ANTENATAL CARE

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.

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

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.

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)

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.

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

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.

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.

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.

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

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

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.

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 15-49 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

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)

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.

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

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.

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.

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.

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?

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

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?”

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

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