1. Risk assessment & Screening Nutrition during pregnancy Other preventive measures Health education during antenatal care

2. Specific Objectives At the end of the lecture you will be able to 1.Appreciate risk screening as a major function of antenatal care and the intention to use this approach. 2.Recall risk factors listed by the MOH present in the antenatal card. 3.Use the WHO scoring system to categories woman in to very high, high and usual risk (low risk) categories. 4.Use MOH scoring system and its categories. 5.State actions taken to deal with a women in each category in both systems.

3. 6. Describe nutritional requirements in pregnancy. 7. Describe common nutritional problems among pregnant women in Iraq with stress on anemia. 8. Enumerate other preventive measures applied during antenatal care i.e vaccination, supplements malaria chemoprophylaxis, treatment of hook worm infestation and STDs treatment and prevention. 9. Suggest an important topics that should be discussed during health education sessions during antenatal care.

4. Risk screening is a major function of ANC it involves using a list of risk factors & some form of scoring system to separate women into risk categories,typically High risk & Low risk.

5. The intention of risk screening is to  Predict problems even before they occur &  Identify women whose pregnancy or delivery is likely to raise problem &  To refer them at the appropriate time to hospital facility where necessary medical equipments & expertise are available.

6. Criteria put by Ministry of Health for risk factors included  Maternal age Primi < 16 yrs Primi > = 30 years Multi >35 years  Weight Less than 45 kgs more than 90 kgs  Height <150 cm

7. Criteria put by Ministry of Health for risk factors included PPrevious obstetric history Threatened abortion Habitual abortion Missed abortion More than 2 abortions Stillbirth HDP Prematurity

8. Criteria put by Ministry of Health for risk factors included PPrevious delivery history Premature labour Post mature labour Previous Cs Previous obstructed labour Fetal abnormality

9. Criteria put by Ministry of Health for risk factors included MMedical history Hypertension, renal diseases, DM, CVD, Thyroid disease, epilepsy.

10.  Present obstetrical History HDP Anemia Rh isosensetiation High parity (>4) Too short or too long spacing Abnormal fetal presentation APH

11. Criteria put by Ministry of Health for risk factors included PPresent obstetrical History Twins Minimum or no weight gain Intra uterine growth retardation Post-term pregnancy Smoker mother

12. WHO scoring system for the assessment of risk status of pregnancy Maternal characteristic category score Age <19 >40 4 30-39 2 20-29 0 No.of children >5 4 0-1 2 2-4 0 Spacing <24 months 1 >24 months 0 Medical history previous obstetric 3 complication & perinatal death D.M,CVC,renal disease 5 Maternal education Illiterate 1 Literate 0

13. Action taken according to WHO scoring system Risk status Action Total score Very high referral obligatory. >5 High referral recommended 3-4 Usual (low) local care 0-2

15. Nutrition During Pregnancy Fetal development is accompanied by extensive changes in composition & metabolism of maternal body. Many of these changes begin very early in pregnancy & may be under hormonal control.

16. Nutrition During Pregnancy  General increase in metabolism.  Changes in renal functions ( GFR, excretion of creatinin, excretion of same amino acids ) & glucose urea.  GIT changes: changes in g.I mucosa to high absorption of Iron & Vits. (2times more than normal).  Heamodilution & relative anemia.  Water overload (edema).

17. Nutrition during pregnancy Weight Gain During Pregnancy Products of conception, fetus, placenta, amniotic fluid & membrane. Enlargement of organs of reproduction. Increase in stored fat. Retention of fluid.

18. Nutrition during pregnancy Weight Gain During Pregnancy Healthy pregnant women gain 10- 12 kgs. Undernourished women will gain <7 kgs. Gain in weight of <6 kgs indicates high risk.

19. Nutrition during pregnancy Outcomes of Maternal Malnutrition LBW & Prematurity Fetal & neonatal Mortality & Morbidity Increased chance of death in neonatal period congenital Malformations

20. Possible Outcomes of Maternal Under-Nutrition Anaemia in pregnancy Defined as a hemoglobin concentration of less than 11gm/dl  During pregnancy plasma volume increases by 50% and the red cell mass increases by 20% leading to relative anaemia of pregnancy.  The iron stores, are usually depleted due to the successive periods, pregnancy and lactation and diets containing low iron, mostly of low bio-availability.

21. Possible Outcomes of Maternal Anaemia Degree of anaemia -Moderate (Hb 7 -10 gm/dl) -Severe (Hb 4 -6.9 gm/dl) -Very severe (Hb less than 4 gm/dl) Corresponding haematocrit (PCV) values are: -Moderate (24 – 37 %) -Severe (13 – 23 %) -Very severe (< 13 %)

22. Possible Outcomes of Maternal Under-Nutrition Anaemia  WHO estimates that more than half pregnant women in the world & approximately 2/3 of pregnant women in developing countries have a Hb level indicative of anaemia. This anaemia is associated with a five fold increase in maternal mortality.  Iron & folic acid supplementation may prevent the deterioration during the increased physiological burden of pregnancy.

23. Nutrition during pregnancy Anemia causes: high iron requirement due to fetal & placental growth. Impairment of Iron metabolism. Short spacing. Dietary iron low level. Blood loss (Intestinal parasites). It may be due to folic acid &Vit B deficiency leading to severe anemia ( 7 gm/dl). It may be due to protien deficiency.

24. Nutrition during pregnancy Anemia causes o Io If anemia doesn't respond to iron therapy then it may be Thalesemia

25. Other preventive measures applied during antenatal care  Active immunization by tetanus toxiod 5 doses. first dose at the beginning of the second trimester one month 2 nd dose 6months 1 st booster one year 2 nd booster one year 3 rd booster

26. Other preventive measures applied during antenatal care IIron & folic acid supplementation to treat anemia. NNutritional supplementation (low weight gain during pregnancy & low pre pregnancy weight )  High protein biscuit  Dried skimmed milk

27. Other preventive measures applied during antenatal care  In endemic area for malaria chemoprophylaxis.  Treatment of hook worms & other helminthes.  Prevention & treatment of STDs.

28. Health Education PProper nutrition. PPersonal hygiene & environmental sanitation. NNormal changes during pregnancy & important dangerous signs. IImportance of tetanus toxoid vaccination.

29. Health Education  Home activities: sleep,rest,exercise,avoidance of exhausting work.  Training for child birth & clean delivery.  Preparation for :BF, principles of child care, feeding, weaning, vaccination ….,etc

30. Conclusion Essential element in MCH services include six elements. Pre-conceptional care is the first step followed by antenatal care which is a vital and called a normal care. Services provided during such care are intended to promote and protect health and well being of mothers and their fetus.