For pregnant women

2. DEFINITION
IT IS THE CARE YOU GET
FROM HEALTH
PROFESSIONALS DURING
YOUR PREGNANCY.
IT HELPS TO PREVENT
MATERNAL MORTALITY.

3. Hemorrhage
Infection
Eclampsia
Prolonged and obstructed labor
Unsafe abortion
Other indirect causes: –HIV/AIDS, malaria and TB, heart disease,
anemia

4.  1. Choice on contraception – to ensure that individuals
and couples have the information and services to plan
the timing, number and spacing of pregnancies
 2. Antenatal care – For the identification of risk factors
and early diagnosis of pregnancy complications and
appropriate management, and health education
 3. Clean and safe delivery – to ensure that all health
workers have the knowledge, skills and equipment to
perform clean and safe delivery and provide
postpartum care to mother and baby
 4. Essential obstetric care – to ensure that essential
care for high-risk pregnancies and complications is
made available to all women who need it
 5. Choice on termination of pregnancy – to provide
women who have unwanted pregnancies with a legal,
safe and acceptable choice

5.  to ensure that pregnancy causes no harm to the mother
 to keep the fetus healthy during the antenatal period.
 to provide health education.
 This may be achieved by:
 Screening for pregnancy problems
 Assessment of pregnancy risk
 The fetal condition must be repeatedly assessed
 Treatment of problems that may arise during the antenatal
period
 Giving medications that may improve pregnancy outcome
 Provision of information to pregnant women
 Physical and psychological preparation for childbirth and
parenthood

6. WHO
RECOMME
NDS A
MINIMUM
OF FOUR
ANC
VISITS
First visit: On confirmation of
pregnancy
Second visit: 20-28 weeks
Third visit: 34-36 weeks
Fourth visit: before expected date of
delivery or when the pregnant woman
feels she needs to consult health worker

7. FIRST ANC VISIT
Confirm that the patient is
pregnant before beginning
antenatal care.
History of missed
menstrual period
Urine pregnancy
tests

8. THE
FIRST
ANTENA
TAL
VISIT
 Can be as soon as a woman
suspects pregnancy, even as early
as the first missed menstrual
period
 Urine pregnancy tests must be
done
 If found to be pregnant must be
issued with an antenatal card and
receive first visit antenatal care.
 Those who request termination of
pregnancy should be appropriately
counselled and referred.

9. A full history must be taken.
A full physical examination
must be done.
The duration of pregnancy
must be established.
Important screening tests
must be done.
Some high-risk patients can
be identified

10. ESTIMATI
ON OF
GESTATIO
NAL AGE
The first estimation of gestational
age, with the expected date of
delivery, should be used for the
remainder of the pregnancy and
must not be changed unless
important new information
becomes available.
Indicate on the antenatal card
how the gestational age was
estimated.

11. •Last normal
menstrual period
•Symphysis to fundal
height measurement
•Ultrasonography
Estimation
of
gestational
age may be
based on

12. LAST
MENSTR
UAL
PERIOD
 This is valid if the woman is sure of
her dates,
 Gestation age must be calculated
from the first day of the last
menstrual period.

13.  This is used for estimation of
gestational age after 24
weeks if the dates from the
last menstrual period are
unknown or wrong, in the
presence of a normal
singleton pregnancy.
 The SFH measurement is of
little value for estimation of
gestational age at less than
20 weeks and term.

14.  A difference between the
gestational age according to
the menstrual dates and the
size of the uterus is usually
the result of incorrect dates.

15. An ultrasound scan for gestational age estimation
should be requested for women who are unsure of
dates with SFH measurement less than 24 cm.
Fetal measurements by ultrasound give reasonably
accurate gestational age estimates before 24 weeks of
gestation. Ultrasound after 24 weeks is less reliable.

16.  A uterus bigger than dates
could suggest:
 Multiple pregnancy.
 Polyhydramnios.
 A fetus which is large for
the gestational age.
 Diabetes mellitus.

17.  A uterus smaller than dates
could suggest:
 Intra-uterine growth
restriction.
 Oligohydramnios.
 Intra-uterine death.
 Rupture of the
membranes.

18. PREVIOUS
OBSTETRIC
HISTORY
 Establish the number of
pregnancies (gravidity)
 the number of previous
pregnancies reaching
viability (parity)
 number of miscarriages and
ectopic pregnancies that
the patient may have had.

19.  A full history, containing the
following:
 The previous obstetric
history.
 The present obstetric
history.
 A medical history.
 HIV status.
 History of medication and
allergies.
 A surgical history.
 A family history.
 The social circumstances of
the patient.

20. PREVIOUS
OBSTETRIC
HISTORY
 Grande multiparity (i.e., five
or more pregnancies which
have reached viability).
 Miscarriages: 3 or more
successive first-trimester
miscarriages suggest a
possible genetic abnormality
in the father or mother. A
previous midtrimester
miscarriage suggests a
possible incompetent internal
cervical os.
 Ectopic pregnancy: ensure
that the present pregnancy is
intrauterine.
 Multiple pregnancy: non-
identical twins tend to recur.

21. PREVIOUS
OBSTETRIC
HISTORY
 The birth weight,
gestational age, and
method of delivery of each
previous infant as well as of
previous perinatal deaths.
 Previous complications of
pregnancy or labor.

22.  Complications in previous
pregnancies tend to recur in
subsequent pregnancies.
 patients with a
previous perinatal
death are at high risk
of another perinatal
death,
 patients with a
previous spontaneous
preterm labor are at
high risk of preterm
labor in their next
pregnancy.

23. The first day of the last
normal menstrual period
must be determined as
accurately as possible.
Any medical or obstetric
problems which the patient
has had since the start of
this pregnancy, for example:
Pyrexial illnesses (such as
influenza) with or without
skin rashes.
Symptoms of a urinary tract
infection.
Any vaginal bleeding.

24. Attention must be given to minor symptoms which
the patient may experience during her present
pregnancy, for example: Nausea and vomiting,
Heartburn, Constipation, Oedema of the ankles and
hands.
Is the pregnancy planned and wanted, and was there
a period of infertility before she became pregnant?
If the patient is already in the third trimester of her
pregnancy, attention must be given to the condition
of the fetus.

25. MEDICAL
HISTORY
 Some medical conditions
may become worse during
pregnancy, e.g., a patient
with heart valve disease
may go into cardiac failure
while a hypertensive
patient is at high risk of
developing pre-eclampsia.

26. Ask the patient if she has had any of the following:
1. Hypertension.
2. Diabetes mellitus.
3. Rheumatic or other heart disease.
4. Epilepsy.
5. Asthma.
6. Tuberculosis.
7. Psychiatric illness.
8. Any other major illness.

27. It is important to ask whether the patient
knows her HIV status.
If she had an HIV test, both the date and
result need to be noted.
If she is HIV positive, record whether she is
on ARV treatment and which drugs she is
taking.
If she is not on ARV treatment, note whether
she knows her CD4 count and when it was
done

28. MEDICAL
HISTORY
 Ask about the regular use of any
medication. This is often a pointer
to an illness not mentioned in the
medical history.
 Certain drugs, e.g., efavirenz,
can be teratogenic (damage to
the fetus) during the first
trimester of pregnancy.
 Some drugs, such as Warfarin,
can be dangerous to the fetus if
they are taken close to term.
 Drug allergies are also
important, and the patient
must be specifically asked if
she is allergic to penicillin

29.  Operations on the urogenital
tract, e.g., Caesarean section,
myomectomy, a cone biopsy of
the cervix, operations for stress
incontinence, and vesicovaginal
fistula repair.
 Cardiac surgery, e.g., heart valve
replacement.

30.  Close family members with a
condition such as diabetes,
multiple pregnancy, bleeding
tendencies or mental
retardation increases the risk
of these conditions in the
patient and her unborn
infant. Some birth defects
are inherited.

31.  Ask if the woman smokes cigarettes or drinks alcohol.
 Smoking may cause intra-uterine growth restriction (fetal
growth restriction) while alcohol may cause both intrauterine
growth restriction and congenital malformations.

32. An unmarried mother may need help to
plan for the care of her infant.
Unemployment, poor housing, and
overcrowding increase the risk of
tuberculosis, malnutrition, and intra-
uterine growth restriction.
Patients living in poor social conditions
need special support and help.

33.  Do a general examination including
weight, height, heart rate, color of
mucous membranes, blood pressure, a
check for edema, and palpate for
lymph nodes
 Do a systemic examination including
the following systems or organs:
 The thyroid gland.
 The breasts.
 Lymph nodes in the neck, axillae
(armpits) and inguinal areas.
 The respiratory system.
 The cardiovascular system.
 The abdomen.
 Both external and internal
genitalia.

34.  Examine the pregnancy
including inspection and
palpation of the pregnant
uterus, with measurement of
the symphysis-fundal height
(SFH) in cm. Listen to the
fetal heart from 26 weeks
gestation.

35.  ‘After extensive discussion and consultation, the National
Committee on Confidential Enquiries into Maternal Deaths
(NCCEMD) has included MUAC in the national Maternal
Death Notification Form. The MUAC gives useful
information on nutritional status and pregnancy risk and is
easily done during the antenatal period or during labour.
Use of the MUAC in pregnancy is supported by research
done in a number of African countries and elsewhere’

36.  ‘MUAC is advantageous over body-mass index because
height does not need to be measured, accurate scales are not
required, the woman does not have to stand up straight, no
calculations need be done, and MUAC, unlike weight, does not
normally increase significantly during pregnancy’

37.  An MUAC ≥33 cm:
 Suggests obesity
 Is associated with an increased risk of pre-eclampsia and
maternal diabetes
 Is associated with an increased risk of delivery of a larger
than normal infant
 Indicates that blood pressure measurement with a normal-
sized adult cuff may be an overestimation

38.  An MUAC<23 cm:
 Suggests undernutrition or a chronic wasting illness
 Is associated with delivery of a smaller than normal infant

39.  Syphilis serology. Nonspecific reagin tests (RPR, WR, VDRL) are
performed, using a rapid card test.
 Rhesus (D) blood group, using a rapid card test
 Hemoglobin (Hb) level, using a portable haemoglobinometer or copper
sulphate screening method
 Human immunodeficiency virus (HIV) serology, using rapid test kit.
This must follow National guidelines on routine counselling and
voluntary testing.
 Urine dipstick testing for protein and glucose
 All of the above tests can be performed by midwives or appropriately
trained auxiliary staff at the clinic ‘on site’, with the results available to
the pregnant women before they complete the first visit.

40. Inform pregnant women
that the following
screening tests are not
routinely offered, but
may be indicated in
special circumstances:
ABO blood group
Triple screen for Down’s
syndrome and neural
tube defects
Rubella serology Blood glucose screening
Cervical (Papanicolaou)
smear
Urine culture Ultrasound scan

41.  The following are given to all pregnant women:
 Ferrous sulphate tablets 200 mg daily, to prevent anaemia
 Calcium tablets 1000 mg daily, to prevent complications of pre-eclampsia
 Folic acid tablets 5 mg daily, to help prevent fetal neural tube defects
 Tetanus toxoid (TT) immunization, to prevent neonatal tetanus:
 First pregnancy: TT1 at first antenatal visit, TT2 4 weeks later and TT3 6
months later
 Later pregnancies: Two TT boosters, one in each pregnancy at the first visit,
for the two subsequent pregnancies, at least one year apart.
 A total of five properly spaced doses of TT provide life-long protection against
tetanus
 If in a subsequent pregnancy, there is no record of previous immunization,
treat as for a first pregnancy

42.  Five danger signs and symptoms of pregnancy
 Severe headache
 Abdominal pain (not discomfort)
 Drainage of liquor from the vagina
 Vaginal bleeding
 Reduced fetal movements
 A woman that experiences any of these symptoms should
report immediately to her clinic or hospital with her antenatal
card.

43. Diet and
exercise
Personal
hygiene and
breast care
Use of
medications
Abuse of alcohol,
tobacco and
recreational
drugs

44. A delivery plan
At the end of the first visit, all pregnant women should be given a
provisional delivery plan:
• The expected date of delivery, based on the best estimate of gestational age
• The expected place of delivery, whether community health centre or
hospital
• The expected mode of delivery, whether vaginal or caesarean section
• Who will deliver the baby, whether midwife or doctor
• Pain relief options including nonpharmacological methods.
• A transport plan for emergency or delivery, including important contact
numbers
• Preparation for possible home delivery

45.  Newborn and infant care
 Plans for infant feeding and techniques, whether breast or
formula
 Details of follow up care: immunization and where this can be
obtained
 Future pregnancies and contraception
 Information on genetic disorders and birth defects
 Contraception that will be used after the pregnancy

46.  Following an early booking visit (<12 weeks), return visits
should be scheduled for 20, 26, 32, and 38 weeks, and 41
weeks if still pregnant.
 This is not applicable for women with risk factors, whose
return visits schedules will depend on their specific
problems.

47.  Ask about general well-being, fetal movements, danger symptoms and
any problems
 Check the blood pressure, heart rate and colour of the mucous
membranes
 Measure the symphysis-fundal height (SFH) in cm. Plot the SFH on the
graph against the gestational age and compare with the 10th, 50th
and 90th centiles for gestational age and with previous measurements
 Palpate carefully for breech presentation at 38 weeks
 Test the urine for protein, glucose, blood and ketones
 Repeat HIV test at 32 weeks for all women who tested negative at
initial testing

48. Repeat blood tests: Hb at 32 and
38 weeks, and a repeat RPR at
±36 weeks if the first test was
negative before 20 weeks of
pregnancy
Repeat information for danger
signs of pregnancy, and review
delivery and transport plans, as
well as feeding and contraception
choices at 32 and 38 weeks.
At 38 weeks, remind the woman
to bring her antenatal card when
she presents to the clinic or
hospital in labour

49. DENTAL CARE:
 The teeth should be brushed carefully in the morning and
after every meal.
 Encourage the woman the to see her dentist regularly for
routine examination & cleaning.
 Encourage the woman to snack on nutritious foods, such as
fresh fruit & vegetables to avoid sugar encountering the teeth.
 A tooth can be extracted during pregnancy, but local
anesthesia is recommended.

50. DRESSING:
 Woman should avoid wearing tight cloths such as belt or
constricting bans on the legs, because these could delay lower
extremity circulation.
 Suggest wearing shoes with a moderate to low heel to
minimize pelvic tilt & possible backache.
 Loose, and light clothes are the most comfortable.

51. TRAVEL:
Many women have questions about travel during pregnancy.
 Early in normal pregnancy, there are no restrictions.
 Late in pregnancy, travel plans should take into consideration
the possibility of early labor.

52. SEXUAL ACTIVITY:
 Sexual intercourse is allowed with moderation, is absolutely
safe and normal unless specific problem exist such as: vaginal
bleeding or ruptured membrane.
 If a woman has a history of miscarriage, she should avoid
sexual intercourse in the early months of pregnancy.

53. EXERCISES:
 Exercise should be simple. Walking is ideal, but long period of
walking should be avoided.
 The pregnant woman should avoid lifting heavy weights as it
may lead to abortion.
 She should avoid long period of standing because it
predisposes her to varicose vein.
 She should avoid sitting with legs crossed because it will delay
circulation.

54.  Maintain adequate fluid intake.
 Warm up slowly, use stretching exercises but avoid over
stretching to prevent injury to ligaments.
 Avoid jerking or bouncing exercises.
 Be careful of loose thrown rugs that could slip& cause injury.
 Exercises on regular basis (three times per week).
 After first trimester, avoid exercises that require supine
position.

55. -Vaginal bleeding.
-Sever anemia.
-History of preterm labor,
-Extreme over or under weight.
-Hypertension, heart, lung, thyroid diseases

56. SLEEP:
The pregnant woman should lie down to relax or sleep for 1 or 2 hours during the
afternoon.
At least 8 hours sleep should be obtained every night & increased towards term,
because the highest level of growth hormone secretion occurs at sleep.
Advise woman to use natural sedatives where needed such as: warm bath &
glass of warm milk.
A good sleeping position is sims’ position, with the top leg forward. This puts the
weight of the fetus on the bed, not on the woman, and allows good circulation in
the lower extremities.
avoid resting in supine position, as supine hypotension syndrome can develop.

57.  -Daily requirement in pregnancy about 2500 calories.
 - Women should be advised to eat more vegetables, fruits,
proteins, and vitamins and to minimize their intake of fats.
 Purpose:
 Growing fetus.
 Maintain mother health.
 Physical strength & vitality in labor.
 Successful lactation.

58. REFERENCE
S
 WORLD HEALTH
ORGANIZATION
 YOU TUBE VIDEOS
 GOOGLE