2. GROUP THREE
• GROUP MEMBERS
• KAKEMBO MUSA NTAMBI 21/U.24098/HTG
• ATUHEIRWE GLORIOUS 21/U/24085/HTG
• NALUKWAGO DORCUS
• LAKONY PETER
3. HEALTH ASSESSMENT IN ANTENATAL
CARE
• Interview
• History
• Physical assessment
• Pelvic assessment
• Lab and diagnostic procedures
4. definitions
• Health assessment is a plan of care that
identifies the specific needs of a person and
how those needs will be addressed by the
healthcare system or skilled nursing facility. a
set of questions, answered by patients, that
asks about personal behaviors, risks, life-
changing events, health goals and priorities,
and overall health.
5. Definition Cont…
• Antenatal care (ANC) can be defined as the
care provided by skilled health-care
professionals to pregnant women and
adolescent girls in order to ensure the best
health conditions for both mother and baby
during pregnancy.
6. FOCUSED ANTENATAL
CARE(FANC)
• This is a timely, appropriate and friendly care for
pregnant women. It emphasizes a woman's
holistic care, preparation for child birth and
readiness for complications that may arise in
pregnancy,labour and puerperium
7. Goal
The overall goal of ANC is;
To reduce maternal and perinatal morbidity and
mortality .
8. Objectives/Aims of ANC
• To Promote and maintain good health of the mother
throughout pregnancy to have normal fetal
development and a live healthy baby at the end of
pregnancy.
• Timely detection and treatment of pregnancy related
complications.
• To Identify women and girls at increased risk of
developing complications during labour and delivery,
thus ensuring referral to an appropriate level of care.
9. Objectives cont……
• ANC also provide an important opportunity to prevent
and manage concurrent diseases through integrated
services delivery
• To prepare mothers physically and emotionally for
pregnancy, child birth, lactation and care of the baby
afterwards.
• To offer education for parenthood.
• To educate women on danger signs.
• To give education and counseling on family planning.
• To give advise and health education to mother on diet.
10. Different versions of ANC
• In the 1990s, the traditional approach to ANC was
criticized for irregular visits, long waiting times,
little communication with women and maternity
units, and lack of focus on the psychosocial
aspects of pregnancy.
11. Different versions of ANC
To over come the deficiencies of the traditional
approach, the WHO adopted focused antenatal
care (FANC) in 2002, an evidence-based and
goal-orientated approach.
This approach was based on a model of four
ANC visits and low- and middle-income
countries widely embraced it. However, globally
only 64% of pregnant women had the
recommended four visits during 2007–2014.
12. versions of ANC………..
• Furthermore, studies showed that FANC had
little or no effect on cesarean section rates or
maternal mortality, and was likely associated with
more perinatal deaths than models with at least
eight visits. Therefore, FANC is no longer
recommended.
• The 2016 ANC guidelines include a significant
new recommendation that pregnant women have
eight contacts with the health system during
each pregnancy.
13. 2016 WHO ANC
WHO recommends eight (8) ANC contacts,
although many African countries are still
struggling to achieve high coverage of four
ANC visits.
Under the new recommendations, a routine
ANC visit is considered a contact instead of
‘visit’ to mean an active connection between
a pregnant woman and a health care provider.
15. Complete antepartum care includes
the following:
• Diagnosing pregnancy and determining gestational age
• Monitoring the progress of the pregnancy with periodic
examinations and appropriate screening tests.
• Assessing the well-being of the woman and her fetus
16. Components of ANC
• Antenatal care comprises of:
Registration of pregnancy
History taking
Health education
General examination
Laboratory investigations
Routine drugs
17. First ANC
• First confirm pregnancy by pregnancy test or
ultra sound san
• History taking
• Physical examination
• Investigation
• Based on the results further work up and
program of care is planned on individual basis.
18. History taking
• Particulars of the client,
• Chief complaints with duration
• Past histories
Obstetric history
Gynaecological history
Menstrual history
Contraceptive history
Medical history
Surgical history
Social history
• History of present pregnancy
19. Particulars of the client
This is basically bio data or demographic data which
include:
Name
Reg No
age
address
Tribe
religion
occupation
level of education
NOK
Relationship to the NOK
20. Chief complaint
• Here you ask the woman what made her to
come to the clinic.
• History of presenting complain:
When did the problem start
characteristic
Relieving factors
Aggravating factors
Associated factors
21. Past Histories
• Obstetric history:
• Inquire about previous pregnancies:
• mode of delivery for example;
vaginal,caesarean section,forcep delivery and
location of delivery,
• any complication during labor,
• Weight of infant at birth and length of
gestation
• Pueperium
• immunization of the babies where applicable
22. Past Histories cont..
• gynecological history:
• any abortion, ectopic pregnancy
• any gynecological procedure like
D&C, myomectomy, vaginal fistula
repair
23. • Family History:
• Position,
• history of familial diseases like hypertension,
sickle cell, DM, psychiatric disorders.
• Multiple pregnancy.
• Social History:
• Parents: alive or dead, staying together or
separated
• Marital status
• Relationship with family and others
• history of smoking or drinking
• Health status of the husband if applicable
24. Histories cont…
Medical history:
• Childhood illnesses like poliomyelitis, rickets, RF;
chronic conditions like hypertension, diabetes
mellitus, cardiac disease, renal disease, epilepsy
• Drug allergies
• Surgical history
• Laparatomy
• Accidents involving the pelvis and lower limbs.
• Blood transfusion
25. Histories cont…
• Menstrual history, Menarche,
• duration of bleeding, length of the cycle
• Amount: Normal or heavy
• Contraceptive History
• Ask for history of contraceptive use, type
• for how long was it used
• when was it discontinued.
• why?
26. Histories cont….
• History of Present Pregnancy:
• gravidity, parity, LNMP, EDD, WOA
• Nutritional status
27. Calculation of EDD
• Naegele’s rule is an easy way to calculate the EDD: add 7 days
to the first day of the last normal menstrual flow and add 9
months or subtract 3 months from the month.
• In a patient with an idealized 28-day menstrual cycle, ovulation
occurs on day 14; therefore, the conception age of the
pregnancy is actually 38 weeks.
• The use of the first day of the last menstrual period as a
starting point for gestational age is standard, and gestational,
not conceptional. “Normal” pregnancy lasts 40 ±2 weeks,
calculated from the first day of the last normal menses
(menstrual or gestational age).
28. • To establish an accurate gestational age, the date of
onset of the last normal menses is crucial.
• A light bleeding episode should not be mistaken for a
normal menstrual period.
• A history of irregular periods or taking medications that
alter cycle length (e.g., oral contraceptives, other
hormonal preparations, and psychoactive medications)
can confuse the menstrual history.
• If sexual intercourse is infrequent or timed for conception
based on assisted reproductive techniques (ARTs), a
patient may know when conception is
most likely to have occurred, thus facilitating an accurate
calculation of gestational age
29. Examples for practice
• Taking today's date as 28/7/2022, calculate
the EDD and weeks of amenorrhea as for the
following LNMPs:
• 20/2/2022
• 29/2/2022
• 26/3/2022
• 25/5/2022
• 23/12/2021
• 18/7/2022
30. General examination
• Height: it may be an indication to the pelvis.
• A height of less than 152cm may indicate a small
pelvis
• Weight: if first taken in early pregnancy is a good
indication to the pre-pregnancy weight and
subsequent gain is easy to asses.
• The total weight gain in pregnancy is about 10-15kg.
32. • Blood pressure: very important in early pregnancy
to help in assessing subsequent readings.
• If BP is high in early pregnancy below 20weeks, it
indicates essential hypertension
• Occurring later in pregnancy it may be a sign a sign
of preeclampsia.
• Measure BP in sitting position
• If diastolic BP is 90mmHg or higher repeat
measurement after 4 hours rest.
• If diastolic BP is still 90mmHg or higher, check urine
for proteins.
33.
34. investigations
• Urinalysis: the urine is tested for infections, protein,
sugar and acetone
• Hemoglobin , HB: to detect anemia.
• If HB is less than 11g/dl, investigations and treatment
are carried out.
• ABO Blood grouping: so that blood may be readily
available for cross-matching in case of emergency as
with hemorrhage.
• Rhesus factor: to determine if the mother is rhesus
positive or negative so that adequate management can
be given in case she is rhesus negative. Also to ensure
that rhesus positive blood is not given to rhesus
negative mother if need for blood transfusion.
35. • Serological test for syphilis:
• This is done so that if syphilis is present adequate
treatment is give to prevent the serious effect of
syphilis on the fetus.
• HIV test
• Other tests may be carried out depending on the
condition of the mother.
36. Subsequent antenatal visits
• Regular monitoring of the mother and fetus is essential for
identifying complications that may arise during pregnancy and to
provide assurance and support for mother and family, especially
for first pregnancies or when previous pregnancies have been
complicated or had unfortunate outcomes.
• For a patient with a normal pregnancy, periodic antepartum visits
at 4-week intervals are usually scheduled until 28 weeks, at 2- to
3-week intervals between 28 and 36 weeks, and weekly thereafter.
• Patients with high-risk pregnancies or those with ongoing
complications usually are seen more frequently, depending on the
clinical circumstances.
37. • At each visit, patients are asked about how they are
feeling and if they are having any problems, such as
vaginal bleeding, nausea and vomiting, dysuria, or
vaginal discharge.
• After quickening, patients are asked if they continue
to feel fetal movement, and if it is the same or less
since the last antepartum visit.
• Decreased fetal movement after the time of fetal
viability is a warning sign requiring further
evaluation of fetal well-being
38. Preventive measures
1. Tetanus toxoid
• Is advised in pregnancy.
• The antibodies produced by the mother cross to the fetus and
provide passive immunity and prevent neonatal tetanus.
• The mother is given a first dose at the first visit to the
antenatal clinic and second dose after 4weeks.
2. Intermittent Presumptive Treatment (IPT)of Malaria
This preventive treatment is to be given to pregnant women
starting as early as possible in the second trimester (i.e. not
during the first trimester). The women should receive at least
3 doses of SP during her pregnancy, with each dose being
given at least 1 month apart – SP can safely be administered
up until the time of delivery.
Note: pregnant women on ART should not be given fansider.
39. 3. Folic acid:
• Folic acid is a man-made form of a B vitamin called
folate.
• Folate plays an important role in the production of
red blood cells and helps your baby's neural tube
develop into her brain and spinal cord.
• Birth defects occur within the first 3-4 weeks of
pregnancy. So it's important to have folate in your
system during those early stages when your baby's
brain and spinal cord are developing.
• Pregnant women should receive 0.4mg daily.
40. 4. Ferrous sulphate
• This medication is an iron supplement used to
treat or prevent low blood levels of iron (such as
those caused by anemia or pregnancy).
• Iron is best absorbed on an empty stomach
(usually if taken 1 hour before or 2 hours after
meals).
• Dose: 1 tablet orally once a day. Usually 60-
120mg daily.
• It should be taken after 1st trimester and can be
continued up to 6weeks postpartum.
41. 5. Deworming
• Preventive chemotherapy (deworming), using
single-dose mebendazole (500 mg), is
recommended as a public health intervention
for pregnant women, after the first trimester,
• It is then given after every 3 months.
42. Health promotion
• Targeting care seeking behavior change and
antenatal care utilization
• Birth preparedness and complication
readiness
• Sleeping under mosquito nets
• Skilled care for childbirth
• Companionship in labour and childbirth
• Nutritional advice and supplements
44. Examination of the mother
• Ensure the woman has emptied her bladder.
• Appearance:
• Note the general appearance of the mother, if
she looks healthy and happy, tired, ill,
depressed or malnourished.
• Note any difficulty in breathing, any cough
and the standard of her personal hygiene
45. o Head:
o Examine the condition of hair and scalp, any lesions,
any loss of hair or head lice
o Note eyes for any signs of infection, pallor indicating
anemia, any sign of cyanosis or jaundice or any
oedema
o Any discharge from the ears or nose
o Mouth and teeth, note any infection such as
Candida, or lesions, any coating of the tongue,
pallor of the tongue and gums indicating anemia,
any sign of cyanosis. Look for dental caries
o Note the condition of the skin, any rashes, skin
diseases scars or septic spots.
46. • The neck:
o Examine for enlargement of the thyroid gland and
palpate gently for enlarged lymph nodes.
o Note any pulsation of the carotid artery and
enlargement of the jugular vein.
• The arms and hands:
o Note if they are equal in size, any sign of edema,
any pallor of the palms and nail beds which may
indicate anemia.
o Apply pressure on the nail beds to observe venous
return.
o Note the size of the hands, small hands may
47. • The breasts:
o They are examined to assess their suitability for breast
feeding and to exclude any abnormality.
o The mother sits with her hands on her hips
o On inspection, note the shape and size, if they are
equal, the texture of the skin and skin changes, any
scars,
o The nipples if protruding, flat, inverted or any discharge
or any discharges.
o Gently lift the breasts to inspect underneath for
soreness.
o palpation, with the flat of your fingers gently palpate
the breast starting from the axilla palpate for enlarged
lymph glands which may indicate infection of cancer of
the breast. Then palpate the breast from the base to
the nipple for tenderness or lumps.
48. o Then with the flat of your hand press the breast using
gentle pressure against the chest wall.
o The nipples are drawn forward to see if they are
protractile.
o The vulva: is inspected for abnormal discharges,
bleeding, edema, varicose veins, rashes, lesions such as
warts, sores or chancre.
o The legs and feet:
o The size is noted to see if they are equal, any
deformities, septic wounds spots or other infections.
o Note the size of the feet, a shoe size of 4 or less is
abnormally small and may indicate a small pelvis
o Examine for edema and varicose veins.
49. Abdominal examination
• The bladder should be empty.
• The mother lies comfortably with her arms by the
side and a pillow supporting her head and shoulder.
• The knees may be slightly flexed to relax the
abdominal muscles.
• Only the abdomen is exposed
• Your hands should be warm and clean and nails
short.
• The examination includes: inspection, palpation and
auscultation.
50. • On inspection:
observe the size and shape, signs of pregnancy and
abdominal scar.
The size, should correspond with the weeks of
gestation.
It may be larger for dates In cases of mistaken dates,
multiple pregnancy, hydramnios, large baby, fibroids
or a pelvic mass pushing the uterus upwards
It may be small for dates in case of mistaken dates,
fetal growth retardation, transverse lie of the fetus,
oligohydramnios, intrauterine death of the fetus.
51. • Palpation:
Using both hands and fingers close together
palpate using the flat of your fingers and moving
your hands smoothly over the abdomen.
Superficial palpation: is done to rule tenderness or
abdominal mass.
The liver and spleen; are palpated for tenderness or
enlargement.
The height of fundus: to compare with the weeks of
gestation. Measure the distance of the fundus from
the symphysis pubis using a tape measure.
The weeks of gestation corresponds with the
number of centimeters
52. • Pelvic palpation:
facing the woman's feet place your hands on
the sides of the uterus just below the level of
the umbilicus with fingers directed
downwards and inwards palpate the lower
pole of the uterus to find what part of the
uterus is presenting. If the head is presenting
note its size and if it is free, fixed or engaged.
If the head is presenting a smooth hard round
mass will
53. Pelvis assessment
• A pelvic exam involves physically and visually examining the
female reproductive and sexual organs. It allows a doctor to
look for signs of infection and illness. The doctor
performing the exam may be a gynecologist or an OB-GYN.
They will examine the:
• vulva
• vagina
• cervix
• uterus
• ovaries and fallopian tubes
• What is the pro
54. Pelvic Assessment Cont.
• During a pelvic exam, a doctor will check the following
reproductive organs:
• the vulva, which is the external genital organ
• the vagina, which leads from the external organ to the cervix
• the uterus, which is also called the womb
• the cervix, which is the opening between the uterus and
vagina
• the fallopian tubes, which carry eggs to the womb
• the ovaries, which produce eggs
• the bladder, a sac-like organ that stores urine
• the rectum, which connects the colon to the anus
55. Why have a pelvic exam?
These examinations are performed for many
reasons, including: as part of an annual
checkup to check that reproductive organs are
healthy during pregnancy to look for signs of
infections to determine the cause of pain in the
pelvis or lower back
56. A pelvic exam is often performed on the same day as other
preventive screenings – a breast examination and a Pap
smear.
The purpose of a breast exam is to look for abnormalities and
other signs of cancers that begin in the breast tissue. Pap
smears can show signs of cancer and pre-cancer Trusted
Source of the cervix.
Pelvic exams are also part of sexual assault assessments.
57. Pelvic exam procedure
Before the exam, the doctor or nurse practitioner
will ask the person to take off their clothes, put on
a gown, sit on the exam table, and cover up with a
sheet. Then they will ask about health concerns.
The person will then lie on their back and place
their feet in footrests. The doctor or nurse will ask
them to relax. They will press on the lower part of
the person’s stomach and feel for the organs. The
doctor will then ask the person to move toward the
end of the table and bend their knees.
58. • First, the doctor will examine the vulva for signs
of infection, swelling, and sores. Next, they will
insert a lubricated speculum into the vagina to
widen it, and make the internal organs easier to
see.
• Then, they may perform a Pap smear. This
involves taking a sample of cells from the cervix
to check for abnormalities, especially cervical
cancer. They may also take a sample of vaginal
discharge, to check for infections.
59. • Next, they will remove the speculum and perform a
bimanual examination. This involves placing two
fingers inside the vagina and pressing down on the
pelvis with the other hand. The aim is to check for
changes or abnormalities in the reproductive organs.
• The doctor may then conduct a rectal exam, by
inserting a gloved finger in the rectum to check for
tumors and other abnormalities behind the vaginal
wall, uterus, and rectum.
• If a person feels any pain during the exam, they should
let the doctor know right away.
60. Also, a pelvic exam can help a doctor to
evaluate the size of the pelvis and cervix
Trusted Source. This will help them to
evaluate whether cervical weakness could
lead to miscarriage or preterm labor.
Pelvic exams are usually done early on in
pregnancy. If there are no complications,
another exam is performed at around 36
weeks, to check for changes to the cervix.
61. • After that, the doctor will perform an exam as
often as needed to determine if the person is
in labor.
• There is little information about the risks of
pelvic exams during pregnancy. It is possible
that an exam may increase the risk of
infection.
62. • Fundal palpation:
facing the patients head and moving your fingers
smoothly over the abdomen palpate to see what
part of the fetus is lying in the fundus.
This helps to diagnose the lie and presentation of
the fetus.
Palpate the mass between your hands to assess its
size and mobility. Usually it is the breech and is felt
as a soft mass.
The head is felt hard round and ballotable because
of the free movement of the neck.
63. • Lateral palpation:
to locate the back in order to determine the
position.
You continue to face the mothers head and
placing your hands on both sides of the umbilicus
with one hand apply pressure to steady the uterus
with the other and gently palpate to the lateral
side. You repeat on the other side.
The back is felt as a continuous, smooth, hard
mass. The limbs are felt as knobbly small parts
that slip away from the examining fingers.
64. • Auscultation:
to assess fetal wellbeing
Place the stethoscope on the mothers abdomen at
the point where the back was located is where the
fetal heart is more clearly heard.
With your ears close to the stethoscope, listen and
count carefully at the same time checking the
mothers pulse. The fetal heart is more rapid than
the mothers pulse.
Note the rate and rhythm.
The normal fetal heart is a steady coupled beat at
the rate of 120-160 beats per minute.
65. TIMING
OF
CONTA
CT
HISTORY
TAKING
EXAMINATION LABORATORY
INVESTIGATIO
NS
PROMOTIO
N
ACTION
m
an
al
Contact
1:
Anytim
e
≤ 12
weeks
-
Presentin
g
complaint
- LNMP
- Estimate
period of
gestation
-
Contracep
tive?
-
Obstetric
General exam
- Vital exam
(e.g. BP, pulse)
- SFH
measurement
-
Abdominal/spe
cific exam
- Vulva exam
(Speculum if
indicated)
- Nutritional
assessment
- Hb (CBC
where
available)
- HIV test
- Syphilis test
(RPR)
- Blood
group/RhD
- Urine
albumen,
Glucose
- Gram staining
for ASB, urine
H/E on
common
pregnancy
complaints
- Address
any
problem
- Involve
husband in
ANC
- Draw up a
birth and
emergency
Tetanus/Di
phtheria
vaccine (Td)
- Ferrous
SO4
- Folic acid
- Treat
incidental
ailments
- Condom
use for HIV
prevention
in
66. Laboratory Investigations during
Antenatal Care
• Baseline investigations:
• - Hb (normal 10.5-15gm)
• - Blood group (ABO and Rhesus factor)
• - Urinalysis (protein and sugar)
• - VDRL, RPR for syphilis .
• Elisa test for HIV
• - Sickling test
67. Investigations contd
• RDT for Malaria (where indicated)
• - Hepatitis B test.
• Rhesus antibodies for RH-ve mothers
• - Mid-stream urine for culture and sensitivity
• - High vaginal swab (HVS) .
68. REFERENCES
Diane M.Fraser, Margaret
A.Cooper,Anna G.W.Nolte,Myles text
books for Midwives
Birungi, H., & Onyango-Ouma, W. (2006).
Acceptability and sustainability of the
WHO Focused Antenatal Care package in
Kenya.
