1. an care tutor 20 dec

Antenatal Care Module

Tutor’s Guide

Jakarta, Indonesia

December 2012

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Table of Contents

1. Introduction................................................................................................................... 4

Student Characteristics..............................................................................................................4

2. How to Use the Antenatal Care Module..................................................................5

3. Learning Objectives...................................................................................................... 6

3.1 Develop knowledge base....................................................................................................6

3.2 Develop clinical skills..........................................................................................................8

3.3 Enhance professional development...............................................................................9

4. Core Topics and Clinical Conditions........................................................................9

5. Physical Examination and Procedural Skills.....................................................10

6. Guide to Ethical Behaviour...................................................................................... 10

7. Teaching and Learning Programme.....................................................................11

7.1 Overview............................................................................................................................... 11

7.2 The Programme.................................................................................................................. 12

7.2.1 Introduction....................................................................................................................................12

7.2.2 Clinical Skills Session..................................................................................................................12

7.2.3 Clinical Teaching...........................................................................................................................12

7.2.4 Problem-based Learning...........................................................................................................12

7.2.5 Topic Tutorials...............................................................................................................................12

7.3 Topics, Teaching and Learning Methodology and Assessment/Evaluation....13

8. Learning Resources................................................................................................... 16

References...................................................................................................................................................16

9. Assessment................................................................................................................... 17

10. Procedural Skills Tutorial..................................................................................... 18

10.1 Taking an Obstetric History.........................................................................................18

10.2 Performing an Obstetric Examination......................................................................23

11. Teaching and Learning Materials.......................................................................27

11.1 Group Discussion.............................................................................................................27

11.1.1 Group Exercise: Use of pregnancy calculator................................................................27

11.1.2 Discussion: Birth and emergency preparedness plan...............................................29

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11.2 Case-based Learning Case Triggers...........................................................................33

Case Study 1: Focused Antenatal Care............................................................................................33

Case Study 2: Health education for women following the basic component of

Focused Antenatal Care........................................................................................................................38

11.3 Problem-based Learning Case Triggers...................................................................39

Case Study 1: Counselling for HIV Testing During Antenatal Care.....................................39

Case Study 2: Antenatal Assessment and Care (Anaemia)....................................................41

11.4 Knowledge Assessment.................................................................................................49

11.4.1 Knowledge Assessment on Focused Antenatal Care:................................................49

11.4.2 Knowledge Assessment:.........................................................................................................49

Prevention and Management of Malaria and Other Causes of Fever In Pregnancy...49


Preventing Mother-To-Child Transmission of HIV....................................................................51


Postpartum family planning...............................................................................................................53

11.5 Checklists........................................................................................................................... 56

11.5.1 Checklist for Focused Antenatal care................................................................................56

11.5.2 Checklist for birth and emergency preparedness plan.............................................62

11.5.3 Checklist for demonstration of breast feeding..............................................................63

11.6 Learner’s Guide:............................................................................................................... 65

11.6.1 Learner’s Guide: Antenatal Assessment - Taking an Obstetric History.............65

11.6.2 Learner’s Guide: Antenatal Assessment - Physical Examination..........................70

11.7 Counseling Guide for Postpartum Family Planning – Postpartum IUD.........75

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1. Introduction

The module on antenatal careis an inter-related learning experience between several basic

sciences and clinical disciplines. These modules include:

- Anatomy and Embryology Modules for anatomy of the female genital tract and fetal growth

and development (third year)

- Physiology Module for physiology of pregnancy (third year)

- Microbiology and Infectious Disease Modules for STI/RTI and HIV (third year)

- Pharmacology Module for prescribing medicines in pregnancy and the puerperium (third

year)

- Haematology and Clinical Pathology Modules for urine and blood investigations (third year)

- Women’s Health Module for obstetric and gynaecological issues (fifth year)

- Medicine Module for medical disorders in pregnancy (fifth year)

- Nutrition Module for nutrition during pregnancy and breastfeeding (third year)

- Community Medicine Module (third year)that will cover public health topics closely related to

Obstetrics and safe motherhood. These are:

Maternal and Neonatal Mortality and Morbidity

Initiatives to improve maternal and newborn health

Services for maternal and neonatal health in Indonesia

The Empathy Module (first year), Basic Clinical Skills Module including counseling (second

and third year) and subjects such as Ethics and Professionalism and Cultural Competence

are critical elements of antenatal care provision.

The Antenatal Care module is based on the WHO Antenatal Care model which has been used

extensively in low and middle-income countries as the Focused Antenatal Care model.

The Antenatal Care module is primarily for the doctor practising as a general practitioner at

the health centre/puskesmas level; and can also be used by midwives working at this level.

Student Characteristics

Students who can take the Antenatal Care module are those who have completed Stage 1 of

their education and have acquired learning skills of Stage 1 – General Education. These

students must have achieved basic skills and attitudes, such as life-long learning skills,

generic skills and concern for the environment and the community.

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2. How to Use the Antenatal Care Module

The Antenatal Care module is introduced in the third year and will be undertaken in the Basic

Clinical Skills Module (fourth year), Women’s Health Module (fifth year) and in the Pre-

internship training.

This module contains the following information:

Learning Objectives

The Core Topics and Clinical Conditions you are to be able to address as a result of your

learning experience related to this module

Teaching/Learning materials:

- TheCase-Based and Problem-based Learning Case Triggers

- The worksheets for taking an obstetric history and conducting an obstetric examination as

part of procedural skills

- Checklists and Learner’s Guide

- A Counselling Guide for post-partum family planning

In the Fifth Year when going through the Women’s Health rotation, you will complete a Clinical

Skills logbook which will reflect your tasks and observations related to antenatal care.

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3. Learning Objectives

Antenatal care (ANC) is the care provided throughout pregnancy to help ensure that women

go through pregnancy and childbirth in good health and that their newborns are healthy. The

emphasis in this module is on Focused ANC (FANC), which relies on evidence-based

interventions provided to women during pregnancy by skilled healthcare providers such as

midwives, doctors, and nurses with midwifery and life-saving skills. Focused ANC includes

assessment of maternal and fetal well-being, preventive measures, preparation of a birth and

emergency preparedness plans and health messages and counseling.

3.1 Develop knowledge base

During the third year, a knowledge base will have been developed of the

following in the respective Modules:

Normal Anatomy and Physiology

Obstetrics: anatomy of the female pelvis, fetal growth and development

Obstetrics: physiology of pregnancy

Gynaecology: menstrual cycle

Microbiology

Sexually transmitted infections/Reproductive tract infections (gonorrhea and chlamydia

infections, syphilis, HIV/AIDS, candidiasis, trichonomas vaginitis, bacterial vaginosis, Human

Papilloma Virus (HPV) infection, genital herpes)

Haematology and Clinical Pathology

Haematological, biochemical and other laboratory investigations

Pharmacology

Safe prescribing of medicines in pregnancy and puerperium

Population health issues

Sexually transmitted infections/Reproductive tract infections

Mental health in obstetrics

Public health interventions conducted for the mother and newborn in Indonesia and

internationally

Community Medicine

Maternal and Neonatal Mortality and Morbidity

Initiatives to improve maternal and newborn health

Services for maternal and neonatal health in Indonesia

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Cultural competence

In the Antenatal Module, the Learning Objectives are:

To explain management of the normal antenatal period:

Obstetrics:

Pre-pregnancy counseling

Evidence-based interventions and care during the antenatal period which can prevent and

treat complications of pregnancy

Focused antenatal care (FANC), basic elements of FANC assessment and care - first and

subsequent antenatal visits (assessment, interventions including referral, counseling and

advice) for the basic component of antenatal care

Common clinical problems in the antenatal period

Maternal nutrition and immunization

Birth and emergency preparedness plans and the relation to the Three Delays.

To explainmanagement of the normal post-partum period:

Obstetrics:

Postpartum care, breastfeeding, maternal complications

Gynaecology:

Contraception for women who breast feed and those who do not breast feed.

To explain early newborn care

Early newborn care, neonatal complications

To explain and interpret theinvestigations carried out routinely during the antenatal

period

Blood for Haemoglobin

Blood group and Rhesus

Blood sugar

Urine for protein, sugar, bacteriuria

Ultrasound scans

Perform, interpret and explain the following investigations: blood pressure, mid-upper arm

circumference.

interpret and explain the following investigations:haemoglobin estimation, blood

sugar,urinalysis, urinary pregnancy test, genital swabs (high vaginal swab, endocervical

swab) and cervical smear.

To provide informationon common issues in pregnancy

Obtain knowledge to be able to provide information on:

- Normal pregnancy

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- Nutrition requirements and mineral and vitamin supplements

- Minor disorders in pregnancy

- Investigations routinely carried out in antenatal period

- Prevention of maternal to child transmission of HIV and syphilis

- Immunization

- Skilled attendance at delivery

- Birth and emergency preparedness plans and the relation to the Three Delays

- Post-partum care and newborn care in the early puerperium, including breast feeding.

To communicatewith clients, their families and other health professionals

Communicate clearly and sensitively with clients, their families and with other health

professionals during process of antenatal care.

Communicate effectively with clients and their families on diagnosis, procedures and

management in a culturally appropriate manner.

Appreciate the diversity of traditions and cultures of different population sub-groups and adapt

provision of care.

Communicate clearly and sensitively with clients and their families to abandon practices that

are harmful or of no proven effect on the mother and newborn.

3.2 Develop clinical skills

Obstetrics:

Develop basic clinical skills (obstetric history taking, calculate estimated date of delivery

(EDD) and physical examination) to arrive at a provisional diagnosis and differential

diagnoses.

Elicit history from an Obstetric patient.

Measure mid-upper arm circumference (MUAC)

Perform breast examination, an abdominal examination in women during pregnancy (early

pregnancy and pregnancy over 20 weeks) and recognize normal findings and common

abnormalities.

Identify women with specific conditions and complications of pregnancy who require referral

to a district hospital.

Gynaecology:

Perform bivalve speculum examination and recognize normal findings, signs of vaginal and

cervical infection and common abnormalities.

Communication and Counselling

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Develop skills in communicating and counseling with the woman and her husband and family

on issues such as care of a normal pregnancy, birth and emergency preparedness,

postpartum and early newborn care (including breast feeding and family planning).

The skills developed during the Community Medicine rotation: the counseling process, the

guiding principles and the factors that can influence the counseling process will be reinforced

in this module.

3.3 Enhance professional development

Develop the following attitudes:

Inter-professional Relationship: Multi-disciplinary health care is an integral part of antenatal

care and this module offers an opportunity to develop inter-professional relationships.

Muilti-cultural Approach: Develop respect for the differing cultural positions in antenatal care.

Encourage traditional practices that are beneficial and be able to counsel on harmful

practices.Conceptualise the clinical problem in a clinical and social context.

Sense of Responsibility: By virtue of the unique and close relationship and involvement with

the client and her family in preventive and promotive activities and care throughout the

pregnancy, to develop a sense of responsibility.

Appreciate ethical issues

To develop an understanding of common ethical issues in provision of antenatal care related

to respect for the clients/patient, privacy and confidentiality; and an approach to issues where

the health provider’s stance is at variance with that of the client.

4. Core Topics and Clinical Conditions

The core topics and clinical conditions in the Antenatal Care Module will also be covered in

the related basic sciences, community medicine and clinical modules.

Normal pregnancy

- Pre-pregnancy counselling and the use folic acid preconception and nutritional

requirements and lifestyle changes in pregnancy.

- Consideration of past obstetric history, including mode of delivery

- Safe drug prescribing in pregnancy and the puerperium

- The risk of substance abuse in pregnancy

- Nutrition requirements and mineral and vitamin supplements in pregnancy

- Minor disorders in pregnancy

- Changing demographics of pregnancy.

Focused antenatal care

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- Principles and concepts

- Basic component of focused antenatal care

- The booking visit (history and examination)

- Routine investigations during antenatal period/visits

- Prevention of maternal to child transmission of HIV and syphilis

- Immunization

- Care during subsequent visits (2nd, 3rd and 4th) for the Basic component of focused

antenatal care

- Skilled attendance at delivery

- Birth and emergency preparedness plans

- Sexual relations during pregnancy

- Immediate post-partum and early newborn care

5. Physical Examination and Procedural Skills

Take history in pregnancy (Obstetric history taking)

Perform breast and obstetric examination

Perform a speculum examination

Apply the Classifying Form to identify clients/woman for the basic component of antenatal

care

Identify women with complications for referral

Communicate and counsel the woman, her husband and family

Complete clinic medical records and Mother and Child Book (which is kept with the mother).

6. Guide to Ethical Behaviour

You are expected to apply the principles of ethical conduct that you learnt in The Empathy

Module (first year) and Basic Clinical Skills Module.

Respect for the patient

Respect for the patient includes deference to and acknowledgement of the patient’s right in

making decisions, treating the patient with compassion and dignity, maintaining confidentiality

and respect for patient privacy, avoiding misrepresentations, deception and nondisclosure,

and keeping promises.

Privacy

It is important to respect the client/patient’s privacy. Before starting a physical examination,

explain to the client/patient what you will be doing and obtain consent. Make sure you have

drawn the curtains. If you are a male student, you may want to ask a nurse or a fellow female

student to be present during the examination. Only the area to be examined should be

exposed at any time and do not leave the patient exposed longer than necessary. Speculum

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or vaginal examination should be performed only with the client/patient’s consent and under

supervision of a doctor.

Consent

Your clinical handbook will explain the process of obtaining agreement/consent from

out-patient/ward staff to interview a client/patient. You should proceed to the

client/patient only when you have obtained the agreement.

Once agreement/consent is obtained, you should introduce yourself to the

client/patient you wish to interview that you are a medical student and explain why

you are there.

You need to obtain consent from every client/patient you wish to interview.

The client/patient must be made aware that their agreement to be

interviewed/examined is voluntary, that they are free to agree or refuse and that their

medical care will not be affected in any way by their decision.

Confidentiality

You are expected to uphold the same standards of confidentiality as doctors.

You should not reveal the name of any patient to anyone who is not involved in the

care of the client/patient. Details other than names can lead to identification of a

client/patient, so caution needs to be exercised in sharing such details.

Discussing the client/patient that you have seen with your tutors and fellow students

is an important part of medical education. It is acceptable to share your experiences

with family and friends but make sure that you do not disclose any identifying

information.

Other Points in Clinical interactions

Help the patient sit up and to get dressed (as appropriate)

Thank her for agreeing to be interviewed or examined

Dress appropriately out of respect for the client/patient and doctors who are helping

you in your medical education

Wear your photo identity card

Turn off mobile phones during tutorials and interactions with clients/patients

7. Teaching and Learning Programme

7.1 Overview

It is important to participate in all activities related to this module. You will be introduced to the

principles of antenatal care and focused antenatal care in the third year. The opportunity to

put your skills on taking an obstetric history and performing an obstetric examination will be

given in the fourth year and consolidated during the fifth year in the Women’s Health module.

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This includes clerking of in-patients (pregnant women/patients), participation in out-patient

clinics. These skills will be reinforced in the pre-internship rotation.

7.2 The Programme

7.2.1 Introduction

You will have an introductory lecture on antenatal care to develop some foundation in the

concepts of antenatal care, obstetric history taking and performing an obstetric examination.

7.2.2 Clinical Skills Session

You will have opportunities to take obstetric history during role play and perform an obstetric

examination on mannikins during the third year. In the fourth and fifth year, you will have the

experience of taking a history and performing an examination on women coming for antenatal

care or those admitted to the obstetric ward. You will encounter women with minor

disorders/ailments of pregnancy or those with complications during the antenatal period.

In the application of the Focused antenatal care model, basic antenatal care will be provided

to women who have an uncomplicated pregnancy. However, it is important to be able to

identify women who develop conditions or complications that require more specialized care.

Therefore, it is important for you to identify these women through performing a thorough

history and physical examination. You will also need to acquire the skills to communicate

effectively with women and their families (i) to adhere to the antenatal care visit schedule and

interventions, (ii) to plan for delivery and (iii) to convince them to seek care at the next referral

level/district hospital as required.

7.2.3 Clinical Teaching

You are expected to attend all the outpatient antenatal clinics which provides opportunities to

interact with pregnant women and their families. Problem-based learning (PBL) and clinical

tutorials will be scheduled to be at the outpatient clinic sessions.

7.2.4 Problem-based Learning

The problem-based learning (tutorials) will take place during the clinical weeks 2-6 and 8-9 of

the Women’s Health rotation.

7.2.5 Topic Tutorials

There will be two topic tutorials scheduled each week: one in Obstetrics and Gynaecology

and another in Neonatal Paediatrics in the Women’s Health rotation.

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7.3 Topics, Teaching and Learning Methodology and Assessment/Evaluation

Table 1: Topics, Teaching and Learning Methodology and Assessment/Evaluation

Topic Sub-topics to be covered Method Year Assessment &

Evaluation

Antenatal care (ANC) Elements of care in pregnancy

Purpose of antenatal care

Introduction Lectures 3rd Assessment

Self-assessment

Questions

Group discussion

Case-based discussion

Directly observed

practical skills

OSCE

Mini CEX

Evaluation

Clinical Log Book

Directly observed

practical skills

MCQ, MEQ,

Long case based

Focused antenatal care

(FANC)

Concepts and Principles of FANC

Goals of FANC

Comparions of traditional and focused

antenatal care

Application of Classifying Form

Introduction Lectures

Presentation/Discussion

3rd

First antenatal Visit1 Obstetric History Role play

Interaction with Clients

3rd,4th,5th

Clinical Examination Practice on mannikins

Examination on Clients

3rd,4th,5th

Essential/Supporting Investigations Introduction Lectures


3rd

Interventions for Basic ANC Component

Assessment for Referral

Advice, Questions and Scheduling

Introduction Lectures

Problem/Case-based

discussion

3rd

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Evaluation

examination

Research by student

group

Birth and emergency preparedness and

complication readiness

The Three Delays

Self-study

Group Discussion

3rd

Subsequent Visits (2nd, 3rd,

4th)

History and Clinical Examination

Interventions for Basic ANC Component

Assessment for Referral

Advice, Questions and Scheduling

Presentation/Discussion

Problem/Case-based

discussion

3rd,4th,5th

Common Minor Ailments Nausea, Vomiting

Leucorrhoea, etc

Topic discussion 5th

Communication/Counselling Anaemia

Nutrition

Counselling for Testing for HIV and syphilis

(pre-test counseling, provider-initiated

counseling counseling and testing, post- test

counseling)

Postpartum family planning

Problem/Case-based

discussion

Role play on different

scenarios

3rd

Postpartum care and Early

Newborn Care

Mother

Postpartum care and hygiene

Nutrition

Clinical morning discussion

Topic discussion

3rd

1In providing FANC, health service providers give emphasis to individualised assessment and the actions needed to make decisions about antenatal care by the provider andthe pregnant woman together. Each visit comprises of eliciting history/information; conducting an examination and supporting investigations/tests; assessing the need for referral; implementing interventions; counselling, responding to questions and scheduling the next visit; and maintaining complete records

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Evaluation

Breast-feeding

Family planning

Danger signs in post-partum period

Sexual relations in the puerperium

Baby

Thermal protection

Cord care

Sleeping patterns

Hygiene (washing, bathing)

Danger Signs for newborn

Pre-pregnancy counselling Pre-pregnancy counselling

Use of folic acid preconception

Lifestyle changes in pregnancy

Self study 3rd

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8. Learning Resources

Lecture notes will be available one day before the activity. There are useful references on the

website that will be sent out prior to the learning activity.

References

WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model

(2002) WHO

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal

care (2001) Villar, J et al Lancet 357 1551- 64

Standards for Maternal and Newborn Care (2007) Department of Making Pregnancy Safer –

WHO

Pregnancy, Childbirth, Postpartum and Newborn Care (2006), WHO

Managing Newborn Problems, (2003) WHO

Decision-making tool for family planning providers and clients (2007) WHO and JHPIEGO

WHO Reproductive Health Library

Oxford Handbook of Obstetrics and Gynaecology (2008) 2nd edition

Basic Maternal and Newborn Care: A Guide for Skilled Providers (2004)AuthorsBarbara

Kinzie and Patricia Gomez - ACCESS JHPIEGO/Maternal and Neonatal Health Program

Best Practices in Maternal and Newborn Care - A Learning Resource Package for Essential

and Basic Emergency Obstetric and Newborn Care–(2008) JHPIEGO USAID- ACCESS

Postpartum Intrauterine Contraceptive Device Services – Trainer’s Notebook (2010)

JHPIEGO USAID- ACCESS

Antenatal Care, Part 2 - Blended Learning Module for the Health Extension

ProgrammeEthiopian Federal Ministry of Health, the Ethiopian Office of UNICEF, The Open

University UK and AMREF (the African Medical and Research Foundation).

Pocket Book of Maternal Health Care – Indonesia (2011 Draft)

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Thaddeus, S and Maine, D (1994) “Too Far To Walk: Maternal Mortality in Context”

9. Assessment

Self-assessment Questions (SAQ)

- Self-Assessment Questions after the introduction lectures.

Group discussion

- Calculating expected date of delivery

- Discussion on birth and emergency preparedness plans

Clinical Log Book


- Case Study 1: Focused Antenatal Care

- Case Study 2: Health education for women following the basic component of focused

antenatal care

Problem-based discussion

- Case Study 3: Counselling for HIV Testing During Antenatal Care

- Case Study 4: Antenatal Assessment and Care- anaemia

Directly observed Practical Skills

- Checklist for obstetric history taking

- Checklist for obstetric examination

- Checklist for birth and emergency preparedness plans

- Checklist for postpartum family planning (postpartum IUD insertion)

- Checklist for demonstrationof breastfeeding

MCQ, MEQ,

OSCE

Obstetric history taking

Obstetric examination

Interpretation of investigations from first and subsequent antenatal visits

Demonstration of breastfeeding

Mini Clinical Evaluation Exercise (Mini CEX)

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10. Procedural Skills Tutorial

10.1 Taking an Obstetric History

Identification

Name, Age

Husband’s name, Husband’s Age

Address, Phone Number

Religion

Current Pregnancy History

The first day of last menstrual period (LMP)

Expected date of delivery (EDD)

Maturity by Dates

Menstrual cycle, Regularity

Vaginal bleeding

Leucorrhea

Nausea and vomiting

Problems in current pregnancy

Use of medications and herbs (jamu)

Gynacological (including Contraceptive History)

Previous contraceptive history

Recent history of contraception before pregnancy

Any surgical procedures

Period(s) of infertility: when? duration? cause?

Previous Obstetric History

Number of pregnancy

Number of delivery, Number of labours at term/ Number of preterm labour

Date (month and year) of outcome of each event (live birth, still birth, miscarriage, abortion,

ectopic, hydatidiform, mole) specify (validate) preterm births and type of abortion if possible.

Number of living children, birth weight, and sex, Infant weight of <2.5 kg or> 4 kg

Presence of problems in previouspregnancy, labour and puerperium:

Mother: Bleeding in previous pregnancy, labour, and puerperium (placenta abruption,

placenta praevia); Presence of hypertension, pre-eclampsia, gestational diabetes in previous

pregnancies; breech or transverse presentation;labour: (spontaneous, induced,

LSCS);delivery: spontaneous, assisted with vacuum, forceps, LSCS;obstructed labour e.g.

shoulder dystocia;PPH, puerperal sepsis;exclusive breast feeding.

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Baby: Malformed or abnormal baby, macrosomic (4500g) newborn, IUGR, resuscitation or

other treatment of newborn;twins; anyperinatal, neonatal or fetal death.

The Obstetric History is usually summarized in a pre-formatted table (Table 2).

Medical History

Heart disease

Hypertension

Diabetes mellitus (DM)

Liver diseases (hepatitis)

Tuberculosis (TB)

Chronic Renal conditions

Thalassemia and other hematological disorders

Asthma

Psychiatric disorders

Epilepsy

Sexually transmitted infections

HIV status if known

History of surgery, operations other than cesarean section

Any regular medication - specify

Allergy to medicines/food

History of trauma/accident

Blood group (if Known)

History of blood transfusion, Rhesus (D) antibodies

Status of tetanus immunization

Use of medications and herbs (jamu).

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Table 2: Summary of Obstetric History

Index Age & Sex

of Child

Pregnancy

(Normal or

complicated)

Duration of

pregnancy

Delivery

(Normal or

complicated)

Postpartum

(Normal or

complicated)

Birth weight Status at

birth

Other issues of

note

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Family History

Hypertension

Diabetes mellitus

Twins

Congenital abnormalities

Socio-economic History

Marital status, number of times married and age of marriage(s)

Occupation and daily activities

Occupation of the spouse

Education

Income (if possible)

Ethnic group

Eating or drinking habits

Smoking habit, use of recreational drugs and alcohol

Options of place for delivery

Maternal and family responses to pregnancy and labour preparedness

Number of family members helping at home

Decision maker in the family

Sexual life, history of casual sex and sexual history of the spouse

Housing: type, size, number of occupants

Sanitary conditions: type of toilet, source of water

Electricity or source of heating and lighting

Cooking facilities

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Table 3: Summary of History to be Completed at First Visit

(based on table in draft pocket book of Maternal Health Care)

Identity Current Pregnancy HistoryName, Age Leucorrhea Husband’s name Nausea and vomiting Address Vaginal bleedingPhone Number Other problems/abnormalities Religion Use of medication, traditional medicine and

herbs

Menstrual History Family HistoryThe first day of last menstrual period Diabetes mellitusMenstrual cycle HypertensionExpected date of delivery Multiple pregnancyMaturity by dates Congenital abnormalitiesContraceptive History Other Medical HistoryPrevious contraceptive history Heart diseaseHistory of contraception before pregnancy Hypertension Previous Obstetric History Diabetes mellitus (DM) Number of pregnancies Liver diseases such as hepatitis Number of deliveries Tuberculosis (TB)Number of labour at term, preterm labor Chronic renal diseaseMode of delivery MalariaNumber of living children, birth weight, and sex

Asthma

Number of miscarriage(s), abortion(s) Epilepsy Bleeding in previous pregnancy, labour, and puerperium

Any regular medication

Presence of hypertension, pre-eclampsiain previous pregnancies

Allergy to medication, food

Other problems in previous pregnancies, labours and puerperium

History of surgery (other than CS)

Breech or transverse presentation Sexually transmitted diseasesDuration of exclusive breast feeding HIV status if knownInfant weight of <2.5 kg or> 4 kg History of blood transfusionIUGR Blood groupTwins History of trauma/accident Perinatal, neonatal, fetal death Status of tetanus immunization

Socio-economic HistoryMarital status, number of times married and age of marriage(s)

Number of family members helping at home

Occupation and daily activities Decision maker in the familyOccupation of the spouse Maternal and family responses to pregnancy

and labor preparednessEducation Options of place for deliveryIncome (if possible) HousingEating or drinking habits Sanitation conditionsEthnic group ElectricitySmoking, use of recreational drugs and alcohol

Cooking facilities

Sexual life, history of casual sex

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10.2 Performing an Obstetric Examination

General physical examination at the first visit:

• General status, appearance, co-operativeor not

• Face: is there palpebral edema or pallor

• Eyes, mouth and dental hygiene, caries, thyroid

• Vital signs: (blood pressure, body temperature, pulse rate, respiratory rate)

• Body weight

• Height

• Mid Upper arm circumference (MUAC)

• Heart, lungs, breast (if there are lumps), nipples, abdomen (surgical scar), spine,

extremities (edema, varicose veins, patellar reflex), as well as cleanliness of the skin.

Measure mid-upper arm circumference (MUAC)

Measure the MUAC just before or just after checking the blood pressure

Use a soft tape-measure, as for symphysis-fundal height

Measure the MUAC at any gestation, or during or after labour

Measurethearmcircumferenceineithertherightorleftarm,midwaybetweenthetipoftheshoulder(acr

omion)and the tip of the elbow (olecranon)

Record the measurement to the nearest 1 mm

The arm should hang freely (elbow extended)

Record the MUAC on the antenatal card

An MUAC ≥33 cm:

Suggests obesity

Is associated with an increased risk of pre-eclampsia and maternal diabetes

Is associated with an increased risk of delivery of a larger than normal infant

Indicates that blood pressure measurement with a normal-sized adult cuff may be an

overestimation

An MUAC<23 cm:

Suggests undernutrition or a chronic wasting illness

Is associated with delivery of a smaller than normal infant

Breast Examination

Visual Inspection of the Breasts

- Help the woman prepare for examination

- Ask the woman to uncover her body from the waist up.

- Have her remain seated with her arms at her sides.

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- Visually inspect the overall appearance of the woman’s breasts, such as contours, skin,

and nipples; note any abnormalities.

Contours are regular with no dimpling or visible lumps.

Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no

lesions, sores, or rashes.

Normal variations:

- Breasts may be larger (and more tender) than usual.

- Veins may be larger and darker, more visible beneath the skin.

- Areolas may be larger and darker than usual, with tiny bumps on them.

Nipples - There is no abnormal nipple discharge.

Nipples are not inverted.

Normal variations:

- Nipples may be larger, darker, and more erectile than usual.

- Colostrum (a clear, yellowish, watery fluid) may leak spontaneously from nipples after 6

weeks’ gestation.

- Place the thumb and fingers on either side of the areola and gently squeeze.

- If the nipple goes in when it is gently squeezed, then it is inverted.

Palpation

Palpation of both breasts with the flat of the hand and then with the fingers while the woman

in the sitting position, and thenwhen she is lying down/supine.

Palpate the axillary and supraclavicular nodeslymph nodes.

Obstetric physical examination at the first visit:

- Shape of abdomen (note any surgical scars)

- Fundal height

Vaginal Examination

- Vulva/perineum to check for presence of varicose veins, condylomata, edema,

hemorrhoids, or other abnormalities.

- Speculum examination to assess cervix, signs of infection, and fluid from the uterine os.

- Vaginal examination to assess: cervix*, uterus*, adnexa*, Bartholin’s, urethral, Skene’s

glands (*when gestational age is <12 weeks). This is usually not carried out in Indonesia.

Obstetric physical examination at each subsequent visit:

- Monitor fetal growth and development by measuring uterine fundal height (Table 4). A chart

should be used to determine uterine height. Figure 1 is an option if a local standard chart is

24

not available.

Palpate abdomen using Leopold’s maneuvers I-IV as shown below:

Leopold I: determining uterine fundal height and fetal parts located in the uterine fundus

(carried out since the early first trimester).

Leopold II: determining position of the fetal back (performed by the end of second trimester).

Leopold III: determining fetal parts located at the bottom ofthe uterus (carried out by the end

of second trimester).

Leopold IV: determining how far fetus enters the pelvis (doneat the end of the second

trimester).

Auscultate fetal heart rate using a fetoscope or Doppler (ifgestational age is > 16 weeks).

Assessment of fetal heart rate with a fetoscope can be started around 20week of gestation.

With the help of ultrasonic Doppler fetal heart beating can be detected between 14 and 20

weeks of gestation.

Assessment of fetal heart with fetoscope (Pinard stethoscope)

The best place to hear the fetal heart is through the fetal back. It is better to assess the fetal

heart beat after determining the fetal lie, position and presentation. If the position of the fetus

seems to be left occipital anterior the wide end of the Pinard stethoscope should be placed at

about half way between the umbilicus and the symphysis pubis and about 5 cm to the left. If

presentation of the fetus is breech, the stethoscope should be placed above the umbilicus.

Position the bell end of the stethoscope over the place on the maternal abdomen under which

the baby's back is felt.

Apply the ear to the flat end. Apply gentle pressure and indent the abdomen nearly a

centimeter, depending on the thickness of the abdominal wall.

Take your hand away from the stethoscope and listen. You are listening for a sound that feels

more like a vibration than a sound, or something similar to watch ticking under a pillow. If you

hear a slow “shooching” noise, feel the maternal pulse at the same time and if it coincides

with the “shooching” you are hearing the uterine vessels.

Normal fetal heart rate is regular, with a range is 120-160 beats per minute.

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Table 4: Estimated uterine fundal height

Gestational age Uterine Fundal Height

By Palpation By Tape Measure

12 weeksPalpable above the pubic symphysis

16 weeksIn between the pubic symphysis and umbilicus

-

20 weeksAt the umbilicus (20 ± 2) cm

22-27 weeks(Gestational age in weeks ± 2) cm

28 weeksin between the umbilicus and the xiphoid process

(28 ± 2) cm

29-35 weeks(Gestational age in weeks ±

2) cm

36 weeks At the xiphoid process (36 ± 2) cm

Adapted from Pocket Book of Maternal Health Care – Final Draft (Department of Obstetrics

and Gynaecology, Faculty of Medicine, University of Indonesia and WHO, Indonesia)

Figure 1: Uterine height values by weeks of gestation

Belizan, J et al –American Journal of Obstetrics and Gynaecology (1978)

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Leopold Maneuvers: I, II, III and iV

11. Teaching and Learning Materials

11.1 Group Discussion

11.1.1 Group Exercise: Use of pregnancy calculator

Divide students into groups.

Give groups examples: “Exercises for Calculating Expected Date of Delivery

(EDD)” of LMP dates.

Give instructions to participants to provide gestation and EDD.

Ask one representative of each group to write the answer on the board.

1. Mrs. A. comes to the antenatal clinic on 3 January. She tells you that her last normal

menstrual period started on 10 October. How many weeks pregnant is she? What is her

EDD?

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2. Mrs. B. comes to the antenatal clinic on 15 May. She tells you that her last normal

menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?

3. Mrs. C. comes to the antenatal clinic on July 11. She tells you that her last normal

menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?

4. Mrs. D. comes to the antenatal clinic on 15 May. She tells you that her last normal

menstrual period started on 1 January. How many weeks pregnant is she? What is her EDD?

5. Mrs. E. comes to the antenatal clinic for first visit on 20 April. She tells you that her last

normal menstrual period started on 10 November. How many weeks pregnant is she? What is

her EDD?

6. Mrs. F. comes to the antenatal clinic for the first time today, 14 June. This is her first

pregnancy. She does not have regular menses and does not remember when she had her

last menses. She does remember that she felt some breast changes and nausea at the

beginning of March and the baby began moving yesterday. On examination you measure her

uterus at 1 cm below the umbilicus and you hear the fetal heart at 156 beats/min.

Approximately how many weeks pregnant is she and when will her date of delivery be?

Answer Key

• Due Date—Calendar Method Add 7 days to the date of the first day of the last normal

menstrual period. Subtract 3 months. (If the first day of the last normal menstrual

period is in January to March, add 9 months)

• Gestation and Due Date—Gestation Wheel MethodCalculate on the gestation/pregnancy

wheel (if available).

1. Mrs. A. comes to the antenatal clinic on 3 January. She tells you that her last normal

menstrual period started on 10 October. What is her EDD?Her gestational age is 12 weeks.

Her EDD is July 16 by wheel and July 17 of the following year (Oct 10 + 7 minus 3 months =

July 17).

2. Mrs. B. comes to the antenatal clinic on 15 May. She tells you that her last normal

menstrual period started on 6 March. What is her EDD?Her gestational age is 10 weeks and

her EDD is December 12 by wheel and December 13 by calculation of same year (March 6 +

7 = March 13 minus 3 months = Dec 13).

3. Mrs. C. comes to the antenatal clinic on July 11. She tells you that her last normal

menstrual period started on 6 March. What is her EDD?Her gestational age is 18 weeks. Her

EDD is December 12 by wheel and December 13 by calculation of same year (March 6 + 7 =

March 13 minus 3 months = Dec 13).

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4. Mrs. D. comes to the antenatal clinic on 15 May. She tells you that her last normal

menstrual period started on 1 January. What is her EDD?Gestational age is approximately

19weeks. Her EDD is October 9 by wheel and October 8 (calculation) of the same year (Jan 1

+ 7 = Jan 8 minus 3 months = Oct. 8).

5. Mrs. E. comes to the antenatal clinic for first visit on 20 April. She tells you that her last

normal menstrual period started on 10 November. What is her gestation? What is her EDD?

Gestationalage=23weeks. Due date is August 16 by wheel and August 17 by calculation

(Nov. 10 + 7 = Nov 17 minus 3 months = Aug. 17).

6. Mrs. F. comes to the antenatal clinic for the first time today, 14 June. This is her first

pregnancy. She does not have regular menses and does not remember when she had her

last menses. She does remember that she felt some breast changes and nausea at the

beginning of March and the baby began moving yesterday. On examination youmeasure her

uterus at 1 cm below the umbilicus and you hear the fetal heart at 156 beats/min.

What is her approximategestational age and when will be her date of delivery?

Her gestational age is approximately 20 weeks. Her due date isapproximately 3 November.

(From Best Practices in Maternal and Newborn Care - A Learning Resource Package for

Essential and Basic Emergency Obstetric and Newborn Care - 2008 (JGPIEGO USAID-

ACCESS)

11.1.2 Discussion: Birth and emergency preparedness plan

Divide into groups of four to discuss birth and emergency preparedness plans displayed in

PowerPoint slide.

Reassemble and discuss answers in large group.

Discuss reasons for having a Birth and Emergency Readiness Plan. What do you

understand by the “Three Delays”?

The Three Delays

Delay in deciding to seek medical care

• Failure to recognize danger signs

• Lack of money to pay for medical expenses and cost of transportation

• Fear of being ill-treated in the health facility

• Reluctance from the mother or the family due to cultural constraints

• The woman or family member present at childbirth lack power to make a decision

• Lack of encouragement from relatives and community members to seek care

• No available person to take care of the children, the home and livestock

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• Lack of a companion in going to the health facility

Delay in identifying and arriving at the health facility

• Distance from a woman’s home to a facility or provider

• Lack of roads or poor condition of roads

• Lack of emergency transportation whether by land or water

• Lack of awareness of existing services

• Lack of community support

• Weak referral system includes transportation and communication

Delay in the provision ofappropriate and adequate care at the health facility

• Lack of healthcare personnel

• Gender insensitivity of healthcare providers

• Shortages of supplies, i.e. emergency medicines or blood

• Lack of equipment for emergency obstetric care (EmOC)

• Lack of competence of health care providers to deliver EmOC

• Administrative delays

(Reference: S Thaddeus and D Maine (1994) “Too Far To Walk: Maternal Mortality in

Context”)

Birth and Emergency Readiness Plan

Assist the woman in developing a birth plan that includes both birth preparedness (all the

arrangements that should be made for a normal birth) and emergency/complication readiness

(an exact plan for what to do if a danger sign arises). The woman’s family, husband, or other

key decision makers in her life should be involved in this process; if she permits, invite them

to join in this discussion. Honour the woman’s choices except when doing so may put her or

her newborn at risk. Also, be sensitive to cultural beliefs or social norms (e.g. superstitions

that urge against buying items for a baby not yet born) that may impede the planning process.

Onthefirstvisit,introducetheconceptofabirthplan(including emergency/complicationreadiness):

Ensurethatthewomanandherfamilyunderstandthattheyshouldaddresseachoftheitemswellbefor

e the estimated date of delivery (EDD). Oneachreturnvisit,reviewandupdatethebirthplan:

What arrangements have been made since the last visit?

Has anything changed?

Have any obstacles or problems been encountered?

By32weeks,finalizethebirthplan.Thewomanandherfamilyshouldhavemadeallofthe

arrangements by now. If needed, provide additional assistance at this time to complete the

plan.

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Components of the Birth and Complication Readiness Plan

(Note: Although this section focuses on what the skilled birth attendant/provider, the woman,

and her family can do to prepare for birth and possible complications, birth

preparedness/complication readiness is actually a community-wide issue. In order for an

individual birth plan to be effective in saving a woman’s life, it must also have support—in the

form of actions, resources, skills, and attitudes—from policymakers, healthcare facilities, and

individual community members.)

Note: Items to be included in the emergency/complication readiness plan, which should be

discussed/reviewed at every encounter/visit with the woman during the entire childbearing

cycle, are indicated with an asterisk (*).

Women are encouraged to have delivery in a health facility (health centre/puskesmas or

district hospital). If she decides to deliver at home, the birth should be attended by a skilled

birth attendant.

Skilled Birth Attendant/Provider

Assist the woman in arranging for a skilled birth attendant/provider to attend the birth; this

person should be trained in supporting normal labour/childbirth and managing complications,

if they arise.

Note: Ensure that the woman knows how to contact the skilled birth attendant/provider or

thehealthcare facility at the appropriate time. The attendant is usually a midwife from the

puskesmas.

Items Needed for Clean and Safe Birth and the Newborn

Make sure the woman has gathered necessary items for a clean and safe birth. Discuss the

importance of keeping items together for easy retrieval when needed.

Items needed for the birthinclude:perinealpads/cloths;soap;cleanbed cloths; placenta

receptacle; clean, unused razor blade; waterproof/plastic cover; clean cord ties.

Items needed for the newborninclude:blankets,diapers/napkins,hat, clothes, etc. that have

been washed and dried in the sun. Ensure that the woman has an appropriate place for the

birth to take place based on her individual needs. For complication readiness, assist the

woman in choosing the appropriate healthcare facility (e.g., district hospital, health centre) to

go to if danger signs arise.

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Note: Items needed depend on the individual requirements of the intended place of birth,

whether in a healthcare facility or in the home.

Transportation*

Ensure that the woman is familiar with local transportation systems and has transportation to

an appropriate place for the birth based on her individual needs.For emergency/complication

readiness, assist the woman in identifying (and choosing) emergency transportation to an

appropriate healthcare facility if danger signs arise.

Funds*

Assist the woman in planning to have funds available when needed to pay for care during

normal birth. For example, putting aside even a small amount on a weekly basis can result in

savings.

For complication readiness, discuss emergency funds that are available through the

community and/or healthcare facility if danger signs arise.

Decision-Making*

Discuss how decisions are made in the woman’s family (who usually makes decisions?), and

decide the following:

- Howdecisionswillbemadewhenlabourbeginsorifdangersignsarise(who is the key decision

maker?)

- Whoelsecanmakedecisionsifthatpersonisnotpresent

Support*

Assist the woman in deciding on/making arrangements for necessary support, including the

following:

- Companionofherchoicetostaywithherduringlaborandchildbirth,and accompany her during

transport if needed

- Someonetocareforherhouseandchildrenduringherabsence

Blood Donor*

Ensure that the woman has identified an appropriate blood donor and that this person will be

available in case of emergency.

Danger Signs* and Signs of Labor

Ensure that the woman knows the danger signs which indicate a need to enact the

emergency/complication readiness plan:

Vaginal bleeding

Breathing difficulty

Fever

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Severe abdominal pain

Severe headache/blurred vision

Convulsions/loss of consciousness

Foul-smellingdischarge/fluidfromvagina

Decreased/absentfetalmovements

Leakingofgreenish/brownish(meconium-stained)fluidfromthevagina

Also ensure that she knows the signs of labour, which indicate a need to contact the skilled

provider and enact the birth preparedness plan:

Regular, progressively painful contractions

Lower back pain radiating from uterus

Bloody show

Rupture of membranes

(Reference: Basic Maternal and Newborn Care: A Guide for Skilled Providers:

JHPIEGO/Maternal and Neonatal Health Program, 2004)

11.2Case-based Learning Case Triggers

Case Study 1: Focused Antenatal Care

Directions

Read and analyze this case study individually. When the others in your group have finished

reading it, answer the case study questions. The other groups in the room are working on the

same or a similar case study. When all groups have finished, we will discuss the case studies

and the answers each group developed.

Client Profile

A 29-year-old pregnant woman called Sara comes to see you. She tells you that this is her

third pregnancy and the last time she had her menstrual period was 25 weeks ago.

Pre-Assessment

1. Before beginning your assessment, what should you do for and ask Sara?

Assessment(Information gathering through history, physical examination and testing)

2. What history will you include in your assessment of Sara, and why?

3. What physical examination will you include in your assessment of Sara, and why?

4. What laboratory tests will you include in your assessment of Sara, and why?

33

Diagnosis (Interpreting information to identify problems/needs)

You have completed your assessment of Sara and your main findings include the following:

History:

• According to Sara’s menstrual history, she is 25 weeks pregnant.

• She came for antenatal care now as she felt well.

• She has noted fetal movements for about a month.

• She is not taking any medication at present.

• Her two previous pregnancies were uneventful and she delivered at the local puskesmas

• All other aspects of her history are normal or without significance.

Physical examination:

Sara has mild conjunctival pallor.

All other aspects of her physical examination are within normal range.

Her blood pressure is 110/70 mm Hg.

Her breast examination is normal.

Sara’s fundal height measurement is 24 weeks, consistent with the EDD.

Fetal heart rate is 136 beats/minute and regular.

Tests: Hemoglobin is 9 g/dL. Other test results: RPR – non-reactive; HIV – negative; blood

type - A, Rh-positive.

5. Based on these findings, what is Sara's diagnosis, and why?

Care Provision (Implementing plan of care and interventions)

6. Based on your diagnosis (problem/need identification), what is your plan of care for

Sara, and why?

Evaluation

Sara comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is

120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 32-

week size. What do these signs suggest and what actions would you take?

Sara says that she would like to space her pregnancy and may consider not to have further

children after this delivery. Previously she has not used a modern method of contraception

but the pregnancies were spaced by breastfeeding.

7. Based on these findings, what is your continuing plan of care for Sara?

Case Study 1: Focused Antenatal Care – Answer Key

34

Directions

As all groups have finished, we will discuss the case studies and the answers each group

developed.

Client Profile

A 29-year-old pregnant woman called Sara comes to see you. She tells you that this is her

third pregnancy and the last time she had her menstrual period was 25 weeks ago.

Pre-Assessment

1. Before beginning your assessment, what should you do for and ask Sara?

Sara should be greeted respectfully and with kindness and offered a seat to help her feel

comfortable and welcome, establish rapport and build trust. A good relationship helps to

ensure that the client will adhere to the care plan and return for continued care.

You should confirm (through written records and/or verbal communication) with the clinic staff

member who received Sara when she first arrived at the clinic that she has undergone a

Quick Check. If she has not, you should conduct a Quick Check of her vital signs now to

detect signs/symptoms of life-threatening complications that need immediate/emergency

care.

Assessment (Information gathering through history, physical examination and testing)

2. What history will you include in your assessment of Sara, and why?



As Sara is already 25 weeks pregnant, you should cover all the services of the first and the

second FANC visits. As this is her first visit, you should take a complete history (calculate the

EDD) to guide further assessment and help individualize care provision.

Give close attention to investigating her medical, obstetric, menstrual, medical,family

andsocial history.When asking about medications, it will be important to know whether Sara is

taking iron tablets.


Perform a complete physical examination, including a general examination, blood pressure,

pulse, temperature, respiration rate, breast examination, mid-upper arm circumference,

abdominalexamination to measure fundal height, check for presentation and lie of the fetus

and listen to the fetal heart sound.

35

The purpose is to determine Sara’s eligibility to follow the basic component of FANC. Also

advise her on nutrition, hygiene and rest.


Sara will have routine investigations (as mentioned under Tests).

5. Based on these findings, what is Sara's diagnosis, and why?

Sara is eligible to follow the Basic Component of FANC. However, her two children are 3

years and 18 months respectively.



Sara, and why?

Discuss birth and emergency preparedness (birth preparedness, complication readiness and

emergency planning) with her. As she has breast fed her babies in the previous pregnancies,

reinforce her breast feeding practices.

If she is healthy and the pregnancy appears to be progressing normally, tell her that the next

visit should be at 30-32 weeks of pregnancy - but she must seek help at once if she

experiences any of the danger symptoms such as bleeding or foul smelling discharge from

her vagina, fever, blurred vision, or feeling dizzy and confused.

Pale conjunctiva suggests that Sara may be anaemic, so ask her about her nutrition - what

does she eat and how much food does she get each day? Perform a multiple dipstick test on

a sample of her urine to see if it contains excess sugar or protein. If her urine test is normal,

counsel her on improving her nutrition and provide her with iron and folate tablets.Give

injection tetanus toxoid.

Evaluation

Sara comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is

120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 32

weeks size. What do these signs suggest and what actions would you take?

Sara says that she would like to space her pregnancy and may consider not to have further

children after this delivery. Previously she has not used a modern method of contraception

but the pregnancies were spaced by breast feeding.

7. Based on these findings, what is your continuing plan of care for Sara?

36

As the fundal height is equal to dates at 32 weeks, she can be reassured that her pregnancy

is continuing well. Discuss with her and her family about the birth plan.Reinforce information

on the normal (physiological) changes in puerperium, breast feeding the baby and post-

partum family planning.

Counsel on the importance of family planning

• If appropriate, ask Sara if she would like her husband or another family member to be

included in the counselling session.

• Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become

pregnant as soon as four weeks after delivery. Therefore it is important to start

thinking early on about what family planning method they will use.

• She mentioned that she might not want more children. As her two previous children had an

18 month birth interval, inform her that waiting at least 2 years before trying to

become pregnant again is good for the mother and for the baby's health.

• Information on when to start a method after delivery will vary depending whether a woman

is breastfeeding or not.(see the Decision-making tool for family planning providers

and clients for information on methods and on the counselling process).

Method options for the breastfeeding woman

Can be used immediately postpartum

Lactational amenorrhoea method (LAM)

Condoms

Spermicide

Female sterilization (within 7 days or delay 6 weeks)

Copper IUD (within 48 hours or delay 4 weeks)

Delay 6 weeks

Progestogen-only oral contraceptives: Progestogen-only injectables, Implants

Diaphragm

Delay 6 months

Combined oral contraceptives

Combined injectables

Fertility awareness methods

Counsel Sara on safer sex including use of condoms for dual protection from sexually

transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or

HIV.G4

If Sara and her husband chooses female sterilization: it can be performed immediately

37

postpartum if no sign of infection(ideally within 7 days, or delay for 6 weeks). Plan for delivery

in hospital or health centre where they are trained to carry out the procedure. Ensure

counselling and informed consent prior to labour and delivery.

If Sara chooses to use a temporary, long-term method, e.g. an intrauterine device (IUD): it

can be inserted immediately postpartum if no sign of infection (up to 48 hours, or delay 4

weeks) plan for delivery in hospital or health centre where they are trained to insert the IUD.

(Reference: Pregnancy, Childbirth, Postpartum and Newborn Care, WHO, 2006,

Decision-making tool for family planning providers and clients, WHO and JHPIEGO, 2007)

Case Study 2: Health education for women following the basic component of Focused

Antenatal Care

Trigger

Nina, a 20 year-old married woman in her first pregnancy comes for her first antenatal visit at

16 weeks. She is found to be eligible to follow the basic component of focused antenatal care

(FANC). What health education will you give her?

Answer

Health education to Nina, her husband and her family will include:

- Healthy lifestyles

- Healthy diet

- Support and care in the home (including adherence to advice on prophylactic

treatments such as iron supplementation, and use of insecticide-treated bednets)

- Preparation for parenthood

- Exercises to prepare the woman for the process of birth.

- Maternal and neonatal health needs and self-care during pregnancy and the

postnatal period, including the need for social support during and after pregnancy;

- Prepare emotionally and physically the pregnant woman and her partner and, where

required, supporters for birth

- Support care-seeking behaviour, including recognition of danger signs for the woman

and the newborn;

- Birth and emergency preparedness plans

- Promote postpartum family planning/birth spacing

Trigger

Nina and her husband want to know more about diet in pregnancy. They belong to the middle-

income group and they do not have any food taboos. How will you advise them?

38

Answer

Nutritional Support

Based on Nina’s dietary history, the resources available to her and her family, and any other

relevant findings or discussion, individualize the following key nutrition messages.

Nina (and all women) should:

Eatabalanceddietconsistingofbeansandnuts,starchyfoods(e.g.rice,potatoes,cassava,maize),

animal products (fish,eggs,meat, milk, yogurt), and fruits and vegetables.

Eata variety of foods each day, including foods rich in:

Iron:redmeat,liver,eggs,peanuts,lentils,darkgreenleafyvegetables,andshellfish.Substancesthat

inhibit iron absorption, such as coffee or tea should be avoided or taken 2 hours after meals.

Vitamin A: liver, milk products, eggs, sweet potatoes, pumpkin, carrots, and papaya.

Calcium: milk,darkgreenleafyvegetables,shrimp,driedfish,beans,lentils, and oil seeds.

Magnesium:cereal,darkgreenleafyvegetables,seafood,nuts,legumes,andgroundnuts.

VitaminC:orangesorothercitrusfruits,tomatoes,andpotatoes. Pregnant women should also

eatatleastoneadditionalservingofstaplefoodper day

andeatsmaller,morefrequentmealsifunabletoconsumelargeramountsinfewermeals. She should

takemicronutrientsupplementsasdirected.

11.3 Problem-based Learning Case Triggers

Case Study 1: Counselling for HIV Testing During Antenatal Care

Trigger

Marina, a 24 year-old married woman in her first pregnancy comes for her first antenatal visit

at 14 weeks. She has recently moved to this area.

What points will you focus on when taking her history?

While obtaining an obstetric history, Marina mentions that she has lived in another part of

Indonesia and that her husband is a long-distance truck driver. You realize that Marina

resided in an area where STI and HIV prevalence is above the national prevalence and that

her husband’s occupation could have exposed him to casual sex.

Based on her history, what will be included in your interventions/supporting tests?

39

You will offer HIV testing and counselling services and explain about HIV testing:

What is HIV and how it affects the mother and baby

How the test is performed.

How confidentiality is maintained.

Emphasize non-discrimination

When and how results are given (A Rapid test is usually performed and she should

get the results while she is in the clinic)

Support and treatment will be offered if test results are positive

Ask her if she has any questions or concerns.

You will also offer syphilis testing and counseling:

What is syphilis and how it affects the mother and baby

How the test is performed.

How confidentiality is maintained.

When and how results are given (A Rapid test is usually performed and she should

get the results while she is in the clinic)

Support and treatment will be offered if test results are positive

Ask her if she has any questions or concerns.

Perform a speculum examination to check for cervicitis (gonococcal or chlamydial)

Outcome: Marina comes back with the test results which are both negative

The speculum examination is also normal.

Counsel on implications of the HIV test result

Discuss the HIV results with her alone (or with the person of her choice). State test results in

a neutral tone and in a non-judgemental, non-discriminatory manner. Give her time to express

any emotions.

As the Test Result Is Negative:

Explain to Marina that a negative result can mean either that she is not infected with HIV or

that she is infected with HIV but has not yet made antibodies against the virus (this is

sometimes called the “window” period).

Counsel on the importance of staying negative by safer sex including use of condoms.

Counsel on implications of the syphilis test result

Counsel on the importance of staying negative by safer sex including use of condoms.

If Marina had refused to be tested, you will call her back and counsel her in a week’s time.

If Marina had tested positive for syphilis or HIV, refer her to the district level

Explain that:

For HIV

40

Another HIV test will be performed to confirm/refute the results of the Rapid Test and a nurse

will accompany her to the district hospital.A positive test result means that it is likely she is

carrying the infection and has the possibility of transmitting the infection to her unborn child

without any intervention.

Let her talk about her feelings. Respond to her immediate concerns.

Inform her that she will need further assessment to determine the severity of the

infection,appropriate care and treatment needed for herself and her baby. Treatment will slow

down theprogression of her HIV infection and will reduce the risk of infection to the baby.

Provide information on how to prevent HIV re-infection. Inform her that support and

counselling is available if needed, to cope on living with HIV infection. Discuss disclosure and

partner testing. Ask Marina if she wants additional information.

For Syphilis

If RPR or VDRL is reactive, refer her to the district hospital where TPHA will be carried out. A

positive test result means that it is likely she is carrying the infection and has the possibility of

transmitting the infection to her unborn child without any intervention.

Tell Marina that another test will be performed and a nurse will accompany her to the district

hospital for this test.

Let her talk about her feelings. Respond to her immediate concerns.

Inform her that she will need treatment needed for herself and her baby. If positive, she will be

treated with Benzathine penicillin. Inform her that support and counselling is available if

needed. Discuss disclosure and partner testing. Ask Marina if she wants additional

information.

Case Study 2: Antenatal Assessment and Care(Anaemia)

Directions

Read and analyze this case study individually. When the others in your group have finished

reading it, answer the case study questions. The other groups in the room are working on the

same or a similar case study. When all groups have finished, we will discuss the case studies

and the answers each group developed.

Client Profile

Mrs. B., a 26-year-old gravida 3/para 2, presents for her first antenatal clinic visit. Her children

are 18 months and 8 months of age. Both are well. She and her family live in a rural village

that is in a malaria-endemic area. You note that Mrs. B. looks pale and tired.

Pre-Assessment

1. Before beginning your assessment, what should you do for and ask Mrs. B.?

41

Assessment (Information gathering through history, physical examination and testing)

2. What history will you include in your assessment of Mrs. B., and why?

3. What physical examination will you include in your assessment of Mrs. B., and why?

4. What laboratory tests will you include in your assessment of Mrs. B., and why?


You have completed your assessment of Mrs. B. and your main findings include the following:

History:

• According to Mrs. B.’s menstrual history, she is 28 weeks pregnant.

• She admits to feeling weak, tired and dizzy.

• She reports that she has been treated for malaria twice in the past 12 months; the most

recent episode was 4 months ago, during which she was treated with antimalarial drugs.

She denies any symptoms of malaria now.

• She reports that she had no signs or symptoms of anemia during her previous

pregnancies.

• She is not taking any medication at present.

• She and her family have an adequate food supply at present, but Mrs. B.’s appetite has

been poor lately. She does not have any food taboos.

• Mrs. B.’s mother-in-law provides some help with childcare and housework.

• All other aspects of her history are normal or without significance.


Mrs. B. has mild conjunctival pallor.

All other aspects of her physical examination are within normal range.

Her blood pressure is 100/70 mm Hg, and her temperature is 37.6°C. (Although

temperature is not a routine part of antenatal care, because she comes from a

malarious area, this is part of the assessment.)

Her breast exam is normal.

Mrs. B’s fundal height measurement is 28 weeks, consistent with the EDD.

Fetal heart rate is 136 beats/minute and regular.

The vaginal examination is normal.

Testing: Hemoglobin is 9 g/dL Other test results: RPR – non-reactive; HIV – negative; blood

type - O, Rh-positive.

5. Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?


42


Mrs. B., and why?

Evaluation

Mrs. B. comes back to the antenatal clinic on the appointed date, and on assessment your

findings are as follows:

She has taken her iron/folate tablets as directed, even though she has had mild

constipation.

She has been able to rest more because her mother-in-law has provided more help than

usual. She also reports that her appetite has improved.

She appears less tired and is not as pale, generally, as she was at her first antenatal visit.

She says that she “feels much better.”

On physical examination, you find that she still has mild conjunctival pallor.

She does not have a fever.

The fetal heart rate is normal, and Mrs. B. says that the fetus is active.

Mrs. B.’s hemoglobin is now 10 g/dL. It was also measured at the last visit.

7. Based on these findings, what is your continuing plan of care for Mrs. B.?

Case Study 4: Antenatal Assessment and Care (Anemia)— Answer Key

Directions

As all groups have finished, we will discuss the case studies and the answers each group

developed.

Client Profile

Mrs. B., a 26-year-old gravida 3 para 2, presents for her first antenatal clinic visit. Her children

are 18 months and 8 months of age. Both are well. She and her family live in a rural village

that is in a malaria-endemic area. You note that Mrs. B. looks pale and tired.

Pre-Assessment

1. Before beginning your assessment, what should you do for and ask Mrs. B.?

Mrs. B. should be greeted respectfully and with kindness and offered a seat to help her feel

comfortable and welcome, establish rapport and build trust. A good relationship helps

to ensure that the client will adhere to the care plan and return for continued care.

You should confirm (through written records and/or verbal communication) with the clinic

staff member who received Mrs. B. when she first arrived at the clinic that she has

undergone a Quick Check. If she has not, you should conduct a Quick Check now to

detect signs/symptoms of life-threatening complications that need

immediate/emergency care.

43

Assessment (Information gathering through history, physical examination, and testing)

2. What history will you include in your assessment of Mrs. B., and why?

As this is her first visit, you should take a complete history (including calculating the EDD) to

guide further assessment and help individualize care provision. Some responses may point

toward the underlying reason for her pale/tired appearance, or may indicate a special need or

life-threatening complication that requires special care and/or immediate attention.

Ask Mrs. B. if she is experiencing weakness, tiredness, dizziness, breathlessness or fainting

to help determine severity of anemia; ask about fever, chills/rigor, headache or muscle/joint

ache to ascertain whether she may currently have malaria.

When asking about contraceptive history/plans: As Mrs. B. has had three pregnancies in 3

years, it will be important to determine whether she has ever used a modern method of

contraception and what her plans are about doing so in the future. Pregnancies that are

closer together than 3 years increase the risk of maternal and newborn complications.

When asking about medical history and obstetric history:

It will be important to know whether Mrs. B. has been treated for anemia and/or malaria,

during or since her last pregnancy and, if so, how her condition was treated. Living in a

malaria-endemic area and/or episodes of malaria in pregnancy may lead to anemia (even

uncomplicated malaria can lead to anemia), and while the malaria may have been treated, the

associated anemia may not have been.

It will also be important to determine whether Mrs. B. was anemic during her previous

pregnancies and, if so, how her condition was managed. If she does not know whether she

was anemic during her previous pregnancies, she should be asked whether she had

symptoms of anemia (e.g., tiredness, breathlessness).

Ask whether she had fever/infection during previous pregnancies/childbirths or postpartum

hemorrhage, and whether her previous babies were preterm or of low birth weight, as these

factors can also be associated with anemia in pregnancy.

When asking about medications, it will be important to know whether Mrs. B. is taking iron

tablets and, if so, how often and for how long she has been taking them. Pregnant women

require increased iron intake to prevent anemia and for their bodies to use in forming fetal red

blood cells. If she has been taking an adequate dose of iron supplementation, it is less likely

that her anemia is caused by dietary deficiency.

44

When asking about daily habits and lifestyle: Mrs. B should be asked about her social

situation, in particular to determine whether she has anyone to help with child care, cooking,

cleaning, etc., and whether she has access to nutritious foods, especially those rich in iron. A

poor diet, especially one that lacks iron-rich foods, could lead to anemia, and a heavy

workload could increase an already high level of fatigue.

3. What physical examination will you include in your assessment of Mrs. B., and why?

As this is her first visit, you should perform a complete physical examination (i.e., well- being,

blood pressure, conjunctiva, breasts, abdomen [fundal height, lie and presentation after 36

weeks, fetal heart rate after 20 weeks], and genital examination) to guide further assessment

and help individualize care provision. Some findings may point toward the underlying reason

for her pale/tired appearance, or may indicate a special need/condition that requires

additional care or a life-threatening complication that requires immediate attention.

Mrs. B. should be checked carefully for conjunctival pallor, abnormal respiratory rate, rapid

pulse, and breathlessness. Conjunctival pallor is a sign of anemia. When it is accompanied by

a respiratory rate of 30 or more or breathlessness at rest, severe anemia should be

suspected.

Mrs. B. should be checked for fever, which might indicate current malaria infection.

It will also be important to determine whether fetal growth is consistent with EDD, because

anemia in pregnancy is associated with low birth weight.

4. What laboratory tests will you include in your assessment of Mrs. B., and why?

As this is her first visit, you should conduct all routine laboratory tests if available (i.e., RPR

for syphilis, HIV [if she does not “opt out”], blood group, hemoglobin, and tests for other

conditions if applicable to guide further assessment and help individualize care provision.

Some findings may point toward the underlying reason for her pale/tiredappearance, or may

indicate a special need/condition that requires additional care or a life- threatening

complication that requires immediate attention.


You have completed your assessment of Mrs. B., and your main findings include the

following:

History:

According to Mrs. B.’s menstrual history, she is 28 weeks pregnant.

She admits to feeling weak, tired and dizzy.

She reports that she has been treated for malaria twice in the past 12 months; the most

45

recent episode was 4 months ago, during which she was treated with antimalarial drugs.

She denies any symptoms of malaria now.

She reports that she had no signs or symptoms of anemia during her previous pregnancies.

She is not taking any medication at present.

She and her family have an adequate food supply at present, but Mrs. B.’s appetite has been

poor lately.

Mrs. B.’s mother-in-law provides some help with childcare and housework.

All other aspects of her history are normal or without significance.


Mrs. B has mild conjunctival pallor.

All other aspects of her physical examination are within normal range: Her blood pressure is

100/70 mm Hg, and her temperature is 37.6°C. (Although temperature is not a routine part of

antenatal care, because she comes from a malarious area, this is part of the assessment.)

Her breast examination is normal. Mrs. B.’s fundal height measurement is 28 weeks,

consistent with the EDD. Fetal heart rate is 136 beats/minute and regular. The vaginal

examination is normal.

Testing: Hemoglobin is 9 g/dL.Other test results: RPR – non-reactive; HIV – negative; blood

type - O, Rh-positive.

Based on these findings, what is Mrs. B.’s diagnosis (problem/need), and why?

Mrs. B, has a “special need”: She has signs/symptoms consistent with mild to moderate

anemia. Hemoglobin test confirms that Mrs. B. has mild/moderate anemia.

Mrs. B.’s anemia is likely to be associated with the episode of malaria she had earlier in her

pregnancy. Women who live in malaria-endemic areas or who have malaria during pregnancy

are particularly prone to anemia; however, Mrs. B. was not started on iron at the time of her

most recent episode of malaria.

Mrs. B.’s anemia is not likely chronic because she reports that she has an adequate food

supply and that she was not anemic during her previous pregnancies.

The fetus appears to be growing at a rate consistent with EDD.

Otherwise, Mrs. B. is healthy and her pregnancy is progressing normally.



Mrs. B., and why?

Mrs. B. should receive basic care provision (i.e., nutritional support, birth planning, additional

46

health messages and counseling on self-care and other healthy behaviors [e.g.,

hygiene/prevention of infection, sexual relations and safer sex, rest and activity, use of

potentially harmful substances], immunizations and other preventive measures), which will

help support and maintain her normal pregnancy, and ensure a healthy labour/childbirth and

postpartum/newborn period.

Iron/folate supplementation and related counseling are especially important:

Mrs. B. should be given iron/folate, 1 tablet 2 times daily. Taking iron/folate on a regular basis

for the remainder of her pregnancy (and for three months postpartum) should rectify Mrs. B.’s

anemia.

She should be advised to take the iron/folate with meals, at the same time each day, or at

night, with water or fruit juice. Iron/folate should not be taken with tea, coffee or cola as these

interfere with its absorption.

Some women experience constipation when taking iron tablets, so side effects such as

constipation and nausea should be discussed. Mrs. B. should be encouraged to continue

taking the iron/folate if these symptoms occur. Adding more fruits and vegetables to the diet

and drinking more water can help avoid constipation.

A sufficient supply of iron/folate should be dispensed to last until her next antenatal visit.

Mrs. B. should be also counseled about protective measures against malaria, such as

sleeping under a long-lasting insecticide-treated bed net and wearing protective clothing.

In counseling about rest and activity: It is especially important to encourage Mrs. B. to rest

when possible and lighten her workload. Again, a heavy workload and not enough rest could

increase an already high level of fatigue.

In counseling about nutrition: The importance of eating foods that are rich in iron, as well as

foods rich in vitamin C (because vitamin C helps iron to be absorbed), should be emphasized.

Foods rich in iron include lean meat, liver, dried beans, peas, lentils, egg yolks, fish, nuts and

raisins. Foods rich in Vitamin C include citrus fruits (lemons, limes, oranges and grapefruits),

tomatoes, cabbage, potatoes, cassava leaves, peppers and yams. A diet that lacks iron- rich

foods could lead to anemia or worsen existing anemia.

In family planning counseling: Child spacing and family planning methods should be

discussed to encourage Mrs. B. to think about child spacing for the future. Evidence shows

that outcomes for mothers and babies improve if pregnancies are spaced at least 3 years

apart and that the risk of maternal anemia, infection and hemorrhage is decreased.

47

In scheduling a return visit: Mrs. B. should be asked to return for a follow-up visit in one

month, but told that she can return to the clinic any time before then, if she has any concerns.

Because Mrs. B. needs to be monitored closely until her anemia has resolved, the minimum

of four ANC visits are not sufficient in her case.

Evaluation Mrs. B. comes back to the antenatal clinic on the appointed date, and on

assessment your findings are as follows:

She has taken her iron/folate tablets as directed, even though she has had mild constipation.

She has been able to rest more because her mother-in-law has provided more help than

usual. She also reports that her appetite has improved.

She appears less tired and is not as pale, generally, as she was at her first antenatal visit.

She says that she "feels much better."

On physical examination, you find that she still has mild conjunctival pallor.

She does not have a fever.

The fetal heart rate is normal, and Mrs. B says that the fetus is active.

Mrs. B.’s hemoglobin is now 10 g/dL. It was also measured at the last visit.

7. Based on these findings, what is your continuing plan of care for Mrs. B.?

Mrs. B. should be counseled about continuing to take iron/folate. A sufficient supply of

iron/folate tablets should be dispensed to last until her next antenatal visit. She should be

encouraged to add more vegetables, fruits and fluids to her diet, to help lessen her

constipation. She should be encouraged to continue to eat iron-rich and vitamin C-rich foods,

and to rest as much as possible.

Mrs. B. should continue to be monitored closely until her hemoglobin is 11 g/dL; she should

be asked to return for a follow-up visit in 2 weeks, but told that she can return to the clinic any

time before then, if she has danger signs, cannot comply with instructions, or has any

concerns.

Mrs. B. should continue to sleep under long-lasting insecticidal nets.

When Mrs. B.’s hemoglobin reaches 11 g/dL, providing there are no other danger signs or

concerns, she can resume the normal schedule of antenatal visits.

(Reference: Best Practices in Maternal and Newborn Care: Learning Resource Package:

Prevention and Management of Malaria and Other Causes of Fever in Pregnancy)

11.4Knowledge Assessment

48

11.4.1Knowledge Assessment on Focused Antenatal Care:

Instructions: Which of the following statements is false? In each case, explain what is

incorrect.

1. Focused antenatal care focuses on the pregnant woman alone.

2. Women in the basic component receive only 4 FANC visits, unless warning signs or

symptoms are detected at any stage.

3. Pregnant women do not need to prepare any equipment for labour and delivery.

4. The birth plan in FANC is essentially the same for every woman and she is told about it at

the fourth visit.

5. Prophylaxis in FANC focuses on prevention of sexually transmitted infections, including

mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia and tetanus.

Answer Key

1 is false. Focused antenatal care does not focus on the pregnant woman alone (this used to

happen in the traditional approach). FANC includes the woman’s partner and if possible the

whole family in caring for her during pregnancy, watching for danger symptoms, and

preparing for the birth, complication readiness and emergency planning.

2 is true. Women in the basic component receive only 4 FANC visits, unless warning signs or

symptoms are detected at any stage.

3 is false. A pregnant woman should prepare for labour and delivery by assembling very clean

cloths, a new razor blade, very clean new string, soap and a scrubbing brush, clean water for

washing and drinking, buckets and bowls, supplies for making drinks, and a flashlight.

4 is false. The birth plan in FANC is individualised for every woman and her partner and

respects her wishes and preferences. It is discussed at the third visit and revised if necessary

at the fourth visit.

5 is true. Prophylaxis in FANC focuses on prevention of sexually transmitted infections,

including mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia,

urinary tract infections and tetanus.

11.4.2 Knowledge Assessment:

Prevention and Management of Malaria and Other Causes of Fever In Pregnancy

Instructions: Write the letter of the single best answer to each question in the blank next to

the corresponding number on the attached answer sheet.

1. Malaria affects:

a. Nearly as many people as TB and HIV combined

b. Twice as many people as TB, HIV, leprosy and measles combined

c. Five times as many people as TB, HIV, leprosy and measles combined

2. In malaria-endemic areas, malaria during pregnancy may account for:

49

a. Up to 15% of maternal anemia

b. 5–14% of low birth weight

c. 30% of “preventable” low birth weight (LBW)

d. a) and b)

e. All of the above

3. Malaria prevention and control in pregnancy includes:

a. Focused antenatal care and health education

b. Intermittent preventive treatment (IPT)

c. Insecticide-treated nets (ITNs)

d. a) and c)

e. All of the above


incorrect.

4. Malaria is less severe in women during their first or second pregnancies than it is in

subsequent pregnancies.

5. In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.

6. Women who are HIV positive have increased resistance to malaria.

7. IPT should not be used during the first 16 weeks of pregnancy.

8. Quinine is the drug of choice for the treatment of complicated malaria.


Prevention and Management of Malaria and Other Causes of Fever In Pregnancy

—Answer Key



1. Malaria affects

a. Nearly as many people as TB and HIV combined

b. Twice as many people as TB, HIV, leprosy and measles combined

c. Five times as many people as TB, HIV, leprosy and measles combined

2. In malaria-endemic areas, malaria during pregnancy may account for:

a. Up to 15% of maternal anemia

b. 5–14% of low birth weight

c. 30% of “preventable” low birth weight (LBW)

d. a) and b)

e. All of the above

50

3. Malaria prevention and control in pregnancy includes:

a. Focused antenatal care and health education

b. Intermittent preventive treatment (IPT)

c. Long-lasting insecticide-treated nets

d. a) and c)

e. All of the above

Instructions:

Which of the following statements is false? In each case, explain what is incorrect.

4. Malaria is less severe in women during their first or second pregnancies thanit is in

subsequent pregnancies.

5. In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.

6. Women who are HIV + have increased resistance to malaria.

7. IPT should not be used during the first 16 weeks of pregnancy.

8. Quinine is the drug of choice for the treatment of complicated malaria.

4 is False

5 is False

6 is False

7 is True

8 is True

11.4.3Knowledge Assessment:

Preventing Mother-To-Child Transmission of HIV



1. A key risk factor for mother-to-child transmission of HIV is:

a. High viral load of the mother

b. Advanced age of the mother

c. Parity of the mother

2. Some intrapartum interventions to reduce the risk of MTCT include:

a. Using good infection prevention measures

b. Avoiding artificial rupture of membranes and unnecessary trauma

c. Avoiding prolonged rupture of membranes

d. a) and b)

e. All of the above


51

incorrect.

3.Counseling to prevent acquiring HIV is important for HIV-negative women but not for HIV-

positive women.

4. ARVs should be provided during pregnancy for the health of the baby but not for the

mother.

5. There is no evidence of increased MTCT from vaginal rather than C-section delivery if

appropriate ARVs are used and the viral load is controlled.

6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.

7. For HIV survival, all women for whom replacement feeding is not acceptable, feasible,

affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed

their infant for 6 months.

Knowledge Assessment: Preventing Mother-To-Child Transmission of HIV—Answer

Key



1. A key risk factor for mother-to-child transmission of HIV is:

a. High viral load of the mother

b. Advanced age of the mother

c. Parity of the mother

2. Some intrapartum interventions to reduce the risk of MTCT include:

a. Using good infection prevention measures

b. Avoiding artificial rupture of membranes and unnecessary trauma

c. Avoiding prolonged rupture of membranes

d. a) and b)

e. All of the above


incorrect.

3. Counseling to prevent acquiring HIV is important for HIV-negative womenbut not for HIV-

positive women.

4. ARVs should be provided during pregnancy for the health of the baby but not for the

mother.

5. There is no evidence of increased MTCT from vaginal rather than C-section delivery if

appropriate ARVs are used and the viral load is controlled.

6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.

7. For HIV survival, all women for whom replacement feeding is not acceptable, feasible,

affordable, sustainable and safe (AFASS) should beencouraged to exclusively breastfeed

52

their infant for 6 months.

4. The answer is False

5. The answer is True




Postpartum family planning



1. Appropriate timing for postpartum family planning counseling includes:

a) 6 weeks postpartum

b) Immediate postpartum

c) Antenatal

a) and b)

All of the above

2. The criteria for LAM are:

a) Fully or nearly fully breastfeeding, less than 4 months postpartum, menses have not

returned, and baby still feeds at least once during the night

b) Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses have not

returned

c) Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have not

returned

3. IUDs can be inserted:

a) Within 24 hours and after 6 weeks postpartum

b) Within 24 hours and after 4 weeks postpartum

c) Within 48 hours and after 4 weeks postpartum

d) Post-placental only (within 10 minutes of delivery) and after 6 weeks postpartum

4. IUD use:

a) Is associated with infertility

b) Increases risk of PID

c) is contraindicated in any woman who is HIV+

d) None of the above

e) All of the above

53

Instructions: In the space provided, print a capital T if the statement is true or a capital F if

the statement is false.

6. The breastfeeding woman can begin oral progestin-only pills at 6 weeks after delivery.___

7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks

postpartum.______

8. IUDs and hormonal contraception may increase the risk of acquisition of HIV.

9. LAM provides 98% protection from pregnancy. _____

10. Fertility awareness methods (such as Standard Days Method) can be started at 6 weeks postpartum for both breastfeeding and non-breastfeeding women. _____

11. Vasectomy is not effective immediately, so the use of a backup contraceptive method for 1 month after the procedure is recommended. _____

12. IUDs are the most cost-effective reversible method if used for 2 years or more.____

Knowledge Assessment: Postpartum family planning – Answer Key

1. Appropriate timing for postpartum family planning counseling includes:

a. 6 weeks postpartum

b. Immediate postpartum

c. Antenatal

d. a) and b)

e. All of the above

2.The criteria for LAM are:

a. Fully or nearly fully breastfeeding, less than 4 months postpartum, menses have not

returned, and baby still feeds at least once during the night

b. Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses

havenot returned

c. Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have

not returned

3. IUDs can be inserted:

a. Within 24 hours and after 6 weeks postpartum

b. Within 24 hours and after 4 weeks postpartum

c. Within 48 hours and after 4 weeks postpartum

d. Post-placental only (within 10 minutes of delivery) and after 6 weeks postpartum

4. IUD use:

a. Is associated with infertility

b. Increases risk of PID

54

c. Is contraindicated in any woman who is HIV+

d. None of the above

e. All of the above

Instructions: In the space provided, print a capital T if the statement is true or a capital F if

the statement is false.

6. The breastfeeding woman can begin oral progestin-only pills at 6 weeks after delivery.

True

7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks

postpartum. True

8. IUDs and hormonal contraception may increase the risk of acquisition of HIV. False

9. LAM provides 98% protection from pregnancy. True

10. Fertility awareness methods (such as Standard Days Method) can be started at 6 weeks postpartum for both breastfeeding and non-breastfeeding women. False

11. Vasectomy is not effective immediately, so the use of a backup contraceptive method for 1 month after the procedure is recommended. True

12. IUDs are the most cost-effective reversible method if used for 2 years or more.True

(Reference: Best Practices in Maternal and Newborn Care Learning Resource Package

JHPIEGO)

55

11.5 Checklists

11.5.1 Checklist for Focused Antenatal care

First Visit

Antenatal Assessment (History, Physical Examination, Testing) and Care

(To be used by the Facilitator/Teacher at the end of the module)

Rate the performance of each step or task observed using the following rating scale:

1 Needs Improvement: Step or task not performed correctly, performed out of sequence (if

sequence necessary), or omitted

2 Competently Performed: Step or task performed correctly and in proper sequence (if

sequence necessary), but learner does not progress from step to step efficiently

3 Proficiently Performed: Step or task performed correctly, in proper sequence (if sequence

necessary), and efficiently

Learner------------------------------------------------- Date Observed----------------

Antenatal Assessment – First Visit

(History, Physical Examination, Testing) and Care.

Some of the following steps/tasks should be performed simultaneously

Step/Task Cases

Getting Ready

1. Prepare the necessary equipment.

2. Greet the woman respectfully and with kindness and introduce

yourself.

3. Offer the woman a seat.

4. Tell the woman what is going to be done, listen to her and

encourage her to ask questions.

5. Provide reassurance and emotional support as needed.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

History

1. Ask the woman how she is feeling and respond immediately to

any urgent problem(s).

2. Ask the woman her name and age

56

3. Ask the woman number of previous pregnancies and

breastfeeding (number of children, mode of delivery)

4. Ask the woman menstrual history including LMP and

contraceptive history.

5. Calculate the EDD and gestational age.

6. Ask the woman whether she has felt fetal movements within the

last day (if visit is after 16 weeks).

7. Ask the woman about medical conditions, medications and

hospitalizations, including HIV status if known.

8. Ask woman about daily habits, lifestyle, social support and

traditional beliefs and customs.

9. Ask the woman about tetanus immunization.

10. Ask the woman if she is using treated bed nets at all times (in

malarious areas).

11.

Askthewomanaboutotherproblemsorconcernsrelatedtoherpregnancy.

12. Record all pertinent information on the woman’s record/antenatal

card.


Physical Examination

1. Ask the woman to empty her bladder and save and test the urine.

2. Observe the woman’s general appearance.

3. Help the woman on to the examination table and place a pillow

under her head and upper shoulders.

4. Wash hands thoroughly with soap and water and dry them.

5. Explain each step of the physical examination to the woman.

6. Take the woman’s blood pressure, temperature and pulse.

7. Measure mid-upper arm circumference.

8. Check her heart and respiratory system

9. Examine the breasts.

10. Measure/estimate fundal height.

11. Examine abdomen and determine lie and presentation (after 36

weeks).

12. Listen to the fetal heart (second and third trimesters).

13. Wash hands thoroughly with soap and water and dry.

14. Inform the woman about the speculum examination

15. Put examination gloves on both hands.

16. Check external genitalia for sores and/or swelling.

57

17. Check the vaginal orifice for bleeding and/or abnormal

discharge.

18. Check cervix for signs of cervicitis.

19. Immerse both gloved hands in 0.5% chlorine solution and

remove gloves, wash hands.

20. Summarize findings and explain to the woman.

21. Record all relevant findings on the woman’s antenatal card.


Pre-test counseling

Conduct pre-test counseling for HIV and syphilis


Screening Procedures


2. Draw blood and do hemoglobin, blood group and Rh, RPR and

HIV tests (if opt-in), interpreting results accurately.

3. Perform urinalysis for protein, sugar and bacteriuria

4. Empty and soak the test tubes in 0.5% chlorine solution for 10

minutes.

5. Dispose off needle and syringe in puncture-proof container.

6. Immerse both gloved hands in 0.5% chlorine solution and remove

gloves.


8. Record results on the woman’s antenatal card.

9. Discuss the findings with her.


Identify problems/needs

Identify the woman’s individual problems/needs, based on the

findings of the antenatal history, physical examination and screening

procedures.


Provide Care/Take Action

1.Treat the woman for syphilis if the RPR test is positive, provide

post-test counseling on HIV and safer sex, and arrange for referral if

HIV positive.

2. Provide tetanus immunization based on need.

58

3. Provide counseling about necessary self-care topics.

4. Provide counseling about the use of insecticide-treated bed nets.

5. Dispense other necessary medications such as iron and folate.

6. Develop or review individualized birth plan with the woman;

develop or review her emergency preparedness plan, including

danger signs.

7. Record the relevant details of care on the woman’s

record/antenatal card.

8. Ask the woman if she has any further questions or concerns.

9. Ask her if she wants to bring her husband or family member on

her next antenatal visit.

10. Thank the woman for coming and tell her when she should come

for her next antenatal visit.

Adapted from Best Practices in Maternal and Newborn Care Learning Resource Package –

JHPIEGO USAID ACCESS (2008)

Subsequent Visits

Antenatal Assessment (History, Physical Examination, Testing) and Care

Antenatal Assessment – Subsequent Visits

(History, Physical Examination, Testing) and Care.

Some of the following steps/tasks should be performed simultaneously

Step/Task Cases

Getting Ready


2. Greet the woman respectfully and with kindness and introduce

yourself.


4. Tell the woman what is going to be done, listen to her and

encourage her to ask questions.

5. Provide reassurance and emotional support as needed.


History

1. Ask the woman how she is feeling and respond immediately to

59

any urgent problem(s).

2. Verify her name and age

3. Check the EDD and gestational age.



5. Ask the woman about any medical conditions and medications.

6. Ask the woman if she is taking iron and folate.

7. Ask the woman if she is using treated bed nets at all times (in

malarious areas).

8. Ask her if there has been any change in her social situation since

the last visit.

9. Record all pertinent information on the woman’s record/antenatal

card.




2. Observe the woman’s general appearance.





6. Take the woman’s blood pressure.

7. Measure/estimate fundal height.


weeks).

9. Listen to the fetal heart (second and third trimesters).


11. Inform the woman about the findings.



Screening Procedures


2. Draw blood and do hemoglobin if less than 7 g/l at first visit.

3. Perform urinalysis for protein, sugar and bacteriuria

4. Empty and soak the test tubes in 0.5% chlorine solution for 10

minutes.

60

5. Dispose off needle and syringe in puncture-proof container.

6. Immerse both gloved hands in 0.5% chlorine solution and remove

gloves.


8. Record results on the woman’s antenatal card and discuss them

with her.


Identify problems/needs

Identify the woman’s individual problems/needs, based on the

findings of the antenatal history, physical examination and

supportingtests/procedures.


Provide Care/Take Action

1. Provide counseling about necessary self-care topics.

2. Provide counseling about the use of insecticide-treated bed nets.

3. Dispense other necessary medications such as iron and folate.

4. Review individualized birth plan with the woman.

5. Review her emergency preparedness plan

6. Discuss signs of onset of labour

7. Discuss danger signs in pregnancy

8. Discuss postpartum family planning

9. Discuss self-care in post-partum period

10. Discuss breast feeding

11. Discuss care of the newborn

12. Record the relevant details of care on the woman’s

record/antenatal card.

13. Ask the woman if she has any further questions or concerns.

14. Thank the woman for coming and tell her when she should come

for her next antenatal visit.

61

11.5.2 Checklist for birth and emergency preparedness plan

To refer to 11.1.2 Birth and emergency readiness plan

Check List- Birth and emergency preparedness plan

Item Yes No

The discussion between the provider and the pregnant woman, her husband and family

includes: The provider

1. At the first visit, explains why abirthplan(including emergency/complication

readiness) is important

2. Advises her to have delivery in a health facility (puskesmas or district

hospital).

3. Advises that if she decides to deliver at home, the birth should be attended

by a skilled birth attendant

4. Assists the woman in choosing the appropriate healthcare facility (e.g.,

district hospital, health center)

5.Assists the woman in identifying a skilled birth attendant/provider

6. Ensures that the woman is familiar with local transportation systems

7. Checks that she has transportation to an appropriate place for the birth based

on her individual needs.

8. Assists the woman in planning to have funds available when needed to pay

for care during normal birth.

9. For emergency/complication preparedness, discuss emergency funds that

are available through the community and/or healthcare facility if danger signs

arise.

10. Discusses how decisions are made in the woman’s family. (who usually

makes decisions?)

11. Assists the woman in deciding the

companionofherchoicetostaywithherduringlaborandchildbirth,and accompany

her during transport if needed.

12. Assists the woman in making arrangements for

someonetocareforherhouseandchildrenduringher absence.

13. Ensures that the woman has identified an appropriate blood donor and that

this person will be available in case of emergency.

14. Ensures that the woman knows the danger signs which indicate a need to

enact the emergency/complication readiness plan.

15. Ensures that she knows the signs of labour

During Visits at 32 weeks and after thatthe discussion between the provider and the

62

Item Yes No

pregnant woman, her husband and family includes: The provider

16. Checks that the woman and family have finalized thebirthplan.

17. Checks what arrangements have been made since the last visit? (Has

anything changed? Have any obstacles or problems been encountered?)

18. Ensures that the woman knows the danger signs which indicate a need to

enact the emergency/complication readiness plan.

19. Makes sure the woman has gathered necessary items for a clean and safe

birth

20. Makes sure the woman has gathered necessary items for the newborn

11.5.3 Checklist for demonstration of breast feeding

The tutor can use the checklist to assess if the student/trainee can demonstrate the technique

of breastfeeding. The student/trainee can also use the checklist as a guide to demonstrate the

technique of breastfeeding.

Item Yes No

Positioning The mother is comfortable with back and arms supported.

Baby’s head and body are aligned; baby’s abdomen is

turned toward the mother.

Baby’s face is facing the breast with nose opposite nipple.

Baby’s body is held close to the mother.

Baby’s whole body is supported.

The baby is brought to the nipple height.

Holding The mother maysupporttheweightofher breast with her

hand and shape her breast by putting her thumb on the

upper part, so that the nipple and areola are pointing

toward the baby’s mouth; OR

Shemaysupportthebreastbyplacingher fingers flat against

the chest wall, while bringing the baby to her breast to

suckle.Attachment

and Suckling

Nippleandareolaaredrawnintothebaby’s mouth rather than

only the nipple into the mouth.

Thebaby’smouthiswideopen;lowerlipis curled back below

base of nipple.

Thebaby’s chin touches the mother’s breast

Thebabytakesslow,deepsucks,oftenwith visible or audible

swallowing.

Thebabypausesfromtimeto time.

63

The baby may make “smacking” sounds.

Mother

comfort

Mother does not complain of, or appear tohave,

nipple/breast pain during the breastfeed.

Finishing the

breast feed

The newborn should release the breast her/himself rather

than being pulled from the breast.

Feeding may vary in length, anywhere from 4 to 40

minutes per breast.

Breasts are softer at the end of the feed compared to full

and firm at thebeginning.

Newborn looks sleepy and satisfied atthe end of a feed.

“Burp” the baby at the end of the feed

64

11.6 Learner’s Guide:

11.6.1 Learner’s Guide: Antenatal Assessment -Taking an Obstetric History

The Guide can be used by the student/trainee.

The Facilitator/Teacher can use the Guide at the end of the module and grade the

performance of the student/trainee.









Step/Task Case Case Case

Preamble

1. Prepare the necessary documents.

2. Greet and welcome the woman and introduce yourself

3. Ask her if someone is accompanying her, if so invite her

companion


5. Explain that you will proceed with a history taking and obtain

consent

6. If you are a male student, you may want to ask a nurse or a fellow

female student to be present during the history taking.

7. Make sure you have drawn the curtains to ensure privacy.

Introductions

1. Ask her name, age, address, phone number.

2. Ask her husband’s name

3. Observe the woman’s general appearance and whether she is

cooperative or not.

Menstrual History

1. Ask her the first day of last menstrual period

2. Ask her if her menstrual cycle is regular and the length of each

cycle.

3. Calculate the expected date of delivery

65

4. Calculate thematurity by dates



Current Pregnancy History

1. Ask her if she noticed any leucorrhea

2. Ask her if she experienced nausea and vomiting

3. Ask her if she had any vaginal bleeding

4. Ask her if she experienced other problems/abnormalities

5. Ask her if she has usedmedication, traditional medicine and herbs

Previous Obstetric History

1. Ask her the number of pregnancy/pregnancies

2. Ask her the number of delivery/deliveries

3. Ask her the number of labours at term, preterm labours

4. Ask her the mode of delivery

5. Ask her the number of living children, birth weight, and sex

6. Ask her the number of miscarriage, abortion

Note: The obstetric history is usually entered in a tabular form,

see following section.

7. Ask her if she had bleeding in previous pregnancy, labour and

puerperium

8. Ask her if she had hypertension, pre-eclampsiain previous

pregnancies

9. Ask if she had abnormal presentations such as breech or

transverse presentation

10. Ask her if she had other problems in previous pregnancies,

labours and puerperium

11. Ask her if she breast fed her babies and if so, the duration of

exclusive breast feeding

Note: If she mentioned any of the above problems in 7,8,9 or if

she had a C.S., further details need to be elicited. See the

subsequent table.

12. Ask if any of the babies weighed<2.5 kg or> 4 kg

13. Ask her if any baby was small for gestational age (IUGR)

14. Ask if she has delivered twins or triplets, etc

15. Ask if any of her babies had a perinatal, neonatal or fetal death

Note: If she experienced a perinatal, neonatal or fetal death, further details need to be

elicited. See the subsequent table.

Gynaecological (including previous contraceptive) History

1. Ask for history of contraception before pregnancy

66

2. Ask if she had any surgical procedures

3. Ask if there were period(s) of infertility: If so, when? For how long?

and if she knew the reason cause?

Medical History (ask for the following conditions)

1.Known/diagnosed heart disease

2.Hypertension

3.Diabetes mellitus (DM)

4.Liver diseases such as hepatitis

5.Tuberculosis (TB)

6.Chronic renal disease

7.Malaria

8.Asthma

9.Epilepsy

10.Any regular medication prior to pregnancy and continuing during

pregnancy

11.Any allergy to medication, food

12.History of surgery (other than CS)

13.Sexually transmitted diseases2

14.HIV status if known

15.History of blood transfusion

16.Blood group

17.History of trauma/accident

18.Status of tetanus immunization

Family History

1. Ask her if her parents had Diabetes mellitus

2. Ask her if her parents had Hypertension

3. Ask her if her mother, her sister or herself hadmultiple or higher

order pregnancy

4.Ask if there is a history of congenital abnormalities in her family

Socio-economic History – Ask her

1.Marital status, number of times married and age of marriage(s)

2.Her occupation and daily activities

3.Education level

4.Income (if possible)

5.The husband’s occupation and income

6.Eating or drinking habits

7.Ethnic group

2The student could ask this point later after obtaining the social history and if the student feels that the woman could be at increased risk of STI

67

8.Religion

9.Smoking, use of recreational drugs and alcohol

10.Sexual life, history of casual sex

11.Beliefs, perceptions or concerns regarding pregnancy or labour

12.Number of family members helping at home

13.Birth and emergency preparedness plans

14.Who is the decision maker in the family

15.Options of place for delivery

16.Housing

17. Sanitation conditions

18.Electricity

19.Cooking facilities

Thank her and explain that you will be examining her next

To ask in more detail if the following were mentioned in the obstetric history. Only the

more common conditions are covered.

Antepartum haemorrhage

At which month of pregnancy did she bleed?

Was it associated with pain?

Was it repeated and recurrent?

Did she need blood transfusion; if yes, how many units?

Did she need a surgical operation for the bleeding?

Did she have any complications afterwards?

What was the condition of the baby?

Post-partum Haemorrhage

When did she start to bleed?

Did she need blood transfusion; if yes, how many units?

Did she need a surgical procedure for the bleeding?


Pre-eclampsia

At which month of pregnancy did she have high blood pressure?

Was the urine tested for protein?

Did she have fits?

Did she have headache, blurred vision, abdominal pain?

Did she have a spontaneous delivery or was it induced?

Did she need a surgical procedure?


What was the condition of the baby?

68

History of caesarean section

Why was the operation done?

Where was the operation done?

Who performed the operation?

What was the outcome of the baby?

Did she have any complications after the operation?

History ofperinatal, neonatal or fetal death

What was the gestational age of the baby?

Was her antenatal period normal or were there complications?

Were the laboratory investigations normal?

Did she have medical conditions complicating pregnancy? What

treatment did she receive?

Did she have preterm labour or premature rupture of the

membranes?

Did she have spontaneous labour or was it induced?

Was the labour prolonged?

Did she have a normal delivery or assisted vaginal delivery or an

operation (LSCS)?

What is the birth weight of the baby?

Did the baby cry at birth?

Did the baby have any visible abnormalities?

Did the baby need resuscitation?

Was the baby admitted to a special care unit?

Did you breastfeed the baby?

At what age did the baby die?

Do you know what treatment was given to the baby?

What was the reason for the baby’s death?

History Taking at subsequent visits

After greeting her and asking her to sit down

How she is feeling since her last visit?

Are there are any concerns or complaints – e.g. bleeding?

Are there any changes in her personal history since theprevious

visit?

Has she taken medication other than iron-folate, herbal medicines

Has she had other medical consultations, hospitalization?

Does she notice fetal movement? When did she first notice them?

Check on habits e.g. smoking

69

Has she decided where she will deliver?

If home delivery, has she identified the midwife who will assist her?

Check her birth and emergency preparedness plans.

Has she had any pain or bleeding?

11.6.2 Learner’s Guide: Antenatal Assessment - Physical Examination

The Guide can be used by the student/trainee.

The Facilitator/Teacher can use the Guide at the end of the module and grade the

performance of the student/trainee.









Following obstetric history taking, the student/trainee will proceed with an obstetric

examination: the general examination, examination of the cardiovascular and respiratory

system and breast examination. The student/trainee may also need to perform a speculum

examination.

(The general examination and examination of the cardiovascular and respiratory system will

not be elaborated here)

Because of the sensitive nature of these examinations, developing rapport with the patient is

extremely important.


Preamble


2. Explain that you will proceed with a physical examination and

obtain consent

3. If you are a male student, you may want to ask a nurse or a fellow

female student to be present during the examination.

4. Make sure you have drawn the curtains to ensure privacy.


70



2. Observe the woman’s general appearance and gait.





6. Conduct a general examination: check eyes for anaemia,

palpebral edema, tongue, thyroid

7. Take the woman’s blood pressure, temperature and pulse.

8. Measure the Mid-upper arm circumference (MUAC) just before

or just after checking the blood pressure

8.1 Use a soft tape-measure

8.2 Measure the arm circumference in either the right or left arm,

midway between the tip of the shoulder (acromion)and the tip of the

elbow (olecranon)

8.3 The arm should hang freely (elbow extended)

8.4 Record the measurement to the nearest 1 mm

8.5 Record the MUAC on the antenatal card or in the labour ward

admission notes

9. Expose her chest and check her heart and respiratory system.

10. Examine the breasts.

10.1 Inspection: skin, contour

10.2 Protraction or retraction of nipple

10.3 Expression of the nipple

10.4 Palpation of both breasts in the sitting and supine positions

10.5 Palpation of the breasts with the flat of the hand and then with

fingers

10.6 Palpation of the lymph nodes, including axillary and

supraclavicular nodes

10.7 Cover the chest and breasts

11. Abdominal examination

Tell the woman that you will proceed with an abdominal

examination. Expose the abdomen adequately (put a cover sheet to

the lower part of abdomen)

12. Inspection

- Note apparent size of abdominal distension

- Note any symmetry

71


- Note any fetal movements

- Note cutaneous signs of pregnancy linea nigra, straie gravidarum,

straie albicans, flattening/eversion of umbilicus

- Note any prominent superficial veins

- Note any surgical scars

(Note: Pfannenstiel scar may be obscured by pubic hair,

laparoscopy scars hidden within the umbilicus)

13. Measure/estimate symphisio-fundal height.

- palpated < 20 weeks

- measured in cm if more than 20 weeks – put the end of the tape

measure to the symphiyis and bring it up to the fundus.


weeks).

14.1 Leopold I (Fundal grip) determining uterine fundal height and

fetal parts located in the uterine fundus (carried out since the early

first trimester).

14.2 Leopold II: determining position of the fetal back (performed by

the end of second trimester).

14.3 Leopold III: determining fetal parts located at the bottom of the

uterus (carried out by the end of second trimester).

14.4 Leopold IV: determining how far fetus enters the pelvis (done at

the end of the second trimester).

15. Assess amount of liquor (second and third trimesters)

Note: during the examination, maintain eye contact with the woman from time to time

16. Determine where the fetal back is and listen to the fetal heart

(second and third trimesters).

17. Check extremities for oedema.

18. Cover the woman’s abdomen and help her sit up


20. Explain/summarize the findings

If bivalve (Cusco’s) speculum examination will be done: after

step 15 of obstetric examination

1. Cover the woman’s abdomen

2. Inform the woman about the speculum examination and the

purpose. Explain that shemight feel a little discomfort and that the

examination should be over fairly quickly. If they have any questions

72


or concerns then answer them.

3. Obtain consent

Note: Make sure that Point 2 and 3 of Preamble are in place

Make sure all equipment are ready: spot lamp, speculum, KY

jelly, swabs etc). Turn on the spot lamp to the examination site.

4. Ask her to raise her legs in the dorsal position

5. Cover her legs and lower abdomen with drapes

6. Wash hands


Note: Swab the external genitalia

Talk to the woman while you are examining her

8. Inspection: Check external genitalia

8.1 Check for any swelling, inflammation

8.2 Check for skin changes

8.3 Check for ulcers, lesions

8.4 Check the vaginal orifice for bleeding and/or abnormal

discharge.

9. Check if there are any haemorrhoids

10. Speculum introduction and examination

Note: Tell her you will be introducing the speculum

Insert an appropriate sized speculum, you may need to warm the

speculum. Swab the external genitalia.

10.1 The Labia minora are parted with left hand

10.2 Insert the closed speculum, upwards and backwards

10.3 Advance into vagina fully

10.4 Direct visualization as blades open to expose cervix

10.5 if cervix is not seen, close blades, withdraw slightly, change

direction and open again

10.6.Take swabs if there is vaginal discharge as required

10.7 Check for vaginal abnormalities, e.g. septum

10.8 Check cervix: normal or signs of cervical lesions, tumour

10.9 Speculum removal: ensure blades are open while sliding over

cervix

10.10 Partially close blades while withdrawing the speculum and

inspect vaginal walls

10.11 Blades should be closed at introitus, not trapping any vagina

11. Cover the woman’s thighs with drapes

73


12. Immerse both gloved hands in 0.5% chlorine solution and

remove gloves, wash hands.

13. Remove drapes, help her to get up and get dressed

14. Ask her to sit down

15. Summarize findings and explain findings to the woman.

Inform her if the findings are normal or if any conditions/

abnormalities were detected


74

11.7Counseling Guide for Postpartum Family Planning – Postpartum IUD

Place a “Yes” in case box if task/activity is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the

standard procedure or guidelines Not Observed: Step, task or skill not performed by learner during evaluation by trainer

Learner Date Observed----------------------

COUNSELLING ON PPIUD SERVICES

ITEM STEP/TASK ASSESSMENT

GREET—Establish good rapport and initiate counseling on PPFP.

1. Establishes a supportive,

trusting relationship

Greets the woman, using her name and introducing self.

Shows respect for the woman and helps her feel at ease.

2. Allows the woman to talk and

listens to her.

Encourages the woman to explain her needs and concerns and ask questions.

Listens carefully and supports the woman’s informed decisions.

3. Engages woman’s family

members.

Includes woman’s partner or important family member in the discussion, as the woman desires and

with her consent.

ASK—Determine reproductive intentions, knowledge of pregnancy risk and use of various contraceptives.

4. Determines any previous Explores woman’s knowledge and beliefs about the return of fertility and the benefits of pregnancy

75

experiences with family planning. spacing or limiting (as desired).

Asks whether she has had prior experience with family planning methods, any problems, reasons for

discontinuing, etc.

5. Assesses partner/family

attitudes about family planning.

Explores partner’s/family’s knowledge and beliefs about the return of fertility and the benefits of

pregnancy spacing/limiting.

6. Assesses reproductive

intentions.

Asks about desired number of children, desire to space or limit births, desire for long-term family

planning, etc.

7. Assesses need for protection

against sexually transmitted

infections (STIs).

Explores woman’s need for protection from STIs, including HIV.

Explains and supports condom use, as a method of dual protection

8. Determines interest in a

particular family planning method.

Asks whether she has a preference for a specific method based on prior knowledge.

TELL—Provide the woman with information about PPFP methods.

9. Provides general information

about benefits of healthy

pregnancy spacing (or limiting, if

desired).

Advises that to ensure her health and the health of her baby (and family), she should wait at least 2

years after this birth before trying to get pregnant again.

Advises about the return of fertility postpartum and the risk of pregnancy. Advises how LAM and

breastfeeding are different.

Advises about the health, social and economic benefits of healthy pregnancy spacing (or limiting, if

desired).

76

Note: For item 10, if the woman and husband already have a method in mind which is suitable to be used during the post-partum period, the provider may wish to

discuss on the method of choice and LAM and might not need to provide information on other methods that can be used during the post-partum period. The

explanations on the methods should be made in simple, easy-to-understand language.

10. Provides information about

PPFP methods.

Based on availability and on woman’s prior knowledge and interest, briefly explains the advantages,

limitations and use of the following methods:

−LAM

−Condoms

−POPs

−DMPA (injections)

- PPIUD

- No-scalpel vasectomy (male sterilization)

- Postpartum tubal ligation (female sterilization)

Shows the methods (using poster or wall chart or flip chart) and allows the woman to touch or feel the

items, including the IUD, using a contraceptive tray.

Corrects any misconceptions about family planning methods.

77

HELP—Assist the woman in making a choice; give her additional information that she might need to make a decision.

11. Helps the woman to choose a

method.

Gives woman additional information that she may need and answer any questions.

Assesses her knowledge about the selected method; provides additional information as needed.

12. Supports the woman's choice. Acknowledges the woman’s choice and advises her on the steps involved in providing her with her

chosen method.

EVALUATE and EXPLAIN—Determine whether she can safely use the method; provide key information about how to use the method (focus on PPIUD,

per her choice)

13. Evaluates the woman’s health

and determine if she can safely

use the method.

Asks the woman about her medical and reproductive history.

14. Provides key information

about the PPIUD with the woman:

Effectiveness: Prevents almost 100% of pregnancies

Mechanism for preventing pregnancy: Causes a chemical change that damages the sperm BEFORE

the sperm and egg meet

Duration of IUD efficacy: Can be used as long (or short) as woman desires, up to 12 years (for the

Copper T 380A)

Removal: Can be removed at any time by a trained provider with immediate return to fertility

15. Discusses advantages of the

PPIUD:

Simple and convenient IUD placement, especially immediately after delivery of the placenta

No action required by the woman after IUD placement (although one routine follow-up visit is

recommended)

78

Immediate return of fertility upon removal

Does not affect breastfeeding or breast milk

Long-acting and reversible (as described above)

16. Discusses limitations of the

PPIUD:

Heavier and more painful menses for some women, especially first few cycles after interval IUD (less

relevant or noticeable to postpartum women)

Does not protect against STIs, including HIV

Higher risk of expulsion when inserted postpartum (though less with immediate postpartum insertion)

17. Confirms that the woman

understands the method.

Encourages the woman to ask questions.

Asks the woman to repeat key pieces of information.

RETURN—Plan for next steps and for when she will arrive to hospital for delivery.

18. Plans for next steps. Makes notation in the woman’s medical record about her PPFP choice or which methods interest her.

If the woman cannot arrive at a decision at this visit, asks her to plan for a follow-up discussion at her

next visit; advises her to bring partner/family member with her.

Provides information about when the woman should come back for her next antenatal visit OR

continue with the next item on her management plan.

If the woman has PPIUD insertion, the following information should be provided prior to discharge from hospital (in addition to other information).

79

1. Discusses warning signs;

explains that she should return to

the clinic as soon as possible if

any arise.

Bleeding or foul-smelling vaginal discharge (different from the usual lochia)

Lower abdominal pain, especially if the first 20 days after insertion—accompanied by not feeling well,

fever or chills

Concerns she might be pregnant

Concerns the IUD has fallen out

2. Confirms that the woman

understands instructions.

Encourages the woman to ask questions.

Asks the woman to repeat key pieces of information.

3. Concludes the interaction Thanks her

80

1. an care tutor 20 dec

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