ANC LO 3 & 4 - Copy.pptx

MODULE TITLE :
Promoting and Educating on
Ante-natal Care
MODULE CODE : HLT HES3 M06 0122
LEARNING OUT COMES:

1. LO 3 Conduct Home visit and Refer pregnant
Women
Contents:
3. 1. Home to home basic health education
and maternal health care
3.2 Recording vital signs
3.3 Following up of pregnant mother
3.4 Identifying and addressing risk factors
3.5 Pregnancy related danger signs

Contents:
3.6 Maintaining registers of pregnant women
3.7 Antenatal care schedules
3.8 Reminding and assisting ANC attendant
3.9 Maintaining referral and communication
networks

After studying this unit, the HEP will be able to:
Plan and prepare for home visits in the
community

Families are the main unit of health service
in the community and have been for over a
century.
Working in the community and being able
to visit families in their homes is a privilege.
A home visit is conducted to visit mothers
where they live in order to assist them to
achieve as high a level of wellness as
possible.

3.1.1 Reasons for house to house visit
Why is home visiting an essential
component of the HEPs strategy?
a. It takes services into the homes of the
clients
b. It allows HE workers to see how
mothers/people really live
c. It enables the HEPs give advice and
support in the environment in which the
clients live

3.1.2 Types of home visiting
State the various types of home visiting a HEPs can do.
a. Routine home visits to normal mothers and during which
HEPs may find clients who need care or help
b. Special home visits
i. Follow up - this is usually for a mother who is ‘at risk’ for
some reason e.g. a PW who has iron supplementation non
compliance, a baby who is failing to gain weight, a client
who is HIV positive etc
ii. Defaulter tracing - where the HEPs actively searches for a
client who has missed a service e.g. ANC service, PW
Forum.
iii. Inspection and health education - where the HEPs
checks the environment in which her clients live and
educates them on personal & environmental hygiene.

3.1.3 The things a HEPs will consider
when preparing for home visit
a. Materials required for visit are available and
in good condition
b. Identify areas to be visited on the map and
revise route
c. Ensure set time for visit is appropriate
d. Set objectives for each home visit

3.1.4 Deciding where to visit
a. Areas that have not been visited previously
b. Areas that require follow-up
c. Areas with special cases e.g. a postnatal
mother with engorged breast, mother or baby
having malnutrition, anemic mother or baby.

3.1.5 Mapping the kebele
 Mapping the village or Kebele is the first step
in carrying out community based health
activities.
 Community often is defined by its geographic
boundaries and thus is called a geographic
community.

3.1.5 Mapping the kebele(continued)
 On mapping a village or kebele, the Health Extension
Workers (HEWs) should know the following three
points:
1. Identify a defined area (village) limited by
convenient natural boundaries.
2. Mark out this defined area (village or Kebele) on a
map with a marker, fasten it to a piece of board and
hang this up on the wall.
3. Show basic data on the map, such as population of
the village, houses, roads, streams, organizations,
religious sites and others. See the example indicated
below.

3.1.6 Why is it important to carve out areas
for home visit on your community map?
a. To enable you plan your visits in such a way that
all areas are covered
b. For easy flow of movement into homes
c. To trace bearings, show distances and identify
major obstacles in the terrain
d. To mark areas affected by certain important risk
factors/diseases such as low access to ANC services.

3.1.7 Drawing a Map
A map is a most useful tool for a health center as it
allows everyone to see what is in the zone, identify
important landmarks and to see where the HEw’s
activities take place.
The most useful map is one drawn by the HEW
herself, showing landmarks that are important to
her work.

3.1.7 Drawing a Map(Continued)
 A map should be constantly upgraded to show
new activities and information.
 There should be a key which shows the symbols
used on the map.

3.1.7 Drawing a Map(Continued)
A map should contain the following features:
a. Boundaries showing neighboring districts, sub
districts or zones
b. Important towns, villages and their populations
c. Communications such as roads, footpaths, railways
d. Health infrastructure such as private clinics, trained
TBA homes, homes of CHVs, health centers and
outreach points
e. Public infrastructure (e.g. schools, markets,
cemetery); traditional and religious infrastructure (e.g.
Mosques, churches) ; and physical features (e.g. green
areas, forests, rivers, ponds)

3.1.8 Why is it important to carve out areas
for home visit on your community map?
a. To enable you plan your visits in such a way
that all areas are covered
b. For easy flow of movement into homes
c. To trace bearings, show distances and
identify major obstacles in the terrain
d. To mark areas affected by certain
important risk factors/diseases such as low
access to ANC services.

Key
‡ = HP
♣ = Green area
Ç= Mosgue
◊=church
|= river

Exercise
Draw the sketch map of your kebele and divide in
to twenty working days.

3.1. 9 Recording Home Visits and Completing
Reporting Formats
1. What activities do you need to note down during
and after home visits?
a. The types of services rendered
b. Number of households visited
c. The number of people attended/ received services
d. Remarks on some special ones, especially those who
need follow-up visits
e. Child Health Record Cards, TT and FP cards should be
updated
f. The community register should also be updated
g. Write your findings using the appropriate reporting
format

3.2. Recording vital signs
3.2.1 Definition:
Taking vital signs are defined as the
procedure that takes the sign of basic
physiology that includes temperature ,
pulse, respiration and blood pressure.
If any abnormality occurs in the body, vital
signs change immediately.

3.2.2 Purpose:
1. To assess the client’s condition
2. To determine the baseline values for future
comparisons
3. To detect changes and abnormalities in the
condition of the client

3.2.3 Equipments required:
1. Oral/ axilla / rectal thermometer (1)
2. Stethoscope (1)
3. Sphygmomanometer with appropriate cuff size (1)
4. Watch with a second hand (1)
5. Spirit swab or cotton (1)
6. Sponge towel (1)
7. Paper bags: for cleaning & drying
8. Record form
9. Ball- point pen: blue (1) black (1) red (1)
10. Steel tray (1): to set all materials

3.2. 3 a. Relation of Celsius to
Fahrenheit scale
The Fahrenheit scale was first proposed in 1724 by
German physicist Daniel Gabriel Fahrenheit.
Its symbol is 0F.
How to convert oC to Fahrenheit scale:
0 F= (0C x 9/5) + 32
Eg. Water freezes at 0 oc. What is zero 0C in Fahrenheit
scale?
Solu:-
Given= oC = 0
0 F = (0 x 9/5) + 32 = 32

3.2.3a. Relation of Celsius to
Fahrenheit scale (Continued)
 The Celsius scale is named after Swedish
astronomer Andres Celsius, who developed it in
1742.
 Celsius is also referred to as Centigrade. Its
symbol is 0C.
 0C = (0F-32) x 5/9
Eg. Water boils at 212 0F. What is the value in oC?
OC= (212- 32) x 5/9= 100
Thus, 212 0F = 100 0C

3.2.3b. Body temperature
Body temperature is a measurement of how
hot or cold the internal tissues of the body
are.
Although it varies a little bit in hot or cold
weather, or if the person is wearing too
many or too few clothes, or doing heavy
physical work, it generally stays close to a
value known as ‘normal’ temperature,
unless the person is ill.

3.2.3b. Body temperature(Continued)
Body temperature is measured using an
instrument called a thermometer (Figure 9.2a),
which has a ‘bulb’ at one end, usually filled with a
silver liquid metal called mercury.
(Some glass thermometers contain a red dye
instead, and some use digital technology — see
Figure below)

3.2.3c. Types of thermometer
Common types are:
1. Electronic thermometer.
2. Glass thermometer.
3. Digital thermometer
In a glass thermometer (mercury
thermometer), when the bulb of mercury is
warmed by a person’s body, the mercury
expands and rises up the thin glass tube, which
is marked with numbers showing the person’s
body temperature.

(a) Glass thermometers may measure temperature
in degrees Celsius (top) or Fahrenheit (below).
(b) A digital thermometer shows the temperature
as a number in a window.

3.2.3d. Body temperature
Two kinds of body temperature:
1. Core Temperature
 is the temperature of internal organs & it remains
constant most of the time (37oC);
Is the temperature of the deep tissues of the
body.
Remains relatively constant

3.2.3d. Body temperature(Continued)
2.Surface temperature: Is the temperature of the
skin, the subcutaneous tissue and fat.
It, by contrast rises and falls in response to the
environmental changes.
The normal range of the body temperature is
between 36.2 to 37.2 Cº.
Warning sign:
 The woman has a fever — a temperature of
above 37.5°C or above.
 She feels hot to touch.

3.2. 3e. How to check client’s temperature
 If you don’t have a thermometer, put the back of
one hand on the woman’s forehead, and the
other on your own, or that of another healthy
person (see Figure below ).
 If the woman has a fever, you should be able to
feel that her skin is hotter than that of a healthy
person.

You can easily feel if she is hotter than you.

3.2. 3e. Client’s temperature (Continued)
If you have a glass thermometer, clean it well with
soap and clean water, or alcohol.
Hold the thermometer with the ‘bulb’ containing
the silver mercury pointing away from your hand.
Shake it with a snap of the wrist (see figure
below), until the top of the thin column of silver
mercury falls well below ‘normal’ body
temperature, i.e. less than 36°C (or 96°F).

Put the bulb end of the thermometer under the
woman’s tongue or in her armpit, and leave it
there for three minutes.
The woman should keep her mouth closed, or
her arm close to her body.
Take the thermometer out and turn it until you
see the silver line.
The point where the silver stops marks the
temperature.
There is usually a little arrow at the ‘normal’
point.

Always clean the thermometer with soap and
cool water, or with alcohol, after you use it.
Do not use hot water — it can break the
thermometer! Mercury is a very poisonous
metal.
Be careful with glass thermometers, and if they
break, do not pick up the mercury with your bare
hands.
Sweep the mercury into a jar and bury it. Do not
let children play with thermometers or mercury.
Get a digital thermometer if you can

3.2.3f. What to do if the woman has a fever
A fever can be caused by:
Sickness — for example, flu or malaria
An infection of part of the body — like a
bladder infection, or an infection of the
uterus
 A mild fever can also be caused by
dehydration (loss of body fluids due to
not drinking enough water).

3.2.3f. Fever (Continued)
A high fever needs to be lowered right away.
To lower a fever:
Give 500 to 1,000 mg (milligrams)
paracetamol by mouth every four to six
hours
 Have her drink one cup of fluid every hour
Wash her body with a cloth dipped in cool
water.
If the fever does not come down in 8
hours, refer her to a health center.

3.2.4 Checking her pulse
The pulse tells you how fast the heart is beating.
Every time the heart beats (contracts) it pushes
blood out into the arteries.
You can feel each ‘pulse’ by pressing gently on an
artery with your fingers.
Everyone’s pulse is different.That is normal.
You can find the pulse in the throat or wrist, as
shown in figure below

Palpating carotid and radial arteries

3.2.4 Pulse (Continued)
Characteristics of Pulse
1. Quality: refers to the ‘‘feel’’ of the pulse, its
rhythm and forcefulness.
2. Rate - is an indirect measurement of cardiac
output obtained by counting the number of apical
or peripheral pulse waves over a pulse point.
Bradycardia is a heart rate less than 60 beats per
minute in an adult.
Tachycardia is a heart rate in excess of 100 beats
per minute in an adult.

3. Rhythm- is the regularity of the heartbeat. It
describes how evenly the heart is beating:
Regular (the beats are evenly spaced).
 Irregular (the beats are not evenly spaced).
Dysrhythmia (arrhythmia) is an irregular rhythm
caused by an early, late, or missed heartbeat.

4. Volume (strength or amplitude)- is a
measurement of the strength or amplitude of force
exerted by the ejected blood against the arterial
wall with each contraction.
It is described as normal (full, easily palpable).
Weak (thready and usually rapid), or
Strong (bounding).

3.2.4 Pulse (continued)
Healthy pulse:
The normal pulse rate is about 60 to 80
beats a minute when the woman is resting.
Warning sign:
The pulse rate is 100 or more beats a
minute when the woman is resting.

3.2.4a. How to measure her pulse rate
Wait until the woman is resting and
relaxed.
Put the pads of two fingers on the pulse
Do not use your thumbs, because there is
a little pulse in your own thumbs which
could confuse you.
Use two or three fingers (never your
thumb) to feel the pulse in the neck or
inside of the wrist.

Make sure the woman is sitting
in a relaxed position when you
measure her pulse rate.

3.2.4a. Pulse (continued)
If you have a watch with a second hand, or there
is a clock with a second hand, count the number
of beats in the mother’s pulse for one minute.
Write the number down.
Many people find it hard to count accurately
while looking at a watch.
They tend to count one pulse beat every second,
no matter how fast the pulse is really beating.

3.2.5. What to do if the woman has a fast
pulse
If her pulse rate is 100 beats or more a minute,
she may have one or more of the following
problems:
Stress, fear, worry, or depression
 Anaemia
An infection like malaria
Bladder infection, or infection in her uterus
Heavy bleeding
Thyroid trouble
Heart trouble.

3.2.4b. What to do if (Continued)
If you do not know what is causing the fast
pulse rate (above 100 beats per minute), refer
the woman to the nearest health center.

3.2.5 Respiration
Respiration- is Pulmonary ventilation (breathing ).
movement of air in and out of the lungs.
Inspiration (inhalation) is the act of breathing in.
Expiration (exhalation ) is the act of breathing
out.

3. 2.5a. Factors Affecting Respiration
1. Pain, anxiety, exercise .
2. Medications .
3. Trauma .
4. Infection.
5. Respiratory and cardiovascular disease .
6. Alteration in fluids, electrolytes, acid- base
balances.

3.2.5b. Checking for shortness of breath
Healthy respiration:
Rate is you observe a full inspiration & expiration
when counting.
Normal range: is usually 12 – 20 breath / minute
 Some shortness of breath, especially late in
pregnancy, is normal.
 Many women get a little short of breath when
they are 8 or 9 months pregnant.
What do you think causes this?

3.2.5b. Checking for shortness of
breath (Continued)
As the baby gets bigger, it squeezes the lungs so
there is less room to breathe.
 Breathing may get easier when the baby drops
lower in the belly shortly before labour begins.
Warning symptom:
If shortness of breath is making a pregnant
woman uncomfortable, this is a warning
symptom, especially if she has other signs of
illness (see figure below).

Shortness of breath
can be a warning symptom.

3.2.5c. Sites of breathing
measurement
Normal breathing is slightly observable,
effortless, quiet, automatic, and regular.
It can be assessed by observing chest wall
expansion and bilateral symmetrical movement
of the thorax.
Another method the health practitioners can
use to assess breathing is to place the back of the
hand next to the client’s nose and mouth to feel
the expired air.

3.2.5.d. IMPORTANT NOTE :
The health care provider must not tell the
patient that he or she will assess his
respiration because the patient can control
his breathing so that will give a wrong
assessment).
 a complete cycle of an inspiration
composes one respiration .

Terms
Eupnea: refers to easy respirations with a normal
rate of breaths per minute that is age specific.
Bradypnea: is a respiratory rate of 10 or fewer
breaths per minute.
Hypoventilation: is characterized by shallow
respirations; result in alveolar carbon dioxide
pressure increase above normal.
Tachypnea: is a respiratory rate greater than 24
breaths per minute.
Hyperventilation: is characterized by deep, rapid
respirations.

3.2.5e. Common causes of shortness
of breath
Shortness of breath can also be caused by:
Anaemia
Heart problems
Tuberculosis
Asthma
Lung infection
A blood clot in the lung
Allergies.

3.2.6. Checking her blood pressure
Blood pressure (BP)- refers to how hard the blood
is ‘pushing’ on the walls of the major blood vessels
as it is pumped around the body by the heart.
The pressure is measured in millimeters (mm) of
mercury (a liquid silver metal, which has the
chemical symbol Hg), so blood pressure
measurements are expressed as a number
followed by mmHg.
you will see & practice how to measure blood
pressure in Section.

3.2.6a. Definition
A blood pressure measurement is two numbers
written one above the other.
The top number tells you the woman’s blood
pressure at the moment when her heart ‘beats’
and pushes blood out into her body, (systolic BP).
The bottom number tells you her blood pressure
when her heart relaxes between each beat, so it
can refill with blood, (Diastolic BP).

3.2.6b. Healthy blood pressure
Normal blood pressure stays between 90/60
mmHg (you say this aloud as ‘ninety over sixty
millimeters of mercury’,) and
below 140/90 mmHg (‘one hundred and forty
over ninety millimeters of mercury’).
OR
it means:- Normal SBP ranges from 90-140
mmHg, DBP 60-90 mmHg.
It does not go up much during pregnancy.

3.2.6.c Warning signs
High blood pressure is known medically
as hypertension and is a warning sign.
The woman has high blood pressure if
either of these is true:
 The top number is 140 or above.
 The bottom number is 90 or above.

3.2.6.c Warning signs (Continued)
Very low blood pressure or hypotension (less than
90/50 mmHg) is also a warning sign,
which is usually caused only by heavy bleeding
or shock (a dangerous reduction in blood flow
throughout the body).
 This is a very dangerous situation.
The heart is like a pump, pumping blood
through the body.
High blood pressure means that the heart must
work harder to press the blood through tight or
shrunken blood vessels (veins and arteries).

Blood pressure numbers show how hard the
blood has to press.
Note that blood pressure is not the same as
pulse. You can have a slow pulse with a high
blood pressure.
When a woman has high blood pressure during
pregnancy, it is harder for her blood to bring food
and oxygen to the baby via the placenta.
The baby then grows too slowly.

Very high blood pressure can also cause the
woman to have kidney problems, bleeding in the
uterus before birth, or bleeding in the brain
(stroke).
 It can also be a sign of pre-eclampsia, which can
cause premature birth, bleeding, convulsions, or
even death for the mother.

It is very important to check the mother’s blood
pressure at every antenatal visit and refer her to
a health center if it is too high or too low.

3.2.6d. How to measure blood pressure
physical activity increase both the cardiac
output and hence blood pressure, thus,
a rest of 20 to 30 minutes following exercise is
indicated before the blood pressure can be
reliably assessed.

3.2.6d. Types of BP Apparatus
There are several types of blood pressure
equipment.
1.Some have a tall gage, known as mercury
sphygmomanometer
2. Others have a round dial, known as aneroid
sphygmomanometer
3. Digital sphygmomanometer

physical activity increase both the cardiac
output and hence blood pressure, thus,
a rest of 20 to 30 minutes following exercise is
indicated before the blood pressure can be
reliably assessed.

When you take the woman’s blood pressure, first
tell her what you are going to do, and why.
Make sure she is sitting or lying comfortably and
feels relaxed.

Steps for BP Measurement
1. Perform hand hygiene and clean
stethoscope.
2. Introduce self and confirm patient’s
identity.
3. Seek informed consent.
4. Position arm on a pillow so that the
antecubital fossa is level with the heart and
arm is straight but supported.

Steps Continued
5. Palpate brachial artery in antecubital fossa
prior to positioning cuff.
6. Wrap a suitably sized cuff around the
upper arm. The lower border of the cuff
should be approx. 2cm above the antecubital
fossa.
7. The center of the cuff should be over the
brachial artery – the arrow on the cuff should
point towards the artery.

step 1 to 7 show you how to measure blood pressure.

Method(Continued)
As the air leaks out, you will start to hear the
woman’s pulse through your stethoscope.

You can record the woman’s blood pressure:
when you start to hear the pulse (this will be the
top number), and when the pulse disappears or
gets very soft (this will be the bottom number).
Check the woman’s blood pressure at each visit.
Write the blood pressure down on her antenatal
record card so you can check for changes over
time.
 If her blood pressure is going up, ask her to
come back every week until you are sure that it is
not still rising.

Look carefully at this Figure.
Is there a month in which this woman’s blood
pressure is high enough to be a warning sign?

Answer
No. The top number never goes above 110, and
the bottom number never goes above 72. It is
normal for each number to vary a little bit from
month to month.
Part 1 p 106

3.2.7. Weighing pregnant Mother
Regularly weighing pregnant mother on the
basis of subsequent visit helps you to monitor
the weight gain expected during pregnancy.
Steady increase of 1.5–2 kgs weight per month is
expected from 4 month of pregnancy.
Cumulative average increase of 10–12 kgs
weight is expected from pregnancy till birth of a
child.
Weight gain recommended during pregnancy is
based on the pre-pregnancy BMI as shown in the
next Table.

Baseline/
pre-pregnancy BMI
in kg/m2
Recommended
weight gain in kg
Dietry diversification
Underweight
(<18.5)
12.5–18 More calorie and protein
diet adequate vegetables
and fruits
Normal
(18.5 to <25)
11.5–16 Moderate carbohydrate
and protein diet
adequate vegetables and
fruits
Overweight
(25 to <30)
7- 11.5 Normal carbohydrate and
protein diet, very low fat,
more vegetables and
fruits
Obese
(≥30)
5–9 Lower carbohydrate and
protein diet, more
vegetables and fruits,
avoid fat foods

Note: Major calorie sources are carbohydrate and
fat foods

3.3.1 Definition
What do we mean by the following up of
pregnant mother?
It a maternal & fetus through assessment or
the reevaluation of the changes that might
occur from the previous status.

3.3.2. Assessment during subsequent
contacts
In subsequent ANC contacts, the focus of
assessment is to reevaluate the changes from the
previous status and to look for new
developments.
Therefore, gestational age-based assessment in
subsequent visits is to assess maternal wellbeing,
fetal growth and wellbeing.
When there are doubtful conditions, referring the
mother for investigations is needed.

3.3.2. Assessment during subsequent
contacts (Continued)
On top of making a thorough assessment in every
subsequent contacts, instructing the woman on
how to detect her and the wellbeing of the fetus
is critical.
Warning about danger symptoms and signs of
pregnancy is included in the counseling section.

3.4.2 Pregnancy risk identification
 All pregnancies are potentially at risk
Complications often occur in pregnant
women with no known risk conditions,
it is important to do risk identification and
stratification at first contact and in
subsequent visits.

3.4.2 Pregnancy risk (Continued)
Multiple assessment methods for the
following;
 past and present obstetric history,
 medical and surgical history,
 systematic physical examination,
 laboratory, and imaging) are applied to
assess the health and wellbeing of the
mother and the fetus.

3.4.3 Existing and newly developed
high-risk conditions during pregnancy
Existing risky conditions:
Age <19 and >35 years
 Elderly primigravida
 Short stature
Overweight/obese (BMI >25 kg/m2)
or underweight (BMI <18.5 kg/m2)
Severe physical deformity/disability

Existing risky conditions (Continued)
Multiple pregnancy
History of three or more abortions or one or
more stillbirths
Birth weight of previous baby <2500 or >4000
gm
Previous manual removal of placenta,
malpresentation, malposition, post-term, pre-
eclampsia/eclampsia, operative delivery
Rh-sensitized mother

Existing risky conditions (Continued)
Anemia, chronic medical diseases, including
diabetes mellitus, renal, cardiac disease and
chronic hypertension
 Psychiatric illness
Unplanned and/or unwanted pregnancy
High HIV viral load, acute viral hepatitis,
syphilis, TB, malaria, and other systemic
infections
 Imprisoned pregnant women
Homeless pregnant women
On chronic treatment for certain disease

Newly developed risky conditions
Threatened abortion
 History of exposure to teratogenic drugs,
chemicals, or radiation
Pregnancy after sexual assault
 Multiple pregnancy
Antepartum hemorrhage
New onset or superimposed hypertension
Oligohydramnios or polyhydramnios

Newly developed risky
conditions(Continued)
Lack of uterine growth or confirmed fetal
growth restriction
Large for date uterus
Anemia
Rh-sensitized mother
Systemic infection
Acute pyelonephritis
Recurrent lower urinary tract infection
Bacterial vaginosis

Newly developed risky
conditions(Continued)
 Gestational diabetes mellitus
Preterm labor
Post-term pregnancy
Abnormal presentation or abnormal lie
Prelabor rupture of fetal membranes
Chorioamnionitis
 Short cervix

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