1. ANTENATAL CARE

2. General Objective
To enhance the knowledge, attitude and practice of nurses on FOCUSED ANTENATAL CARE
Specific Objectives
To demonstrate how to make an immediate general assessment of the pregnant woman
To apply the process flow of providing antenatal care.
To discuss the importance of a birth and emergency plan
Focused antenatal care is based on the premise that every pregnancy is at risk for complications. All women should receive the same basic care including identifying complications. This model of prenatal care involves a minimum of 4 visits in normal or uncomplicated pregnancies. It stresses quality rather than number of visits and has essential goal-directed elements including screening for diseases that complicate pregnancy like pre-eclampsia and anemia. It also reduces cost, lessens workload and provides more time to interact with patients thereby improving quality of care.

3. Objectives of Prenatal Care
To detect diseases which may complicate pregnancy
Educate women on danger and emergency signs & symptoms
Prepare the woman and her family for childbirth
to detect problems that might affect the woman's pregnancy and require additional care - routinely screen for anemia, hypertension, HIV, syphilis and diabetes mellitus. Recognize other problems that may complicate pregnancy: malnutrition and tuberculosis, vaginal bleeding, vaginal discharge, fetal distress and abnormal fetal position after 36 weeks
Danger and emergency signs: Fever, vaginal bleeding, headache and blurring of vision, severe abdominal pain, convulsion, severe difficulty of breathing
Birth and emergency plan

4. Steps to Follow in Prenatal Care
1) IMMEDIATE ASSESSMENT for emergency signs.
Unconscious/Convulsing
Vaginal bleeding
Severe abdominal pain
Looks very ill
Severe headache with visual disturbance
Severe difficulty in breathing
Dangerous Fever
Severe vomiting
Make an immediate assessment of all pregnant women in the antenatal clinic. Women with emergency signs should be priortized.
* Attend to sick woman quickly.

5. Steps to Follow in Prenatal Care
2) Make the woman comfortable.
Greet her, make sure she is comfortable and ask how she is feeling.
If first visit, register the woman and issue a Mother and Child Book (antenatal record form)

6. Steps to Follow in Prenatal Care 3) Assess the pregnant woman
FIRST visit:
How old is patient?
Past Medical History
Obstetric History: Gravidity? LMP? AOG?
Alcohol/Drug/substance abuse?
Ask about or check record for prior pregnancies:
Convulsions
Stillbirth or death in the first day
Heavy bleeding during or after delivery
Prior cesarean section, forceps or abortion
Discuss the importance of assessing each item in antenatal care:
Age – complications more common in the extremes of age. Young, particularly teen-aged pregnant women are more prone to pre-eclampsia, anemia, premature delivery, obstructed labor etc.
Past medical history: certain diseases may exacerbate during pregnancy or may affect the pregnancy.
Review: gravida, para, how to compute AOG and determine EDC
Women with abnormal findings should be referred to the doctor.

7. Steps to Follow in Prenatal Care 3) Assess the pregnant woman
ON ALL VISITS:
Check duration of pregnancy (AOG).
Ask for bleeding/danger signs during this pregnancy
Check record for previous treatments received during this pregnancy
Prepare birth and emergency plan
Ask patient if she has other concerns
Give education and counseling on family planning and breastfeeding

8. Steps to Follow in Prenatal Care 3) Assess the pregnant woman
THIRD TRIMESTER
Leopold’s exam, fetal heart beat
Give education & counseling on family planning
Do not perform vaginal exam as a routine
prenatal care procedure.
Always record findings.
All pregnancies are at risk. Encourage all pregnant
women to deliver in the health facility.
Refer patients with abnormal findings to higher facility.

9. VDRL or RPR to screen for syphilis
Steps to Follow in Prenatal Care
Get baseline laboratory information of the woman on the first or following the first visit.
Hemoglobin, blood type
Urinalysis
VDRL or RPR to screen for syphilis
If not available, refer to the nearest RHU or hospital for the tests.

10. 5) Check for pallor or anemia.
Steps to Follow in Prenatal Care
5) Check for pallor or anemia.
Ask about getting tired easily or shortness of breath during routine work.
On 1st visit, check hemoglobin & blood type. The normal hemoglobin cut-off level for a pregnant woman is 11g/dl.
On subsequent visits:
Look for conjunctival pallor.
Look for palmar pallor.
Count number of breaths in one minute.
The World Health Organization (WHO) recommends giving ferrous sulfate 320 milligrams (60 mg of elemental iron) twice a day to all pregnant women. If the woman’s hemoglobin is 8 gm or less at any visit, increase her iron supplementation to three times a day for the entire pregnancy. If ferrous sulfate is not available, give an equal amount of elemental iron in another iron preparation.

11. 6) Check for hypertension/ pre-eclampsia.
Steps to Follow in Prenatal Care
6) Check for hypertension/ pre-eclampsia.
Measure BP in sitting position.
If diastolic BP is 90 mm Hg or higher repeat measurement after 1 hour rest.
If diastolic BP is still 90 mm Hg or higher ask the woman if she has:
Severe headache
Blurred vison
Epigastric pain
Check urine for protein.
Distinguish chronic hypertension, pre-eclampsia and severe pre-eclampsia. These patients should be referred to the doctor

12. 7) Check for gestational diabetes.
Steps to Follow in Prenatal Care
7) Check for gestational diabetes.
ASK ABOUT
Family history of diabetes & history of obesity.
Past pregnancy for difficult labor, large babies, congenital malformations and previous unexplained fetal death.
LOOK FOR
signs of maternal overweight or obesity
Polyhydramnios
Signs of large baby or fetal abnormality
Vaginal infection.
Low Risk:
24-28 wks
High Risk:
Immediately,
any AOG

13. Ask about episodes of fever or chills and take temperature.
Steps to Follow in Prenatal Care
8) Check for fever, burning sensation on urination and abnormal vaginal discharge.
Ask about episodes of fever or chills and take temperature.
Ask about pain or burning sensation on urination.
Ask about presence of abnormal vaginal discharge, itching at the vulva or if partner has a urinary problem.

14. 9) Immunize against tetanus.
Steps to Follow in Prenatal Care
9) Immunize against tetanus.
Tetanus Toxoid Immunization Schedule
Vaccine
Minimum Interval
Duration of Protection
TT1
at first contact with woman yrs or at first ANC visit
NIL – no protection
TT2
at least 4 weeks after TT1
Infants born to the mother will be protected from neonatal tetanus
3 years of protection for the mother
TT3
at least 6 months after TT2
5 years of protection for the mother
TT4
at least 1 year after TT3
10 years of protection for the mother
TT5
at least 1 year after TT4
Lifetime protection for the mother

15. Steps to Follow in Prenatal Care
10) Give MEBENDAZOLE to treat for intestinal parasites.
500 mg single dose once in six months (after the 1st trimester)
11) Give iron and folate supplementation to prevent anemia and neural tube defects:
60 mg Fe & 250 mcg Folate
If Hgb <80 gm/dl→ double the dose
12) Refer for preventive intermittent treatment for falcifarum malaria (if area is endemic)

16. Steps to Follow in Prenatal Care
13) Provide health information, advice
HEALTH INFORMATION:
Nutrition
Self-care during pregnancy
Effect of tobacco, alcohol & drugs
Breastfeeding
Birth & Emergency situations
Schedule of appointment
Nutrition – what food to eat and what foods to avoid during pregnancy.
Self-care during pregnancy – the importance of hygiene
Discuss breastfeeding and benefits during the prenatal consultation.
Explain the danger signs and the signs of labor.

17. Steps to Follow in Prenatal Care 14) Advise on Danger Signs
Vaginal bleeding
Convulsions
Severe headache
Severe abdominal pain
Fast or difficult breathing
Fever or burning urination

18. Steps to Follow in Prenatal Care
15) Encourage the woman to come back for return visits.
At least 4 routine antenatal visits
1st visit: before 4 months
2nd visit: 6 months
3rd visit: 8 months
4th visit: 9 months – return if undelivered within 2 weeks after the EDC.
Pregnant women who do not come for prenatal care should be visited at home.

19. The Birth Plan Discussed with the patient and her family
A written document prepared during the first prenatal consultation
Discussed with the patient and her family
May change anytime during pregnancy if a problem is detected.

20. The Birth Plan the woman’s condition during pregnancy
Contains information on:
the woman’s condition during pregnancy
preferences for her place of delivery and choice of birth attendant
available resources for her childbirth and newborn baby
preparations needed should an emergency situation arise during pregnancy, childbirth and postpartum.

21. Emergency Plan Advise on danger signs Where to go? How to go?
Who will go with you to health center?
How much will it cost? Who will pay? How will you pay?
Start saving for these possible costs now.
Who will care for your home and other children when you are away?

22. B I R T H
and E M G N C Y P L A

23. ANTENATAL CARE: Key Messages
Reduced number of visits
Provided by skilled birth attendant
Screening and prevention of diseases that may complicate pregnancy
Preventive Measures: Tetanus immunization, iron and folic acid supplementation
Counseling on family planning, nutrition, breastfeeding, and danger signs
BIRTH PLAN: Birth preparedness and complication readiness
In summary, this is what focused antenatal care is all about.
Reduced number of visits. (You may ask participant “How many visits?”, When?
Screening for diseases – “What diseases?”
Education – “What key messages?”
Birth Plan – “What are included in birth plan?”

24. Because Giving birth should be about giving life not giving up a life.

25. Situation
1. A pregnant mother on her 13th week consulted in King Khaled Hospital OPD. Her history revealed she has 6 year old delivered on 41 week, followed by 4 year old twins on 38 week, another set of 2 year old twins on 36 week and had history of abortion. Write the correct obstetric history of the patient: G P T PA LM 2. Compute for EDB: LMP: May 18, 2012