit. The presenting part may be aon the graph (Figure 2A-8). vertex or breech. If the presenting part is a fetal head, then the amount of head above the Date L L pelvic brim must be determined. 1 20/5 Grande multipara 2 20/5 Gestational diabetes I. Writing notes on the antenatal record card 3 23/6 Pre-eclamsia 4 A space for brief notes is provided on the 5 antenatal card. A block is also provided for a Date problem list. Few notes are needed and usually 20/5 Diabetes to be managed with diet there are no notes for patients that are assessed as being low risk with normal pregnancies 23/6 Good diabetic control (Figure 2A-9). Admit to ward for PET assessment and management Requests tubal ligationFigure 2A-9: A problem list with short notes

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