Tutors Guide
Jakarta, Indonesia
December 2012
Table of Contents
1. Introduction..................................................................4
Student Characteristics...........................................................4
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
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)
- Womens 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.
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.
Cultural competence
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
Nutrition requirements and mineral and vitamin supplements
Immunization
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.
Pre-pregnancy counselling and the use folic acid preconception and nutritional
Immunization
Care during subsequent visits (2nd, 3rd and 4th) for the Basic component of focused
antenatal care
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
or vaginal examination should be performed only with the client/patients 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
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
given in the fourth year and consolidated during the fifth year in the Womens Health module.
This includes clerking of in-patients (pregnant women/patients), participation in out-patient
clinics. These skills will be reinforced in the pre-internship rotation.
Sub-topics to be covered
Method
Year
Assessment
Introduction Lectures
3rd
Evaluation
Assessment
Introduction Lectures
3rd
Goals of FANC
Presentation/Discussion
Focused
antenatal
(FANC)
care
Comparions
of
traditional
and
Self-assessment
Questions
Group discussion
focused
Case-based discussion
antenatal care
First antenatal Visit1
Directly
observed
Role play
3rd,4th,5th
Clinical Examination
3rd,4th,5th
Mini CEX
Essential/Supporting Investigations
Examination on Clients
Introduction Lectures
3rd
Evaluation
Case-based discussion
Interventions for Basic ANC Component
Introduction Lectures
Problem/Case-based
&
and
discussion
Self-study
Group Discussion
practical skills
OSCE
Directly
observed
practical skills
3rd
MCQ, MEQ,
Long
case
examination
based
Topic
Sub-topics to be covered
Method
Year
Assessment
Presentation/Discussion
3rd,4th,5th
Evaluation
Research by
Problem/Case-based
discussion
Topic discussion
5th
Communication/Counsellin
Leucorrhoea, etc
Anaemia
Problem/Case-based
3rd
Nutrition
discussion
scenarios
th
4 )
&
student
group
Newborn Care
Topic discussion
3rd
Nutrition
Breast-feeding
Family planning
Danger signs in post-partum period
Sexual relations in the puerperium
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
Topic
Sub-topics to be covered
Method
Year
Assessment
Evaluation
Baby
Thermal protection
Cord care
Sleeping patterns
Hygiene (washing, bathing)
Pre-pregnancy counselling
Self study
3rd
&
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 Trainers 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)
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
-
Problem-based discussion
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)
breech
or
transverse
presentation;labour:
(spontaneous,
induced,
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).
Pregnancy
of Child
(Normal
complicated)
or
Duration of
Delivery
pregnancy
(Normal
Postpartum
or
complicated
)
(Normal
or
complicated)
Birth weight
Status
birth
at
Other
note
issues
of
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
Menstrual History
The first day of last menstrual period
Menstrual cycle
Expected date of delivery
Maturity by dates
Contraceptive History
Previous contraceptive history
History of contraception before pregnancy
Previous Obstetric History
Number of pregnancies
Number of deliveries
Number of labour at term, preterm labor
Mode of delivery
Number of living children, birth weight, and
sex
Number of miscarriage(s), abortion(s)
Bleeding in previous pregnancy, labour, and
puerperium
Presence of hypertension, pre-eclampsiain
previous pregnancies
Other problems in previous pregnancies,
labours and puerperium
Breech or transverse presentation
Duration of exclusive breast feeding
Infant weight of <2.5 kg or> 4 kg
IUGR
Twins
Perinatal, neonatal, fetal death
Family History
Diabetes mellitus
Hypertension
Multiple pregnancy
Congenital abnormalities
Other Medical History
Heart disease
Hypertension
Diabetes mellitus (DM)
Liver diseases such as hepatitis
Tuberculosis (TB)
Chronic renal disease
Malaria
Asthma
Epilepsy
Any regular medication
Allergy to medication, food
History of surgery (other than CS)
Sexually transmitted diseases
HIV status if known
History of blood transfusion
Blood group
History of trauma/accident
Status of tetanus immunization
Socio-economic History
Marital status, number of times married and Number of family members helping at home
age of marriage(s)
Occupation and daily activities
Decision maker in the family
Occupation of the spouse
Maternal and family responses to pregnancy
and labor preparedness
Education
Options of place for delivery
Income (if possible)
Housing
Eating or drinking habits
Sanitation conditions
Ethnic group
Electricity
Smoking, use of recreational drugs and Cooking facilities
alcohol
Sexual life, history of casual sex
Vital signs: (blood pressure, body temperature, pulse rate, respiratory rate)
Body weight
Height
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:
Breast Examination
Visual Inspection of the Breasts
O
O
O
O
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.
O
C
- Fundal height
Vaginal Examination
O - 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.
O - Vaginal examination to assess: cervix*, uterus*, adnexa*, Bartholins, urethral, Skenes
glands (*when gestational age is <12 weeks). This is usually not carried out in Indonesia.
O
C
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.
22-27 weeks
28 weeks
29-35 weeks
36 weeks
(28 2) cm
2) cm
(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)
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?
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 DateCalendar 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)
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 USAIDACCESS)
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
The woman or family member present at childbirth lack power to make a decision
No available person to take care of the children, the home and livestock
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 womans 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 womans 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.
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 womans 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*
O
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
Severe abdominal pain
Also ensure that she knows the signs of labour, which indicate a need to contact the skilled
provider and enact the birth preparedness plan:
(Reference: Basic Maternal and Newborn Care: A Guide for Skilled Providers:
JHPIEGO/Maternal and Neonatal Health Program, 2004)
History:
Her two previous pregnancies were uneventful and she delivered at the local puskesmas
All other aspects of her physical examination are within normal range.
O
O
Tests: Hemoglobin is 9 g/dL. Other test results: RPR non-reactive; HIV negative; blood
type - A, Rh-positive.
Evaluation
O
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 32week 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
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?
O
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?
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?
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.
3. What physical examination will you include in your assessment of Sara, and why?
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.
The purpose is to determine Saras eligibility to follow the basic component of FANC. Also
advise her on nutrition, hygiene and rest.
4. What laboratory tests will you include in your assessment of Sara, and why?
Sara will have routine investigations (as mentioned under Tests).
O
Evaluation
O
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?
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 postpartum 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).
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
postnatal period, including the need for social support during and after pregnancy;
Prepare emotionally and physically the pregnant woman and her partner and, where
Trigger
Nina and her husband want to know more about diet in pregnancy. They belong to the middleincome group and they do not have any food taboos. How will you advise them?
Answer
Nutritional Support
Based on Ninas 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.
day
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.
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.
Mrs. B.s mother-in-law provides some help with childcare and housework.
All other aspects of her physical examination are within normal range.
Her blood pressure is 100/70 mm Hg, and her temperature is 37.6C. (Although
temperature is not a routine part of antenatal care, because she comes from a malarious
area, this is part of the assessment.)
O
O
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?
6. Based on your diagnosis (problem/need identification), what is your plan of care for
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.
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.
O
O
7. Based on these findings, what is your continuing plan of care for 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.
O
O
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.
O
O
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.
O
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.
O
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).
O
O
O
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.
O
O
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.
O
O
3. What physical examination will you include in your assessment of Mrs. B., and why?
O
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.
O
O
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.
O
O
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.
Diagnosis (Interpreting information to identify problems/needs)
You have completed your assessment of Mrs. B., and your main findings include the
following:
History:
O
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.
O She denies any symptoms of malaria now.
She reports that she had no signs or symptoms of anemia during her previous pregnancies.
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.
O
O
Physical examination:
All other aspects of her physical examination are within normal range: Her blood pressure is
100/70 mm Hg, and her temperature is 37.6C. (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.
O
O
Testing: Hemoglobin is 9 g/dL.Other test results: RPR non-reactive; HIV negative; blood
type - O, Rh-positive.
O
O
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.
O
O
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.
O
O
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.
Mrs. B. should receive basic care provision (i.e., nutritional support, birth planning, additional
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.
O
O
O
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.
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.
O
Evaluation Mrs. B. comes back to the antenatal clinic on the appointed date, and on
assessment your findings are as follows:
O
O
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.
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.
O
O
7. Based on these findings, what is your continuing plan of care for Mrs. B.?
O
O
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.
O
O
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
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 womans 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.
b.
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.
b.
c.
d.
a) and b)
e.
a.
b.
c.
d.
a) and c)
e.
5.
6.
7.
8.
a.
b.
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.
b.
c.
d.
a) and b)
e.
a.
b.
c.
d.
a) and c)
e.
subsequent pregnancies.
5.
6.
7.
8.
O
O 3.Counseling to prevent acquiring HIV is important for HIV-negative women but not for HIVpositive women.
O 4. ARVs should be provided during pregnancy for the health of the baby but not for the
mother.
O 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.
O 6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.
O 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
3. Counseling to prevent acquiring HIV is important for HIV-negative womenbut not for HIVpositive 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
their infant for 6 months.
4. The answer is False
5. The answer is True
6. The answer is True
7. The answer is True
11.4.4 Knowledge Assessment:
Postpartum family planning
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.
4. IUD use:
6 a) Is associated with infertility
7 b) Increases risk of PID
8 c) is contraindicated in any woman who is HIV+
9 d) None of the above
10 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.___
O 7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks
postpartum.______
O
8. IUDs and hormonal contraception may increase the risk of acquisition of HIV.
O11. Vasectomy is not effective immediately, so the use of a backup contraceptive method
for 1 month after the procedure is recommended. _____
O
12. IUDs are the most cost-effective reversible method if used for 2 years or more.____
6 weeks postpartum
b.
Immediate postpartum
c.
Antenatal
d.
e.
a) and b)
All of the above
Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have
not returned
4. IUD use:
a. Is associated with infertility
b. Increases risk of PID
c.
8. IUDs and hormonal contraception may increase the risk of acquisition of HIV. False
O 10. Fertility awareness methods (such as Standard Days Method) can be started at 6
weeks postpartum for both breastfeeding and non-breastfeeding women. False
O11. Vasectomy is not effective immediately, so the use of a backup contraceptive method
for 1 month after the procedure is recommended. True
O
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)
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
3. Ask the woman number of
previous
pregnancies
LMP
and
and
contraceptive history.
5. Calculate the EDD and gestational age.
6. Ask the woman whether she has felt fetal movements within the
minutes.
5. Dispose off needle and syringe in puncture-proof container.
6. Immerse both gloved hands in 0.5% chlorine solution and remove
gloves.
7. Wash hands thoroughly with soap and water and dry.
8. Record results on the womans antenatal card.
9. Discuss the findings with her.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Identify problems/needs
Identify the womans individual problems/needs, based on the
findings of the antenatal history, physical examination and screening
procedures.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
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.
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 womans
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
Getting Ready
Cases
the
woman
in
deciding
companionofherchoicetostaywithherduringlaborandchildbirth,and
her during transport if needed.
12.
Assists
the
woman
in
making
the
accompany
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
O
Item
20. Makes sure the woman has gathered necessary items for the newborn
Yes
No
Yes
The mother is comfortable with back and arms supported.
Babys head and body are aligned; babys abdomen is
turned toward the mother.
Babys face is facing the breast with nose opposite nipple.
Babys body is held close to the mother.
Babys whole body is supported.
The baby is brought to the nipple height.
The mother maysupporttheweightofher breast with her
Holding
Attachment
and Suckling
Mother
comfort
Finishing
breast feed
the
No
Case
Case
Case
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---------------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.
Step/Task
Preamble
1. Prepare the necessary equipment.
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.
Physical Examination
1. Ask the woman to empty her bladder and save and test the urine.
2. Observe the womans general appearance and gait.
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. Conduct a general examination: check eyes for anaemia,
palpebral edema, tongue, thyroid
7. Take the womans 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
Case
Case
Case
Step/Task
Case
Case
Case
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
- 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.
14. Examine abdomen and determine lie and presentation (after 36
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 womans abdomen and help her sit up
Step/Task
19. Wash hands thoroughly with soap and water and dry.
20. Explain/summarize the findings
If bivalve (Cuscos) speculum examination will be done: after
step 15 of obstetric examination
1. Cover the womans 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
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
7. Put examination gloves on both 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 womans thighs with drapes
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
Case
Case
Case
Step/Task
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
16. Record all relevant findings on the womans antenatal card.
Case
Case
Case
Date Observed----------------------
Encourages the woman to explain her needs and concerns and ask questions.
listens to her.
Includes womans partner or important family member in the discussion, as the woman desires and
members.
ASKDetermine reproductive intentions, knowledge of pregnancy risk and use of various contraceptives.
4. Determines any previous
Explores womans knowledge and beliefs about the return of fertility and the benefits of pregnancy
experiences with family planning.
5. Assesses partner/family
Explores partners/familys knowledge and beliefs about the return of fertility and the benefits of
pregnancy spacing/limiting.
71
ASSESSMENT
6. Assesses reproductive
Asks about desired number of children, desire to space or limit births, desire for long-term family
intentions.
7. Assesses need for protection
planning, etc.
Explores womans need for protection from STIs, including HIV.
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
Based on availability and on womans prior knowledge and interest, briefly explains the advantages,
PPFP methods.
72
Gives woman additional information that she may need and answer any questions.
Assesses her knowledge about the selected method; provides additional information as needed.
Acknowledges the womans choice and advises her on the steps involved in providing her with her
chosen method.
EVALUATE and EXPLAINDetermine 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 womans health
Copper T 380A)
Removal: Can be removed at any time by a trained provider with immediate return to fertility
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)
Immediate return of fertility upon removal
Does not affect breastfeeding or breast milk
Long-acting and reversible (as described above)
Heavier and more painful menses for some women, especially first few cycles after interval IUD (less
PPIUD:
73
RETURNPlan for next steps and for when she will arrive to hospital for delivery.
18. Plans for next steps.
Makes notation in the womans 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).
1. Discusses warning signs;
explains that she should return to
the clinic as soon as possible if
any arise.
2. Confirms that the woman
understands instructions.
3. Concludes the interaction
74
75