Antenatal care is essential health care provided during pregnancy to ensure the health of both mother and baby, aimed at promoting safety and minimizing complications. In Ghana, services are offered by various healthcare professionals and include education on health, nutrition, and monitoring for high-risk conditions. The document outlines the objectives, standard visit schedules, examination procedures, and benefits of antenatal care, emphasizing its role in reducing maternal and fetal health risks.

1. ANTENATAL CARE

2. •Antenatal care is the health care and education
given during pregnancy to pregnant women to
ensure they have safe pregnancy and healthy
babies.
•The services are an important part of
preventive and promotive health care
•The care a woman receives throughout her
pregnancy helps to ensure that she and her new
born survive pregnancy, child birth and the
postpartum period in good health

3. •It also helps in minimizing complications of
pregnancy, labour, postpartum and neonatal periods.
Studies have shown that women who have received
prenatal care experience lower rate of maternal
mortality.
•In Ghana antenatal care services are provided by
both public and private health care facilities,
specifically, obstetricians, midwives and trained
TBAs including other health professions whose care
are relevant during pregnancy to ensure that fetal
and maternal health are satisfactory

4. AIM OF ANTENATAL CARE
•The overall aim of antenatal care is to ensure that
the mother reaches the end of her pregnancy
healthy, physically and psychologically to deliver
a healthy baby
Objectives of ANC
•To promote and maintain the physical, mental
and social health of mother and baby by
providing education to the pregnant mother on
nutrition, rest,

5. sleep, personal hygiene, family planning,
immunization, danger signs, STI/HIV/AIDS,
birth preparedness and complication readiness.
•To detect and treat high risk conditions arising
during pregnancy, whether medical, surgical or
obstetric
•To ensure the delivery of a full term healthy
baby with minimal stress or injury to mother
and baby

6. •To help prepare the mother to breast feed
successfully, experience normal puerperium and
take good care of the child physically,
psychologically and socially
•To ensure safe delivery and postpartum health
•To promote quality care through Focus
Antenatal care

7. Benefits of Antenatal Care
•It reduces maternal morbidity and mortality
•It reduces fetal morbidity and mortality
•Reduces perinatal mortality, i.e. death of the baby
within one week of birth, including still births
•Lowers rates of preterm deliveries
•It helps to detect abnormalities early
•It helps reduce maternal and fetal complications
•It helps to improve the general health of the mother
and

8. baby thereby improving the health of the family as a
whole
STANDARD SCHEDULE FOR ANC VISIT
The number of times a pregnant woman needs to be
seen at the antenatal clinic may vary. The standard
recommendation for antenatal clinic attendance is
made according to the following schedule;
Once a month/monthly(every 4 weeks) till 28 weeks
Twice a month/fortnightly (every 2 weeks) till 36
weeks

9. •Weekly (from 36weeks) till labour begins
ANTENATAL CLINIC ACTIVITIES/PROCEDURES
•Reception and registration
•History taking
•General examination includes:
•Vital signs
•Physical examination(includes checking of weight
and height)
•Abdominal/obstetric examination
•Laboratory test/ other investigations e.g. USG

10. •Treatment/ routine drugs/ provision of preventive
measures
•Client education/ counselling
CARE OF SPECIAL CLIENTS
•The elderly primip
•Grande multiparous women
•Pregnant women in their teens
•The HIV positive mother
•Women with bad obstetric history
•Women with infertility problems

11. •Pregnant women with medical problems e.g.
Hypertension, DM , heart problems, kidney
problems

12. Reception & Registration
•Welcome and greet the woman and provide seat
•Discuss issues of confidentiality
•Treat the woman with respect, introduce yourself
•Ask politely about the identity of the woman (her
name)
•Establish a medium of expression/communication
•Ask the woman if she has complaints or questions and
record
•Register her if appropriate

13. •Explain to the woman the importance of her
partner’s involvement in ANC and planning for
delivery
•Ask the woman whether she was accompanied
by someone and if she would like the person to
join her in the consulting or counselling room
•Explain clinic procedures and the purpose of
history taking to the woman

14. History taking
Biographical data/ personal/ social history
•Relevant socioeconomic data are obtained
•Take and record the following;
•Name, age
•Address (traceable address, important landmark)
•Tel. number
•Occupation, religion
•Marital status, next of kin

15. •Religion
•Social habit; consumption of alcohol and drugs
of addiction, cigarette smoking
•Educational level,
•Social support
•Partners name, occupation, address, tel. number

16. Family history
•Ask and record the following;
•History of twins
•Hypertension
•Diabetes mellitus
•Sickle cell disease(SCD)
•Allergies, Asthma
•Epilepsy
•Heart disease
•Mental disorder
•Congenital abnormalities(birth defects)

17. Medical history(personal)
•Allergies to food and drugs
•Cardiac disease
•Hypertension
•Renal disease
•Epilepsy
•Psychosis
•Gastrointestinal or metabolic disease e.g. thyroid disorders and
DM
•Sickle cell disease
•Blood transfusions,

18. •Any medication
•Presence of prolonged cough- for more than two
weeks
•Liver disease(jaundice)
Surgical history
•Abdominal or pelvic operation
•Cardiac surgeries
•Injury to any part of the pelvis which can affect the
diameter
•Any blood transfusion during the operation

19. Menstrual history
Take and record the following;
•Age at menarche
•Length of cycle
•Regularity of cycle
•Duration and amount of menstrual flow
•Whether its painful(dysmenorrhea)
•The date of commencement of the last normal
menstrual period(LMP) for calculation of EDD

20. Gynaecological history
•A history of venereal disease is important
•Also previous disorders such as abnormal cytology,
infertility and gynaecological surgery
Take and record the following;
•Treatment of infertility
•Ectopic pregnancy
•Operation on the vagina and pelvic floor
•Operations on the uterus

21. Obstetric history
This includes;
•Past obstetric history
•Present obstetric history
•Accurate details of all previous pregnancies(not just living
babies) must be obtained
•Year, period of gestation, duration of labour
•Nature of delivery and outcome
•Sex and birth weight of the babies
•Complications arising during pregnancy, labour and the
puerperium

22. •A history of termination of pregnancy(TOP)
should be specifically enquired about in view of
the possibility of cervical incompetence
Past obstetric history
Take and record the history of the following;
•total number of pregnancies
•Number of full term deliveries (including sex,
weight and condition at birth)
•Type of feeding; breast or bottle feeding

23. •Number of preterm deliveries(or babies)
•Number of pregnancies that ended in miscarriage
•Living children and health status of each child under
five years
•Date(s) of previous pregnancies
•Problems with past pregnancies and deliveries such as
high blood pressure, bleeding during pregnancy, rhesus
negative, gestational diabetes, excessive bleeding after
delivery, still birth and neonatal death
•Assisted deliveries i.e. C/S, vacuum extraction, forceps

24. •Problems after delivery i.e. puerperal infection,
postpartum depression
Present obstetric history
Take and record the ff;
•The date of first day of the last menstrual period
•Calculate the EDD
•Estimate gestational age or calculate weeks of amenorrhea
•Ask when the woman thinks she is due to deliver
•Date of quickening- when fetal movements were first felt

25. •If fetal movement have occurred in the past
24hours
•Use of medicine
•Food cravings
•Loss of appetite
•Ability to sleep
•Any vaginal bleeding
•Any discomforts of pregnancy

26. Other histories
•History of STIs
•Contraceptive history
•Lactation history
•Drug history
General examination- temperature
- pulse
- blood pressure
-weight and height
-gait or deformity

27. MEASUREMENT OF HEIGHT
•Height measurement of the pregnant woman is done only
once at the clinic.
•A height of over 160cm and a shoe size above three (3)
gives an indication of a normal sized pelvis.
• Measurement of height below 145cm is likely to get
cephalopelvic disproportion.
•At about 36 weeks of gestation when fetus is about fully
grown the pelvis is reassessed. The fetal head is an excellent
pelvi -meter and if it will engage in the pelvic brim, there is
little cause for concern about cephalopelvic disproportion

28. WEIGHT MEASUREMENT
•This gives some indication of the rate of growth of
pregnancy approximately 1kg weight gain every
month is normal.
• If weight gain is too great this also indicates that
the mother could be accumulating much fluid in the
tissues
• Lack of increase or even loss may mean
malnutrition. A total weight gain by the end of
pregnancy should be 10-12kg

29. BLOOD PRESSURE MEASUREMENT
•The measurement of blood pressure is vital during
pregnancy and is repeated during each visit. A systolic
blood pressure of 90-139mmHg and diastolic pressure
of less than 90mmHg is considered normal.
•However a blood pressure of 130/80mmHg may be an
abnormal pressure in a woman who had 100/60mmHg
at the first visit to the ANC
•An elevated blood pressure may indicate pre-
eclampsia/eclampsia and requires further assessment
and low blood pressure may be a sign of shock.

30. ROUTINE URINE ANALYSIS
•Routine urinalysis is carried out at every visit.
• Frequency of micturition is common in early
pregnancy and reoccurs during late pregnancy.
•The midwife should ensure that the woman is free from
difficulty or painful micturition which is an indication
of STIs.
•That the urine contains no abnormal deposit such as
protein, sugar or ketones which could be a sign of
either diabetes or abnormal kidney function which may
occur as a result of disease condition

31. PHYSICAL EXAMINATION
The general /physical examination on the pregnant woman is
done from head to toe. Instruct the woman to urinate if she has
not done so before mounting the couch
Face- for chloasma
Head -Examination of the head is done by first observing;
carefully the hair of the woman, the hair of a healthy woman
looks shiny and glossy.
Eye should be observed. It should look bright and clear from any
discoloration, Conjunctiva observed for pallor(sign of anaemia)
Nose is examined for discharge, deviated septum

32. Mouth- mucosal surface of the mouth and lips are observed
for pallor
Teeth and the gum in the month are observed for any
bleeding and dental decay, number of decaying and missing
teeth recorded
Ears- are also observed for any discharge or any other
abnormality like swelling
Neck is observed for any abnormality and palpated for any
swelling/ enlargement of lymph nodes & thyroid gland or
growth,
Upper limbs- are examined for oedema, pallor on the nail
beds

33. Breast – observe the breast for shape & size, discharge,
discoloration, dimpling, rashes
•The breast is then gently palpated with the flat part of
the fingers in a gentle and circular manner either
anticlockwise or clockwise until the nipples is reached
to identify any abnormal lump.
•Assess the nipple whether they are flat or inverted
•Heart – refer her to the cardiology department for
proper assessment
•Chest – the symmetry of the chest wall is noted and the
degree of expansion of the chest is assessed

34. •Abdomen – enlargement of liver, kidneys or spleen may
be detected
•Observe the tone of the abdominal wall and any changes
due to the pregnancy abdominal (obstetric) examination
This is carried out to establish and confirm that fetal growth
is consistent with gestational age during the pregnancy
The specific aims are to;
•Observe the signs of pregnancy
•Locate fetal parts
•Detect any deviation from normal
•Diagnose the presentation of the fetus

35. Three methods are employed
•Inspection – using the sense of sight
•Palpation – using the sense of touch
•Auscultation - using the sense of hearing
Inspection
•The size of the uterus is observed, and compared with the
period of gestation
•By looking at the size of the uterus the midwife will be
able to make a rough approximation of the period of
gestation although she will want to confirm the estimate
through palpation.

36. •Its not always easy to palpate the uterus before the 16th
week of
pregnancy particularly in the obese pregnant woman
•in multiple or polyhydramnios, the size of the uterus will be
bigger when compared to the period of gestation
The shape of the uterus is observed, and it is usually ovoid
•When the shape of the uterus is longer than it is broad, the lie of
the fetus is longitudinal (occurs in about 99.5% of cases)
•If the lie of the fetus is transverse the uterus is low and broad.
•If the lie of the fetus is in an occipito-posterior position, a
saucer-like depression may be seen at or below the umbilicus

37. •In multiple pregnancy or polyhydramnios the uterus
will enlarge both the length and the breadth whereas a
large baby increases only the length
•the shape of the fetal back can be felt with the
examining hand
•Fetal movement can be observed and these movements
indicate that the fetus is alive and help the midwife to
diagnose & establish its position because the fetal back
will be on the opposite side of the movement seen
•The woman’s umbilicus becomes less dimpled and
may protrude in the later weeks of pregnancy

38. •Lax abdominal muscles in the parous woman may
cause the uterus to sag forward; this is known as
pendulous abdomen or anterior obliquity of the uterus
•In the primigravida the uterus is ovoid but is
multigravida it sags forward.
•A pendulous abdomen in a primigravida is a serious
sign as it may be due to contracted pelvis
•The abdomen is observed for scars which may
indicate previous obstetric or abdominal surgery
•Observe the skin for stretch marks(straie gravidarum)

39. •Straie from previous pregnancies appear silvery and
recent ones appear pink
•Linea nigra may be seen, this is a normal dark line of
pigmentation running longitudinally in the centre of the
abdomen below and sometimes above the umbilicus
Palpation
•The examining hand should be clean and warm
•Cold hands tend to induce contraction of the abdominal
and uterine muscles and is uncomfortable for the
woman

40. -The nurse should stand at the right side of the woman
-Arms and hands should be relaxed and the pads, not the
tips of the fingers is used
-The hands are moved smoothly over the abdomen to avoid
causing contraction.
Gestational age
•During pregnancy, the uterus grows which is an indication
of fetal growth
•The gestational age should coincide with the fundal height
in weeks
•During the last month of pregnancy, lightening occurs and

41. the fetus sinks down into the lower segment or lower pole of
the uterus
•In order to determine the height of the fundus the nurse should
place her left hand just below the xiphisternum, press it gently
and move the hand down the abdomen until she feels the
curved upper border of the fundus, noting the number of
finger breadth that can be accommodated between the two
•Each finger breadth is considered to be one week
•The distance between the fundus and the symphysis pubis can
be measured with a tape measure
•The height of the fundus in centimeters should correspond to

42. the weeks of gestation
•The gestational age can also be calculated by counting the
total number of days from LMP to the date of visit and
dividing this by 7 or by using a gestational wheel to
calculate the number of weeks of gestation
Fundal palpation
•This helps to determine whether the breech or the head is in
the upper pole or fundus of the uterus
•This information will help to diagnosis the lie and
presentation of the fetus
•The nurse lays both hands on the sides of the fundus, fingers

43. held close together and curving round the upper border of the
uterus
•Gentle pressure is applied by the palm
•If a soft irregular mass is felt then it is a breech.
•If a hard round mass is felt, it is a head
•With a gliding movement the fingertips are separated slightly
in order to grasp the fetal mass, to assess its size and mobility
•The head can be balloted (moved from one hand to the other)
between the fingertips of the two hands
•The head can be moved independently of the body because of
the neck but the breech cannot

44. Lateral palpation
•This is used to locate the fetal back in order to determine
position
•Hands are placed at umbilical level on either side of the
uterus
•Pressure is applied alternately with each hand in order to
detect which side of the uterus offers the greater resistance
•The uterus can be steadied with one hand and using a rotary
movement of the opposite hand to map out the back as a
continuous smooth resistant mass from the breech down to
the neck
•On the other side the same movement reveals the limbs as

45. small parts that slip about under the examining fingers.
•“Walking” the fingertips of both hands over the
abdomen from one side to the other can help in locating
the back on one side and the limbs on the other side
Pelvic palpation
•Pelvic palpation is used to identify the pole of the fetus
in the pelvis to recognize the presentation and the
presenting part
•It is recommended that it should be done after 36 weeks

46. •The nurse should ask the woman to bend her knees
slightly in order to relax the abdominal muscles
•She should also suggest that she should breathe steadily
and breathe out through the mouth slowly
•The sides of the uterus just below the umbilical level are
grasped between the palms of the hands with the fingers
held closely together and pointing downwards
•If the head is presenting, a hard round mass with a
smooth surface is felt
•The nurse also estimates how much of the fetal head is
palpable above the pelvic brim to determine

47. engagement
•Engagement is said to have occurred when the widest
presenting transverse diameter has passed through the
brim of the pelvis
•In cephalic presentation this is the bi-parietal diameter
and in breech presentation the bi-trochanteric diameter
•Engagement of the fetal head is usually measured in
fifths palpable above the pelvic brim
Pawliks Maneuvre
•The nurse stands facing the woman’s head and grasps
the

48. lower pole of the uterus between her fingers and the
thumb
•This method is used to judge the size, flexion and
mobility of the head
Auscultation
•This must be carried out soon after abdominal
examination
•This helps to assess the fetal wellbeing
•The fetal heart sound may be best heard through the
back of the fetus, at the point where it comes in contact
with the abdominal wall.

49. •A pinards stethoscope will enable the nurse to hear the fetal
heart sound directly and determine that it is fetal and not
maternal
•In the left occipito-anterior(LOA) position, fetal heart sound
can be heard to the left side, midway between the umbilicus &
the symphysis pubis at the level of the umbilicus or above, in
posterior positions either in the left or right flank
•The stethoscope should be moved about until the point of
maximum intensity is located where the fetal heart is heard
most clearly
•The ear must be in close, firm contact with the stethoscope but
the hand should not touch it while listening to avoid extraneous
sounds

50. •The nurse should count the beats for one minute
which should be in the range of 110-160bpm
•The nurse should take the woman’s pulse at the same
time as listening to the fetal heart to enable her to
distinguish between the two.
•A sonicaid or Doppler or ultrasound can also be used
The Vulva & Vagina
•Examine the vagina for signs of infection(candida,
trachomatis, gonorrhea or non-specific cervicitis) &
laxity of the vaginal walls

51. -Also observe for varicose veins, previous tears &
episiotomies, state of the perineal body and laxity of the
introitus
•Observe also for abnormal discharge, rashes, warts and
ulcers
The limbs
•Examine the two limbs for equality
•The limbs are observed for oedema, varicosities, rashes
•The nail beds are examined for pallor,
•Assess for Horman’s sign(calf pain)

52. •Evidence of intravenous drug use should be looked
for in women suspected of addiction
Findings
•The nurse should assess all the information gathered
from inspection, palpation and auscultation to
evaluate the well-being of the woman and her fetus
•All findings should be discussed with the woman

53. Laboratory Investigation
•Where the capacity exist request or perform the following;
I. Urine for
•Protein
•Sugar
•Midstream specimen of urine for bacteriuria, ova &
pyuria(pus cells)
•Pregnosticon test to confirm pregnancy in the first trimester
II. Stool for
-Ova
-Parasites e.g. worms

54. III. Blood for
•Haemoglobin level(Hb)
•Sickling (Hb electrophoresis) if positive, G6PD
•Group and Rhesus factor (antibody titre if Rhesus Negative)
•VDRL(IPHA if test is positive)
•HIV (must be accompanied by counselling) then CD4 count if
positive
•Hepatitis B(Hep B surface antigen)
Pelvic or abdominal ultrasound if indicated for dating, fetal
viability,
•All lab investigation results must be reviewed before the next
routine visit is scheduled

55. NUTRITION IN PREGNANCY
The increase in the bulk of the uterine muscles, the formation
of the placenta and the many demands of the rapidly developing
fetus ,make severe demands on the nutritional needs of the
pregnant woman.
•The diet in pregnancy is therefore very essential for the health of
the woman herself, her developing fetus and also for the
alleviation of minor disorders of pregnancy.
•Again, the increase in the circulating blood volume makes
tremendous demand on all the basic constituents involved in the
formation of blood cells namely: iron, folic acid, vitamin B12,
protein etc.

56. Unfortunately these requirements are often not met in most women due to
various reasons, some of these are;
• The amount of available foods may not be adequate
• Appetite of the mother may be low because of pregnancy
• Chronic illness such as malaria and urinary tract infections may cause loss
of appetite and use of her energy
• Worm infestations such as hookworm sucks her blood depleting her of iron
stores while ascaris shares the food in her gut
• She works hard throughout pregnancy burning up the few available
calories.
• Because of taboos, customs and beliefs about what to eat and what not to
eat when pregnant.

57. •The father who is the head of the household usually
takes the best of the available food. The women
within the above category will therefore lose weight
as a result and also their fetus suffers
•Therefore a dietary history should be taken to assess
the mother’s general knowledge & attitudes to
nutrition and the quantity and quality of the
foodstuffs eaten
•Questions should be asked about practices such as
skipping breakfast which lead to hypoglycemia(of
the mother & fetus)

58. - Also about any medical disorders likely to affect nutrition
e.g. malabsorption states, drug & alcohol addiction,
hyperemesis gravidarum, hiatus hernia, DM
- It is therefore important that the midwife/nurse explains
regular intake of food which ensures a regular supply of
nutrient for the unborn baby and also counsel the mother to
avoid rushing or missing of meals.
•The balance of the four star diet ingested should be
assessed
•The woman’s weight in relation to her height & general
evidence of nutritional well-being e.g. Hb level, serum
albumin levels etc. should be noted

59. intestinal parasites should be ruled out
•The pregnant woman should be made aware of the elements
of a good diet
•An ideal diet should be the four star diet, i.e. it should
contain all the essential nutrients in adequate amounts
•She should eat one extra meal each day(4 meals per day)and
snack such as fruits cakes, biscuit or roasted
maize/plantain/groundnuts and have a working knowledge
on the different classes of foodstuffs and their sources
•The effects of over cooking on the quality of food and other
poor methods of food processing should be emphasized; as
well as the importance of water and fibre(vegetables)

60. • The pregnant woman should eat smaller, more frequent meals if unable to eat take
micronutrient supplement as directed
• The nutrient for good nutrition are in the form of the ff and also makes the four
star diet
Staple
• Examples: Grains such as maize, wheat, rice, millet and sorghum,
Root and tubers such as cassava, yam, cocoyam, plantain and
potatoes
Legumes and seeds
• Example: Beans, agushie, neri(werewere), groundnut and sesame
Fruits and vegetables
• Examples: Mango, pawpaw, orange, banana, pineapple, watermelon, yellow
melon, avocado, dark-green leaves, carrots, onions, tomatoes,
kontomire, gboma, cabbage, yellow sweet potato and pumpkin

61. Animal-source foods
• Examples: Chicken, fish, liver, meat, eggs, milk and milk products
Oil and fat such as oil seeds, palm oil, fortified vegetable oil and butter added to
vegetables and other foods will improve the absorption of some vitamins and
provide extra energy
• The pregnant woman should use iodated salt
• She should drink lots of water and fresh fruit juice
Effects of Inadequate Diet
I. Mother
• Abortion, anemia, preeclampsia/eclampsia, prematurity, infection, inadequate
II. Baby
• Malformation, low birth weight, prematurity, infections, neurological defects,
perinatal death, intrauterine growth retardation and intrauterine death

62. DANGER SIGNS OF PREGNANCY
•These are life threatening conditions in pregnancy
that needs to be treated and managed appropriately
to prevent complications in the pregnancy and fetal
compromise. These are;
•Swelling of feet, hands & face
•Severe abdominal pain
•Severe headache

63. •Persistent vomiting
•Jaundice
•Rupture of membranes
•Anaemia- pale conjunctiva, tongue, palms, & nail
beds
•Offensive or discolored discharge from the vagina
•Bleeding from the vagina
•Fever
•Absence of fetal movement

64. •IMMUNIZATION
•Tetanol Diptheria(TD) is given according to the
schedule below;
•TD1- First ANC visit/ FIRST contact
•TD2- Four weeks after
•TD3- Six months after
•TD4- One year
•TD5- One year interval

65. MALARIA PROPHYLAXIS
•All pregnant women should receive 3 doses of
Sulphaddoxine Pyrimethamine
•It should be started from 16weeks or after quickening and
given with one month interval for at least 3 doses or
maximum of 5 doses before delivery(36weeks)
•Counsel her on the purpose of the DOTS for malaria
prevention
•Mothers who are full or partial to G6PD are not served the SP
•A single dose consists of 3 tablets of Sulphadoxin 500mg &
Pyrimethamine 25mg

66. •The health care provider should dispense and directly observe
client taking the dose
•The mother should be educated on environmental cleanliness
and take a four star diet.
•Emphasize on the need to sleep under the insecticide treated bed
net.
•Encourage the woman to take between 6-8 hours of sleep each
night and try to rest for 1-2 hours during the day
•Rest aids return of blood to the heart, resolution of oedema of
the legs, reduction in the incidence and severity of
preeclasmpsia, improvement in varicose veins or prevention of
varicose veins, improvement in blood flow to the uterus, and
reduction of preterm labour

67. •She should also undertake moderate exercise
•She should sit and rest for a while if her work entails prolonged
standing and avoid lifting or call for help to lift heavy items
MEDICATION- Oral iron 60mg daily and folate 0.5mg daily for
non-anaemic clients(routine drugs)
Educate mother on;
•Antenatal drugs, why they are given and how they should be
taken
•Discourage abuse/misuse of drugs and herbs
•Avoidance of alcohol; during pregnancy
•Harmful consequences of smoking
•Effects of skin bleaching

68. Follow up visits
•At the end of the first visit, all information gathered
through history, physical examination, laboratory and
other investigations should be fully documented and
carefully analyzed to plan subsequent care of the
client
•Clients with normal healthy pregnancies will follow
the routine protocols and visit schedules
•Those with identified complications will have to visit
the clinic more frequently for management and
monitoring

69. CLIENTS WHO MAY NEED SPECIAL CARE
•The elderly Primigravida or nullipara
•Grande multiparous women
•Pregnant women in their teens
•The HIV positive mother
•Women with infertility problems
•Women with; bad obstetric history(previous stillbirth, abortion, IUD-
intrauterine death)
•Pregnant women with medical conditions – HPT, DM, Heart disease,
Renal disease
•Women with threatened abortion and antepartum haemorrhage
•Anaemia
•Malpresentation

70. Subsequent visits
•At every subsequent visit, refer to previous antenatal records,
findings and decisions made
Take history
•Ask about her general health status since the last visit
•Ask about any present complains
•Ask about fetal movement if gestation is more than 20weeks
•Follow up on any previous problems identified and/or treated at
the previous visits
•Perform physical examination
•Check blood pressure and weight (weight gain should not
exceed 0.5kg per week after 20weeks)

71. •Look for signs of anaemia, malnutrition, goiter, fever, signs of
pre-eclampsia and physical abuse
•Obstetric examination
•Measure symphysio fundal height and compare with gestational
age(SFH after 20 weeks gestation)
•Auscultate fetal heart sounds and count for one minute and record
•In the third trimester determine lie, presentation, position and
level of descent of the fetal head into the pelvis
Laboratory investigations
•Test urine for sugar and protein
•Estimate haemoglobin level at 28weeks and 36 weeks or more
frequently if indicated

72. •Routine administration of drugs
•Resupply enough iron/folate to last till the next visit and SP
for IPT if due
•Give TD immunization if indicated
•Commence ARV prophylaxis at 28 weeks where indicated
•Client education/ counselling
•Continue to educate client on issues that were not covered
during the previous visit.
If the woman is in the 2nd
trimester;
•Ask about any concerns
•Ask woman about progress made towards birth preparedness

73. complication readiness plan
•Reassess knowledge on danger signs
•Treat other topics not dealt with previously
•Reeducate woman on any other relevant health issues
•Discuss discomforts of pregnancy
•Discuss sexual activity and safer sex
•Discuss what to expect during labour and preparations for
delivery
If the woman is in the 3rd
trimester;
•Ask her about any concerns
•Ask her about progress made towards birth preparedness and
complication readiness plan

74. •Reassess woman’s knowledge of danger signs and care
during labour
•Educate the woman on breastfeeding / breast care
•If the mother is HIV positive, counsel on infant feeding
options
•Educate her on family planning methods (emphasize on child
spacing)
•Educate her on neonatal care, immunization schedule for the
baby and danger signs in the newborn
•At each subsequent ANC visit, information gathered through
history, physical examination and laboratory investigations
for each client should be carefully analyzed to determine if

75. pregnancy is progressing normally or if new
complications have developed
•Complications identified should be managed or the
woman referred for further management by a
specialist

76. BIRTH PREPAREDNESS AND COMPLICATION
READINESS PLAN
•Birth preparedness and complication readiness plan involve
the following key stakeholders;
1. The health provider
•The health provider has the responsibility of explaining to
the woman and relatives what plans they have to develop
for the birth of their babies and any possible complications
that may occur
•The health provider has to tell them of the advantages of
having such a plan in place, most importantly, the avoidance
of delay in getting health care

77. 2. The pregnant women and relatives
•With their knowledge of birth preparedness and
complication readiness plan will take quick
decisions in any situation during pregnancy, labour,
postnatal and care of the newborn to avoid delay in
getting health care thereby saving lives
•They will also give appropriate support when the
need arises

78. 3. The community
•The community will give maximum support if the members
are educated on birth preparedness and complication
readiness plans; e.g. provision of transport from the
community to the health facility to avoid delay
•The community members can also have a savings scheme to
support members in case of financial difficulties e.g.
household “Susu”
4. Referral facilities
•Staff at the referral facility should be ready to respond to
any emergency from the catchment area to avoid delays at
the facility

79. For birth preparedness plan decision must be made by the
woman towards;
•Place of birth(where she will deliver)
•Choice of a skilled provider
•How to contact the provider
•How to get to the place when in labour
•Who will accompany her when in labour (support
person)
•Who will care for the home and her family in her absence
•Preparation of necessary items for the birth and the baby

80. Complication readiness plan
•Discuss how much money will be required and how
to access the funds(plan for finances and other
preparation for delivery)
•How to reach help when complication develop
•Plan for decision making in case of emergency in
the absence of the chief decision maker
•Arrange for a blood donor
•Arrange for a transport

81. Clothing
•The basic requirements are a well-fitting brassier and
loose-fitting maternity clothes
•Undergarments should be of cotton
•Flat-heeled shoes should be worn – they provide a better
base and are more comfortable
•They also maintain the posture necessary to balance the
forward growth of the pregnant uterus
Layette
•Necessary items for the pregnant woman, the labour and
delivery process and the baby

82. •Health Education
•Health education is usually in the form of talks given at
the antenatal clinic
•The clients can be taught individually or in a group
•If possible, husbands/partners should be invited and their
role and responsibility towards the successful care of
their wives and children explained to them
•The nurse should create a friendly atmosphere in order
to help the client to relax
•The discussion should be conducted in a conversational
manner so that the clients may have a chance to espress

83. their views freely
•In this way, any wrong ideas about child bearing can be
corrected
•Talks should be in simple, intelligible language
•They must take into consideration the educational
background, social and economic status and previous
knowledge of pregnancy, labour and child care of the
clients
The following are suggested topics for education
•Nutrition
•Personal and environmental hygiene

84. •Danger signs in pregnancy
•Immunization
•Malaria prophylaxis (IPT)
•Rest and work
•Family planning
•Breast feeding
•Medications
•Follow up visits
•Counselling and testing
•Birth preparedness (including where to deliver-delivery
plan)

85. and complication readiness plan
•Layette
•Lessons on signs of labour
•Support persons
•Care of the baby clothing
Ultrasonography
•Ultrasound is the production of high frequency sound
waves which are reflected or echoed when beamed unto
the body and an interface is encountered between
different types of tissue or structures with different
densities

86. •These echoes can be translated into visible images of
the tissues or structures encountered
•When the transducer, which transforms electrical
energy to sound energy is placed on the body, a sound
wave passes into the body and encounters a structure
•A fraction of that sound is reflected back
•The amount of sound from each organ varies according
to the type of tissue encountered
•Strong echoes give bright white dots, for example bone
•Weaker echoes give various shades of gray according
to their strength

87. •Fluid-filled areas cause no reflection and give rise to a black
image
•The procedure is simple and painless
•In the first trimester, it is necessary to have a full bladder for
the procedure
DIAGNOSTIC USES IN OBSTETRICS
It is used to diagnose or ascertain the following;
•Early pregnancy- pregnancy can be diagnosed by ultrasound by
the 5th
week of gestation
•Ectopic pregnancy
•Hyatidiform mole- produces a characteristic image of scattered
echoes

88. • Gestational age and fetal maturity- an approximated fetal age is
determined by using specific measurements at different stages;
At 5-10weeks, by measuring the gestational sac
8-14weeks, by measuring the crown rump length- this is the
length of the embryo from the top of the head to the rump or
base of the sacrum
14-20weeks, by measuring the length of the femur
18-26weeks, by measuring the biparietal diameter
By the 12thweek of gestation, the fetal head can be shown on
ultrasound
Multiple gestation- can be diagnosed as early as first trimester
Localization of the placenta- helps in the diagnosis of the cause

89. of antepartum haemorrhage (third trimester bleeding)
•It also helps to locate the placenta prior to amniocentesis
•Fetal anomalies- a number of fetal abnormalities can be
identified including abnormalities of the head and spine,
genito-urinanry tract, gastrointestinal defects, cardiac,
thoracopulmonary and musculoskeletal anomalies
•Fetal death- separation and over-lapping of fetal bones
will be seen
•Estimate fetal weight
•Intrauterine growth retardation
•Polyhydramnios

90. •Oligohydramnios
•Placenta grading-used to estimate fetal maturity and fetal
pulmonary maturity
•Biophysical profile- this is used to evaluate the fetal well-being
e.g. in postdated pregnancy
Biparietal diameter
Fetal movement
Respiratory movement
Amniotic fluid volume
Height- weight ratio(ponders index)
Heart rate pattern
•Localization of intrauterine contraceptive devices

91. UNDERSTANDING FOCUSED ANTENATAL CARE
AIM
To enable trainees to understand content and principles of focused
antenatal care
OBJECTIVE
On completion of this session, trainees will be able to;
1. Define focused antenatal care
2. List the five principles underlying the focused antenatal care
model
3. Outline the recommended schedule of visits in focused ANC
4. Explain the principles of client friendly and individualized ANC
5. List 4 benefits of good communication in focused antenatal care

92. INTRODUCTION
•Brief Historical Background of Antenatal Care
•Specialized care for pregnant women through a public health care
system started in the UK and Northern Ireland in the late 1930s.
•This formalized ANC started about 30years after formalized
institutional delivery care, and was primarily initiated to address deaths
due to Eclampsia which had remained high.
•Deaths from sepsis, obstructed labour and haemorrhage had all been
reduced by the institutionalized delivery system
•The new ANC practice was subsequently widely adopted by many other
countries during the 2nd
half of the 20th
Century.
•Developing countries also adopted these ANC practices of their colonial
masters with little or no modifications after colonization &
independence

93. •Institutionalized ANC is considered one of the most successful
maternal health programs in terms of its acceptance and patronage
•Worldwide, over 70% of pregnant women have had at least one
ANC visit(developed 80%, developing 68%)
•Indeed providing access to ANC for women has been easier to
implement than providing supervised delivery in many developing
settings
•It has also become the vehicle for the implementation of many
other programs such as PMTCT
•In recent years(1980-1990s)however, many have questioned the
scientific basis and benefits of many of the practices of
“traditional” ANC e.g. number of visits routine activities like risk
categorization as these did not appear to have reduced significantly

94. the high maternal mortality ratios in many countries
•They were also not cost effective
•For example, for healthy pregnant women, which constitute
about 75% of ANC clients, 12 ANC visits was not found to
be cost effective
•Evidence from recent Randomized Controlled Trials and
systematic reviews have showed that a newer model of
ANC based on fewer but quality visits yielded similar
pregnancy outcomes for mother and baby but at lesser cost
•This new evidence based ANC approach which was
described initially as Refocused Antenatal Care (now
Focused Antenatal Care) is what is being promoted

95. Defining Antenatal Care
•Antenatal Care should address both the medical and psychological
needs of the pregnant woman, within the context of the health
care delivery system and culture in which the woman lives
•Periodic visits to a health care provider are necessary during
pregnancy for the following reasons
•Early detection & treatment of complication
•Establishment of a supportive relationship between the woman
and the health care provider
•Development of a birth and emergency plan with the woman
•Provision of preventive measures
•Provision of advice and counselling

96. The new WHO Antenatal Care Model(Also known as “Focused
ANC”)
•The new WHO approach to antenatal care(2003) is based on
scientific evidence
•It seeks to improve upon the quality of antenatal care provided to
women particularly in low resource settings; described as Focused
Antenatal Care(FANC)
•It has the following principles;
Quality of care rather than quantity of care(Four comprehensive
visits for women with normal pregnancies)
Individualized care
Disease detection and not risk categorization(all pregnant women
are

97. at risk)
•Evidence based practices during antenatal care provision
•Birth preparedness and complication readiness planning
Recommended Schedule of Antenatal Visits
•It is recommended that all healthy pregnant women have four
quality scheduled antenatal visits during pregnancy
•The first contact visit by the pregnant woman with the ANC
provider should occur preferably in the first trimester
•This “Booking Visit” should be used to confirm the pregnancy
and to evaluate if the woman is in good health or has no
potential risk conditions
•If after comprehensive assessment she is found to be healthy and

98. has normal uncomplicated pregnancy then the recommended four
visit schedule below is followed
•During the last(fourth) visit, the woman should be asked to return
if she does not give birth within 2 weeks after expected date of
delivery
The schedule of routine antenatal visits is as follows:
•Booking visit- during first trimester(preferably before 14 weeks)
•1st
scheduled visit At 16-20weeks
•2nd
scheduled visit At 24-28 weeks(in sixth month)
•3rd
scheduled visit At 28-32 weeks(in eight month)
•4th
scheduled visit about 36weeks(in the ninth month
•More frequent visits or different schedules may be required based

99. on the woman’s needs and/or national policies(e.g. malaria or HIV)
•It should be recognized that in many low resource settings many
clients may book late, often during their second trimester of
pregnancy
•This may result in visit scheduling challenges
•In such instances the visit schedules must be modified to ensure
that such clients receive all the essential components of care before
delivery
•For example a healthy client who first visits the clinic at 5 months
gestation(20weeks), should be assessed as comprehensively as
possible at this initial visit
•If she is found to be healthy she should have her visits rescheduled

100. to ensure that she receives all the essential care interventions
before delivery
•At the first contact visit at 20weeks all the care components
which should have been provided at 16weeks could be provided
•Her second visit could be scheduled at 24 weeks, her third visit
at 28-32 weeks and her last 36weeks
Individualized Care
•The unique feature of care during pregnancy period is that a long
term relationship is established between the care provider and a
client
•For many women, pregnancy is that which first brings them to
the health care system

101. •Their perceptions of quality of care they receive and
type of relationship developed with the care provider
can have long term effects on their future use of the
health care system
•Individualized care means that women are provided
with client friendly care that is in tune with their
personal needs, requirements and socioeconomic
circumstances and is culturally appropriate
•Such individualized care also depends on good
rapport and communication between the care
provider and the pregnant woman

102. Client Friendly Antenatal Care
•Client friendly antenatal care means making the
antenatal care service acceptable to the pregnant
woman and her family
•In client friendly care the pregnant woman’s health and
survival, basic human rights and comforts are given
clear priority
•The woman’s personal desires and preferences are also
regarded as important
Her culture, beliefs, traditions as well as gender roles
and relations are respected

103. •Family members are included in the care of the woman as the
woman desires
•The woman’s resources and capabilities are taken into
consideration when health messages are given and
recommendations made to/for her
•She is informed about good health practices, about her health
situation and her consent sought in all decisions relating to her
health and special procedures
•The pregnant woman and her family are supported to become
active participants in her care particularly in making decisions
•She is assisted to overcome problems or challenges that
impede her wellbeing, health and survival

104. Culturally Appropriate Care
•In many African communities pregnancy and childbirth are
considered family and community events
•The childbearing process is spiritually rich and is guided by many
beliefs, rituals, taboos and practices
•These are deeply held and are passed from generation to generation
•The pregnant African woman may visit the antenatal clinic wearing
special protective talisman or clothing
•She may only come to the clinic accompanied by particular
individuals e.g. mother –in-law who must be welcomed as a
partner in her care
•She may not even be permitted to stay out of her home after certain

105. hours or share utensils used by others
•The skilled care provider caring for pregnant women in a
particular area must know and appreciate the cultural
milieu(social setting/ environment) from which her clients
originate and must provide care within this cultural context
•Antenatal clinic set ups for example could be organized to ensure
that harmless traditions are not offended
•For example the clinic set up in such an area could be organized
to provide adequate seats and comfort for the accompanying
mother in-laws whiles clinic hour ensures that women are able to
respect their traditions
•Some cultural practices can have negative impact on the health of
the pregnant woman or even violate her human rights

106. •Negative cultural practices must be carefully assessed and plans for
changing these practices developed in collaboration with key
stakeholders and custodians of these practices
Good Communication with the Antenatal Client
•The long term relationship between the ANC provider and her
client provides several opportunities for establishing good rapport
•Such rapport is essential for achieving all the goals of focused
antenatal care such as early detection and management of
complications and birth preparedness
•By using good communication skills the care provider can establish
good rapport and can effectively provide good quality care to the
client
•Good communication for focused antenatal care can be employed

107. to make the woman(and her companion) feel welcome,
provide information related to the woman’s needs,
recommend treatments and preventive measures for the
woman
•Good communication skills must be employed by the
health provider to explain to the woman what the
treatment is, why it is necessary and give clear and helpful
advice on how to take a medication regularly
•The care provider must also be able to advise a woman on
when to return to the clinic for example when she has any
health problems or concerns about the procedures or
treatments

108. •During all contacts with a pregnant woman at the clinic, the
health care provider should maintain privacy & confidentiality
by ensuring a private place for examination and counselling and
•Ensuring that discussions, especially about sensitive subjects,
cannot be overhead
•She should also ensure that a woman has given her consent
before discussing matters with her partner or family
•Achieving the principle of individualized and client friendly
care requires that as much as possible the antenatal care
provider establishes a unique relationship with her client and
assumes responsibility for all key decisions on the client’s care
at each visit

109. •It implies that the one care provider should have all
the needed information(including sensitive
information) about the woman to enable her/him
make good decisions about the woman’s care
•Antenatal care service delivery system in which
several care providers are responsible for the different
care components of the same client(The Factory
Assembly Line System) often results in poor quality
care, as good rapport is never established, the client is
often not managed wholly or comprehensively and
her needs are therefore never entirely met

110. Disease Detection and not Risk Categorization
•In the traditional ANC, pregnant women were classified by risk
category to determine their chances of complications and the level
of care they need
•However, the evidence showed that many women who have risk
factors will often not develop complications, while women without
risk factors may do so and may die from the complications
•Hence there is a paradigm shift to place emphasis on disease
detection for all women with the recognition that all pregnant
women are at risk
•During focused antenatal care, care provider focuses on the
assessments and actions needed to make decisions for each
woman’s individual situation

111. •This includes taking history, doing physical examination,
interpreting the gathered information by making a diagnosis and
then evaluating the risk conditions
Evidence Based Practices during Antenatal Care Provision
•FANC emphasizes that care is provided by skilled providers who
implement activities and interventions that have been proven to
have health benefits and are effective
•During provision of care to pregnant women only essential
evidence based care practices must be rendered and care
package/interventions which promote the health and survival of
mothers and babies provided
•Evidence based interventions promoted in FANC include
assessing client’s birth preparedness and complication readiness,

112. •Prevention of malaria in pregnancy through the intermittent
preventive treatment (IPT),and prevention of mother-to child
transmission of HIV
•The FANC package also includes the involvement of the clients
partner or support person in the process of ANC and in preparation
for delivery
Birth preparedness and complication readiness planning
•The major complications leading to maternal and newborn death
and ill-health occur around the time of childbirth
•These complications are further aggravated by delays in seeking or
receiving care
•FANC emphasizes the importance of preparing well for childbirth
and these complications as a key intervention for saving women’s

113. lives
•The care provider assists the client and her family to prepare for
delivery by identifying the place for delivery, how to get there
and what items to have in readiness
•She prepares her client for complications by educating her
family to recognize danger signs and symptoms, provide advice
on how to reach care when they occur and on blood donation in
readiness
•Providing FANC require that services are organized in a manner
to ensure that the above principles and components for quality
ANC are met.
•The basic clinic and organizational requirements for providing
such care are discussed in the next session

114. Key lessons
•The new WHO Model for Antenatal Care described as FANC seeks to
improve upon quality of care by focusing on quality rather than
quantity of visits
•For a normal healthy pregnancy four visits are recommended at
around 16, 24, 32 and 36 weeks respectively
•FANC emphasizes the following principles: individualize care,
disease detection and not Risk categorization, birth preparedness and
complication readiness planning
•It also promotes use of evidence based practices in care provision for
the pregnant woman and newborn
•Individualized care means provision of client friendly care that takes
into consideration the cultural milieu of the client and utilizes good
communication skills

115. ORGANIZING ANTENATAL CARE
AIM
• To enable trainees to understand necessary clinic set up requirements
and processes for quality antenatal care
OBJECTIVES
• On completion of this session, trainees will be able to;
• List ten key components of a client friendly antenatal clinic set up
• Critically review clinic set ups to evaluate its client friendliness
• Describe the workplace and administrative procedures that apply to
the provision of antenatal care, including completion of home-based
record and essential clinic records
• Explain the application of Universal Precautions to the provision of
antenatal care

116. • List three ways for mobilizing support and funding for improving
antenatal clinic set up
• Describe how to organize and schedule antenatal care visits
• List the content of antenatal care, including assessment of the pregnant
woman(beginning with Quick Check and rapid assessment and
management(RAM): response to observed signs and volunteered
complaints ;preventive measures; advice and counselling; and
development of a birth and emergency plan
INTRODUCTION
• The set up of ANC can affect the quality of antenatal care provided to
clients and also influence a woman’s decision on whether or not to use the
facility
• FANC emphasizes quality rather than quantity and therefore clinic set ups
must optimize the quality of care by ensuring that services are provided in

117. client friendly environments
ORGANNIZING A CLIENT FRIENDLY
ENVIRONMENT ANTENATAL CLINIC SET UP
Key Requirements include the ff;
General
•Auditory and visual privacy is provided: Using simple
partitions e.g. Curtains, wood panels
•Confidentiality is respected and assured
•Clinic days are scheduled to ensure that the clients, their
partners and the community are able to utilize services
maximally
•Clinic set up promotes partner/support person participation

118. - Clients are able to establish rapport with and see the
same care provider
Waiting area
•There is comfortable waiting area, which is clean, well
ventilated and has enough seats for all clients and their
support persons
•Client flow is organized in such a manner as to promote
good flow, minimize congestion due to bottle necks
•There is ready access to clean and well maintained toilet
facilities (pregnant women often have to empty their
bladder more frequently)

119. •If facility is also used for postnatal care, toilet facilities must
have baby care area
•The waiting area can be equipped with useful client educational
audiovisual materials on pregnancy, childbirth and new born
care such as posters, radio and TV/video
•There is supply of clean water (from tap or from potable
container with tap)
There is access to snacks and drinking water;
Consulting cubicle
•The cubicle is clean, well ventilated and free from clutter
•There is reliable source of light(artificial or natural)
•Natural lights from window may be maximized if examination

120. couch is well positioned towards window
•A lamp or touch light could be used to provide more intensive
light for example pelvic inspection
•Comfortable sitting for provider and client in such a way that
good eye contact can be maintained
•The writing table should not be positioned to form a barrier
between client and provider(as in the office setting)
•A clip board for writing may be more preferable
•There is available sitting for the support person or partner of
the client
•Examination couch or table is comfortable and easy for
pregnant woman to get on and off

121. ESSENTIAL EQUIPMENT AND SUPPLIES
•Furnishings
•Examination surface(table or couch)
•Stepping stools by the couch
•Curtains for privacy
•Seating for care provider, woman and support person/partner
•Writing desk or clip board
•Lamp or torch(light source)
•Clock
•Pillow
•Drape/sheet(for couch and woman)

122. •Records and forms
•Registration log book
•Antenatal record book
•Referral forms
•Chart/job aids(e.g. treatment protocols, IEC guides,
emergency phone numbers)
•Equipment
•Tape measure
•Thermometer
•Sphygmomanometer

123. •Fetal stethoscope
•Adult stethoscope
•Gestational age calendar or calculator
•Laboratory equipment's and supplies(collection tubes or
bottles, test kits and reagents for HIV, Blood sugar,
Haemoglobin, urine examination)
•Infection prevention supplies(e.g. waste containers,
cleaning tools; mop)
•Emergency supplies
•Clean sheet, Sanitary pads
•Syringes and needles

124. •Emergency Treatment & Resuscitation pack(e.g. eclampsia,
shock, adult & new born resuscitation, delivery set)
•Wheel chair
Emergency care treatment point
•There is an equipped screened off area for management of
acute emergencies
•Related services; services such as record units, basic
laboratory services & pharmacy must be preferably located
within the antenatal clinic set up or within very easy reach of
the clinic
•Note that all that may be required is a small service delivery
point manned by staff from these units

125. WORKPLACE & ADMINISTRATIVE PROCEDURES
• Certain workplace & administrative procedures are necessary to support
the proper running of maternal & newborn health services, in this case
antenatal services
Workplace
• Clinic hours should be clearly posted for the benefit of all community
members
• Health care providers should try to be on time with appointments or let
the woman/women know if she/they will need to wait
• Before the clinic begins equipment should be checked to make sure that
it is clean & functioning properly & that supplies & drugs are in place
• The facility should be kept clean at all times
• At the end of the clinic, litter & sharps should be discarded safely,

126. equipment should be cleaned & disinfected, linen should be replaced &
prepared for washing, supplies & drugs should be replenished, & routine
cleaning of all areas should be ensured
Daily & occasional administrative services;
• Records of equipment, supplies, drugs & vaccines should be updated
• Essential equipment should be checked to ensure that it is functioning
properly
• Staff lists & schedules should be established
• Periodic reports on births, deaths & other indicators should be completed
according to regulations
Record keeping;
• Findings must be recorded on a clinical record at the time the woman is
seen,including treatments, reasons for referral(if necessary) and follow-
up

127. recommendations
•Confidential information should not be recorded on home-based
records if the woman does not want it
•All clinical record & other documentation should be maintained &
filed properly
•Distribution of free or low-cost supplies or products should be within
the scope of International Code
•Marketing of breast milk substitute should NOT be allowed at the
health facility
•The health facility should be tobacco free
Universal Precaution
•To protect the woman, her baby & themselves from infection with
bacteria & viruses, including HIV, health care providers must observe

128. universal precautions when providing antenatal care
•MOBILIZING RESOURCES & SUPPORT FOR
ANC
•Providing client friendly FANC requires the support
of all key stakeholders within the health care system
and the community.