antenatal

1. 1
What have we learned so far?
 Maternal and infant mortality – a major public
health concern
 BEmOC and the PCPNC
 Principles of Good Care
 QUICK CHECK and RAM
 Emergency management of the woman
 Referral system

2. 2
ANTENATAL CARE

3. 3
General OBJECTIVE
 To enhance the knowledge, attitude and practice of
skilled health attendants on FOCUSED
ANTENATAL CARE.
 To understand the importance of doing an
immediate general assessment of the pregnant
woman
 To explain the process flow of providing antenatal
care.
 To perform procedures and skills necessary
during antenatal care correctly
Specific Objectives

4. 4
Objectives of Prenatal Care
Screening & Prevention of
diseases which may complicate
pregnancy
Education of women on danger
and emergency signs &
symptoms
Birth Preparedness &
Complication readiness of the
woman and her family for
childbirth

5. 5

6. 6
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclampsia, anemia, Sy & HIV
Respond to observed S/SX
Give PREVENTIVE MEASURES due
RECORD all findings, birth plan
And treatments given
Advise & counsel on nutrition, FP,
labor signs, danger signs, follow-up visits
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

7. 7
1. Always begin with Quick Check
& RAM
 ASK why did she come?
 LOOK for EMERGENCY signs
 Look for PRIORITY signs
B2-B7
B2
B7
To treatment room

8. 8
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

9. 9
2. Assess the pregnant woman: Pregnancy
Status, Birth and Emergency Plan
 How old is patient?
 Gravidity? Parity?
 LMP? AOG?
 History of previous pregnancies
 Check for general danger signs
 Perform abdominal examination
 Help woman decide on appropriate place of birth
 Prepare birth and emergency plan C14
C2

10. 10
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclampsia,
anemia, DM, Sy, & HIV
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

11. 11
3. Check all women for:
 Pre-eclampsia
 Anemia
 Syphilis
 HIV status
 Diabetes Mellitus
C3
C4
C5
C6
ANTENATAL CARE
C18

12. 12
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclampsia, anemia, Sy & HIV
Respond to observed S/SX
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

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4. Respond to observed signs or volunteered
problems
 No fetal movement
 Ruptured membranes and no labor
 Fever or burning urination
 Vaginal discharge
 Signs suggesting HIV infection
 Smoking, alcohol or drug abuse
 Cough or breathing difficulty
 Taking anti-TB drugs
C7-11
C7
C8
C9
C10
C11

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RUPTURED MEMBRANES and NO
LABOR
 < 8 months
 Give antibiotic: ERYTHROMYCIN (B15).
Alternative: Ampicillin
 Give corticosteroids if no sign of infection
 Betamethasone 12 mg IM q 24 hrs x 2 doses OR
 Dexamethasone 6 mg IM q 12 x 4 doses
> 8 months
No clear evidence of benefit of routine
antibiotic and steroid use

15. 15
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclampsia, anemia, Sy & HIV
Respond to observed S/SX
Give PREVENTIVE MEASURES due
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

16. 16
5. Give Preventive Measures
 Tetanus toxoid immunization
 Iron/folate supplementation
 Mebendazole
 Anti-malaria
C12
F2
F3
F3
F4

17. 17
Table 1 Tetanus toxoid immunization schedule for women
of childbearing age and pregnant women without previous
exposure to TT, Td or DTPa
Dose of
TT or Td
When to give Expected Duration
of Protection
1 At first contact or as early as
possible in pregnancy
None
2 At least 4 weeks after TT1 1-3 years
3 At least 6 months after TT2 or
during subsequent pregnancy
At least 5 years
4 At least 1 year after TT3 or
during subsequent pregnancy
At least 10 years
5 At least 1 year after TT4 or
during subsequent pregnancy
For all childbearing
age years and
possibly longer
aSource: Core information for the development of immunization policy. 2002 update. Geneva. WHO, 2002 .

18. 18
At ANTENATAL CARE
Check immunization status
 Not previously been vaccinated or
 Immunization status is unknown
Give two doses of TT/Td one month apart
before delivery
 With 1–4 doses of Td in the past
Give one dose of TT/Td (at least 2 weeks)
before delivery

19. 19
 For the woman to be protected during
pregnancy, the last dose of tetanus toxoid
must be given at least two weeks prior
delivery.
 Two doses protect for 1-3 years; five doses
protects throughout the childbearing years

20. 20
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclampsia, anemia, Sy & HIV
Respond to observed S/SX
Give PREVENTIVE MEASURES due
Advise & counsel on nutrition, FP,
labor signs, danger signs, follow-up visits
DEVELOP A BIRTH and EMERGENCY
PLAN
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

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21
Advise and counsel on:
 Nutrition
 Self-care during pregnancy
 Family planning
 Routine and follow-up visits
C13
C16
C17

22. 22
7. Develop a birthing and
emergency plan
 Facility delivery vs home delivery with skilled
attendant
 Advise on signs of labor
 Advise on DANGER SIGNS
 Discuss how to prepare for an
emergency in pregnancy
 Advise to avoid harmful practices
 Advise on breastfeeding & newborn screening
C15
C14

23. 23
PROCESS FLOW OF ANTENATAL CARE
Quick Check & RAM Assess pregnancy status &
prepare Birth & Emergency plan
CHECK for pre-eclamppsia, anemia, Sy & HIV
Respond to observed S/SX
Give PREVENTIVE MEASURES due
RECORD all findings, birth plan
and treatments given
Advise & counsel on nutrition, FP,
labor signs, danger signs, follow-up visits
Ask, Check Record
Look, Listen & Feel
Identify signs
Classify
Treat & Record

24. 24
8. Record
 Positive findings
 Birth plan
 Treatments given
 Next scheduled visit

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FOCUSED ANTENATAL CARE
 Reduced number of visits
 Screening and prevention of diseases that
may complicate pregnancy
 Education
 BIRTH PLAN: Birth preparedness and
complication readiness

26. 26
SKILLS NECESSARY DURING
ANTENATAL CARE
 Leopold’s maneuver
 Auscultation of fetal heart tones

27. 27
Abdominal examination during pregnancy
 Inspection
 Scars
 Shape and Size
 Palpation
 Checking the fundic height
 Estimation of fetal weight
 Leopold’s maneuver

28. 28
Upper edge
of symphysis
pubis
Top of fundus
(do not push the
fundus down )
Apply the tape with the calibration
hidden to avoid bias
Bladder must be empty
How to measure the fundic height

29. 29

30. 30
Possible Problems with Fundic Height
Fundic height is too large
 Computed AOG is
wrong
 Multiple pregnancy
 Polyhydramnios
 Molar Pregnancy
 Pregnancy with Myoma
or Ovarian Tumor
Fundic height is too
small
 Computed AOG is
wrong
 Baby is not growing
well (IUGR)
REFER

31. 31
LEOPOLD’S MANEUVER:
Determine fetal orientation
First Maneuver: WHAT
OCCUPIES THE
FUNDUS?
Face the woman’s head
with both hands, feel
the height of the
fundus.
Which part of the fetus do
you feel?

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2nd Maneuver:
 Feel the sides of the
uterus to find the
position of the baby’s
back and extremities.
 Back feels smooth
 Extremeties feel irregular

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3rd Maneuver: IDENTIFY
PRESENTING PART
 Grasp area immediately
above the symphysis
between thumb and
fingers
 HEAD: hard and round,
movable if not engaged
 BREECH: feels softer
and irregular

34. 34
4th Maneuver
 Face the woman’s
feet. Place fingers on
both sides of the
lower abdomen and
press downwards
and inwards
 Determine fetal
occipital prominence
 Helps to identify the
presenting part and
whether it is engaged

35. 35
Abdominal examination during pregnancy
 Inspection
 Palpation
 Auscultation of Fetal heart tones
 Easiest to hear over the baby’s back
 Normally 110-160 beats per minute
 If FHT cannot be heard after 6th month
and no fetal movement → REFER

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INTERNAL EXAMINATION
during LABOR

37. 37
> 8 cm
WHEN to do an I.E.
 ONLY DURING LABOR
 When the BOW ruptures (to rule out cord prolapse)
 If malpresentation is suspected on abdominal
examination
 Before transferring a woman to another facility to
ensure she is not likely to deliver on the journey.
 In the 3rd stage, if there is postpartum hemorrhage,
caused by retained placenta or suspected
laceration.

38. 38
> 8 cm
If the woman has had vaginal bleeding after 5th month
of pregnancy
NEVER do an I.E. unless you have a good
indication for doing so. Every I.E. may bring
INFECTION to the woman and her baby.

39. 39
> 8 cm
Procedure for internal examination
 Explain to the woman what you are going to do.
 Take full aseptic precautions
 Rinse the vulva with clean water.
 Wear clean gloves
 INSPECT THE VULVA:
 Is there amniotic fluid? Is it clear or meconium stained?
 Is there any abnormal discharge, blood or pus?
 Feel inside the vagina with the middle and index
fingers.

40. 40
> 8 cm
What to note during internal examination
 Cervix
 Dilatation
 Thickness or Effacement
 Bag of waters
 Presenting part

41. 41
What is cervical dilatation?
 Gradual opening of the cervix
 Measured in centimeters
 Feel with your 2 fingers
 The fully dilated cervix is 10 cm open.

42. 42
Assessing cervical
dilatation.
 Insert the middle
and index finger
into the open
cervix and gently
open them to the
cervical rim. The
distance between
the outer rim of
both fingers is the
cervical dilatation

43. 43
Determine status of Bag of Waters (BOW)
• Is BOW intact or ruptured?
• Is there amniotic fluid leaking?
• Clear or meconium stained?

44. 44
> 8 cm
 BE CAREFUL NOT TO RUPTURE THE BAG
OF WATER IF THE PRESENTING PART IS
FLOATING OR NOT ACCESSIBLE

45. 45
Determine the presenting part
Cephalic: Feels hard. Sutures and
fontanelles of the baby’s head are
felt
Malpresentation: Hardness of
the baby’s head is not felt but soft
buttocks or extremeties (foot or
hand).

46. 46
Determine presenting part
 What is the presentation?
 Is the cord palpable?
 What is the level of the presenting part?

47. 47
> 8 cm
What to note during internal examination
 Cervix
 Bag of waters
 Presenting part
 Pelvis (architecture, adequacy of diameters)

48. 48
Pelvic Architecture
Assess the following:
 Sacral curvature : hollow (deep),
average (normal), or flat (shallow)
 Sacrosciatic notch – wide or narrow
 Ischial spines – sharp/prominent
 Pubic arch – estimate the angle of the
rami at the pubis: narrow ( <), medium
(about 90°) or wide (>90°)

49. 49
≥ 11.5 – 12 cm

50. 50

51. 51
> 8 cm

52. 52
Assessing the
Pubic Arch

53. 53
A pelvis is unlikely to be contracted when…
 The diagonal conjugate is ≥ 11.5 – 12 cm.
 The pelvic sidewalls are parallel
 The ischial spines are not prominent
 The sacrum is not flat
 The subpubic angle is not narrow
 The fetal head is engaged or descends through the
pelvic inlet with fundal pressure

54. 54
Good morning!

55. 55
Good afternoon!

56. 56
General OBJECTIVE
 To enhance the knowledge, attitude and practice of
skilled health attendants on FOCUSED
ANTENATAL CARE.
 To understand the importance of doing an
immediate general assessment of the pregnant
woman
 To explain the process flow of providing antenatal
care.
 To perform procedures and skills necessary
during antenatal care correctly
Specific Objectives