primarymaternalcareantenatalcare-120417044447-phpapp02

7/28/2019 primarymaternalcareantenatalcare-120417044447-phpapp02

http://slidepdf.com/reader/full/primarymaternalcareantenatalcare-120417044447-phpapp02 1/21

1

Antenatal care

Beore you begin this unit, please take thecorresponding test at the end o the book toassess your knowledge o the subject matter. Youshould redo the test afer you’ve worked throughthe unit, to evaluate what you have learned.

Objectives

When you have completed this unit you

should be able to:

Diagnose pregnancy.List the aims o booking the antenatal

visit.

Know what history should be taken and

examination done at the frst visit.

Determine the duration o pregnancy.

List and assess the results o the side

room and screening tests needed at the

frst visit.

Identiy low, intermediate and high-risk

pregnancies.

Plan and provide antenatal care that isproblem oriented.

List what specifc complications to look

or at 28, 34 and 41 weeks.

Provide health inormation during

antenatal visits.

Manage women with HIV inection.

••

•

•

•

•

•

•

•

•

GOALS OF GOOD

ANTENATAL CARE

1-1 What are the aims and principles

o good antenatal care?

Te aims o good antenatal care are to ensurethat pregnancy causes no harm to the motherand to keep the etus healthy during theantenatal period. In addition, the opportunity

must be taken to provide health education.Tese aims can usually be achieved by theollowing:

Antenatal care must ollow a denite plan.Antenatal care must be problem oriented.Possible complications and risk actors thatmay occur at a particular gestational agemust be looked or at these visits.Te etal condition must be repeatedly assessed.Health care education must be provided.

All inormation relating to the pregnancy mustbe entered on a patient-held antenatal card.Te antenatal card can also serve as a reerralletter i a patient is reerred to the next level o care and thereore serves as link between thedierent levels o care as well as the antenatalclinic and labour ward.

The antenatal card is an important source

o inormation during the antenatal period

and labour.

1.2.3.

4.

5.



15ANTENATAL CARE

DIAGNOSING PREGNANCY

1-2 How can you confrm that

a patient is pregnant?

Te common symptoms o pregnancy areamenorrhoea (no menstruation), nausea,breast tenderness and urinary requency. I the history suggests that a patient is pregnant,the diagnosis is easily conrmed by testingthe urine with a standard pregnancy test. Tetest becomes positive by the time the rst

menstrual period is missed.

A positive pregnancy test is produced by both an intra-uterine and an extra-uterinepregnancy. Tereore, it is important toestablish whether the pregnancy is intra-uterine or not.

Confrm that the patient is pregnant beore

beginning antenatal care.

1-3 How do you diagnose an

intra-uterine pregnancy?Te characteristics o an intra-uterinepregnancy are:

Te size o the uterus is appropriate or theduration o pregnancy.Tere is no lower abdominal pain or vaginal bleeding.Tere is no tenderness o the lowerabdomen.

1-4 How do you diagnose an

extra-uterine pregnancy?Te characteristics o an extra-uterine(ectopic) pregnancy are:

Te uterus is smaller than expected or theduration o pregnancy.Lower abdominal pain and vaginalbleeding are usually present.enderness over the lower abdomen isusually present.

1.

2.

3.

1.

2.

3.

THE FIRSTANTENATAL VISIT

Tis visit is usually the patient’s rst contactwith the medical services during her pregnancy.She must be treated with kindness andunderstanding in order to gain her condenceand to ensure her uture co-operation andregular attendance. Tis opportunity must betaken to book the patient or antenatal careand, thereby, ensure the early detection andmanagement o treatable complications.

1-5 At what gestational age should a

patient frst attend an antenatal clinic?

As early as possible, preerably when thesecond menstrual period has been missed, i.e.at a gestational age (duration o pregnancy)o 8 weeks. Note that or practical reasonsthe gestational age is measured rom the rstday o the last normal menstrual period.Antenatal care should start at the time that thepregnancy is conrmed.

It is important that all pregnant women book as

early as possible.

1-6 What are the aims o the

frst antenatal visit?

A ull history must be taken.A ull physical examination must be done.Te duration o pregnancy must beestablished.Important screening tests must be done.Some high-risk patients can be identied.

1-7 What history should be taken?

A ull history, containing the ollowing:

Te previous obstetric history.Te present obstetric history.A medical history.HIV status.History o medication and allergies.A surgical history.A amily history.

1.2.3.

4.5.

1.2.3.4.5.6.7.



16 PRIMARY MATERNAL CARE

Te social circumstances o the patient.

1-8 What is important in the

previous obstetric history?

Establish the number o pregnancies(gravidity), the number o previouspregnancies reaching viability (parity) andthe number o miscarriages and ectopicpregnancies that the patient may have had.Tis inormation may reveal the ollowingimportant actors:

Grande multiparity (i.e. 5 or more

pregnancies which have reached viability).Miscarriages: 3 or more successive rsttrimester miscarriages suggest a possiblegenetic abnormality in the ather ormother. A previous midtrimestermiscarriage suggests a possibleincompetent internal cervical os.Ectopic pregnancy: ensure that thepresent pregnancy is intra-uterine.Multiple pregnancy: non-identicaltwins tend to recur.

Te birth weight, gestational age andmethod o delivery o each previous inantas well as o previous perinatal deaths areimportant:

Previous low birth weight inants orspontaneous preterm labours tend torecur.Previous large inants (4 kg or more)suggest maternal diabetes.Te type o previous delivery is alsoimportant: a orceps delivery or vacuum extraction may suggest that adegree o cephalopelvic disproportionhad been present. I the patient hada previous caesarean section, theindication or the caesarean sectionmust be determined.Te type o incision in the uterus is alsoimportant (this inormation must beobtained rom the patient’s older) asonly patients with a transverse lowersegment incision should be consideredor a possible vaginal delivery.

8.

1.

•

•

•

•

2.

•

•

•

•

Having had one or more perinataldeaths places the patient at high risk o urther perinatal deaths. Tereore,every eort must be made to nd outthe cause o any previous deaths. I nocause can be ound, then the risk o arecurrence o perinatal death is evenhigher.

Previous complications o pregnancy orlabour:

In the antenatal period, e.g. pre-eclampsia, preterm labour, diabetes,and antepartum haemorrhage. Patientswho develop pre-eclampsia beore 34weeks gestation have a greater risk o pre-eclampsia in urther pregnancies.First stage o labour, e.g. a long labour.Second stage o labour, e.g. impactedshoulders.Tird stage o labour, e.g. a retainedplacenta or a postpartum haemorrhage.

Complications in previous pregnancies tend to

recur in subsequent pregnancies. Thereore,

patients with a previous perinatal death are

at high risk o another perinatal death, whilepatients with a previous spontaneous preterm

labour are at high risk o preterm labour in their

next pregnancy.

1-9 What inormation should be asked or

when taking the present obstetric history?

Te rst day o the last normal menstrualperiod must be determined as accurately aspossible.Any medical or obstetric problems whichthe patient has had since the start o thispregnancy, or example:

Pyrexial illnesses (such as inuenza)with or without skin rashes.Symptoms o a urinary tract inection.Any vaginal bleeding.

Attention must be given to minor symptomswhich the patient may experience duringher present pregnancy, or example:

Nausea and vomiting.Heartburn.

•

3.

•

••

•

1.

2.

•

••

3.

••



17ANTENATAL CARE

Constipation.Oedema o the ankles and hands.

Is the pregnancy planned and wanted, andwas there a period o inertility beore shebecame pregnant?I the patient is already in the thirdtrimester o her pregnancy, attention mustbe given to the condition o the etus.

1-10 What important acts must be

considered when determining the

date o the last menstrual period?

Te date should be used to measure theduration o pregnancy only i the patienthad a regular menstrual cycle.Were the date o onset and the duration o the last period normal? I the last periodwas shorter in duration and earlier inonset than usual, it may have been animplantation bleed. Ten the previousperiod must be used to determine theduration o pregnancy.Patients on oral or injectable contraceptionmust have menstruated spontaneously

afer stopping contraception, otherwise thedate o the last period should not be usedto measure the duration o pregnancy.

1-11 Why is the medical history important?

Some medical conditions may become worseduring pregnancy, e.g. a patient with heart valve disease may go into cardiac ailurewhile a hypertensive patient is at high risk o developing pre-eclampsia.

Ask the patient i she has had any o theollowing:

Hypertension.Diabetes mellitus.Rheumatic or other heart disease.Epilepsy.Asthma.uberculosis.Psychiatric illness.Any other major illness.

••

4.

5.

1.

2.

3.

1.2.3.4.5.6.7.8.

1-12 Why is it important to ask about anymedication taken and a history o allergy?

Ask about the regular use o any medication. Tis is ofen a pointer to anillness not mentioned in the medical history.Certain drugs can be teratogenic (damagethe etus) during the rst trimester o pregnancy, e.g. retinoids which are usedor acne and eavirenz (Stocrin) used inantiretroviral treatment.Some drugs can be dangerous to the etus i they are taken close to term, e.g. Wararin.

Allergies are also important and the patientmust be specically asked i she is allergicto penicillin.

1-13 What previous operations

may be important?

Operations on the urogenital tract,e.g. caesarean section, myomectomy, acone biopsy o the cervix, operations orstress incontinence and vesicovaginalstula repair.Cardiac surgery, e.g. heart valve

replacement.

1-14 Why is the amily history important?

Close amily members with a condition suchas diabetes, multiple pregnancy, bleedingtendencies or mental retardation increases therisk o these conditions in the patient and herunborn inant. Some birth deects are inherited.

1-15 Why is inormation about the patient’s

social circumstances very important?

Ask i the woman smokes cigarettes ordrinks alcohol. Smoking may cause intra-uterine growth restriction while alcoholmay cause both intra-uterine growthrestriction and congenital malormations.Te unmarried mother may need help toassist her to plan or the care o her inant.Unemployment, poor housing andovercrowding increase the risk o tuberculosis, malnutrition and intra-uterine growth restriction. Patients living

1.

2.

3.

4.

1.

2.

1.

2.

3.




in poor social conditions need specialsupport and help.

1-16 To which systems must you

pay particular attention when

doing a physical examination?

Te general appearance o the patient is o great importance as it can indicate whetheror not she is in good health.A woman’s height and weight may reecther past and present nutritional status.In addition the ollowing systems or organs

must be careully examined:Te thyroid gland.Te breasts.Lymph nodes in the neck, axillae(armpits) and inguinal areas.Te respiratory system.Te cardiovascular system.Te abdomen.Both external and internal genitalia.


examination o the thyroid gland?

A thyroid gland which is visibly enlargedis possibly abnormal and must beexamined by a doctor.A thyroid gland which on palpation isonly slightly, diusely enlarged is normalin pregnancy.An obviously enlarged gland, a singlepalpable nodule or a nodular goitre isabnormal and needs urther investigation.


examination o the breasts?

Inverted or at nipples must be diagnosedand treated so that the patient will be morelikely to breasteed successully.A breast lump or a blood-stained dischargerom the nipple must be investigated urtheras it may indicate the presence o a tumour.Whenever possible, patients should beadvised and encouraged to breasteed.eaching the advantages o breasteedingis an essential part o antenatal care and

1.

2.

3.

•••

••••

1.

2.

3.

1.

2.

3.

must be emphasised in the ollowinggroups o women:

HIV-negative women.Women with unknown HIV status.HIV-positive women who have electedto exclusively breasteed.


examination o the respiratory

and cardiovascular systems?

Look or any signs which suggest that thepatient has diculty breathing (dyspnoea).

Te blood pressure must be measured andthe pulse rate counted.

1-20 How do you examine the

abdomen at the booking visit?

Te abdomen is palpated or enlargedorgans or masses.Te height o the undus above thesymphysis pubis is measured.

1-21 What must be looked or

when the external and internalgenitalia are examined?

Signs o sexually transmitted diseaseswhich may present as single or multipleulcers, a purulent discharge or enlargedinguinal lymph nodes.Carcinoma o the cervix is the commonestorm o cancer in most communities.Advanced stages o this disease presentas a wart-like growth or an ulcer on thecervix. A cervix which looks normal doesnot exclude the possibility o an early

cervical carcinoma.

1-22 When must a cervical smear be

taken when examining the internal

genitalia (gynaecological examination)?

All patients aged 30 years or more whohave not previously had a cervical smearthat was reported as normal.All patients who have previously hada cervical smear that was reported asabnormal.

•••

1.

2.

1.

2.

1.

2.

1.

2.



19ANTENATAL CARE

All patients who have a cervix that looksabnormal.All HIV-positive patients who did not havea cervical smear reported as normal withinthe last year.

A cervix that looks normal may have an early

carcinoma.

DETERMINING THE

DURATION OF PREGNAN CY

All available inormation is now used toassess the duration o pregnancy as accurately as possible:

Last normal menstrual period.Size o the uterus on bimanual orabdominal examination up to 18 weeks.Height o undus at or afer 18 weeks.Te result o an ultrasound examination(ultrasonology).

An accurate assessment o the duration o

pregnancy is o great importance, especially i the woman develops complications later in her

pregnancy.

1-23 When is the duration o

pregnancy calculated rom the

last normal menstrual period?

When there is certainty about the accuracy o the dates o the last, normal menstrual period.Te duration o pregnancy is then calculatedrom the rst day o that period.

1-24 How does the size o the uterus

indicate the duration o pregnancy?

Up to 12 weeks the size o the uterus,assessed by bimanual examination,is a reasonably accurate method o determining the duration o pregnancy.Tereore, i there is uncertainty about theduration o pregnancy beore 12 weeks

3.

4.

1.2.

3.4.

1.

the patient should be reerred or abimanual examination.From 13 to 17 weeks, when the unduso the uterus is still below the umbilicus,the abdominal examination is the mostaccurate method o determining theduration o pregnancy.From 18 weeks, the symphysis-undusheight measurement is the more accuratemethod.

1-25 How should you determine the

duration o pregnancy i the uterinesize and the menstrual dates do not

indicate the same gestational age?

I the undus is below the umbilicus(in other words, the patient is less than22 weeks pregnant):

I the dates and the uterine size dier by 3 weeks or more, the uterine size shouldbe considered as the more accurateindicator o the duration o pregnancy.I the dates and the uterine size dierby less than 3 weeks, the dates are more

likely to be correct.I the undus is at or above the umbilicus(in other words, the patient is 22 weeks ormore pregnant):

I the dates and the uterine size dier by 4 weeks or more, the uterine size shouldbe considered as the more accurateindicator o the duration o pregnancy.I the dates and the uterine size dierby less than 4 weeks, the dates are morelikely to be correct.

1-26 How should you use the symphysis-undus height measurement to

determine the duration o pregnancy?

From 18 weeks gestation, the symphysis-undus (S-F) height measurement in cm isplotted on the 50th centile o the S-F growthcurve to determine the duration o pregnancy.For example, a S-F measurement o 26 cmcorresponds to a gestation o 27 weeks.

2.

3.

1.

•

•

2.

•

•




A dierence between the gestational ageaccording to the menstrual dates and the size o

the uterus is usually the result o incorrect dates.

1-27 What conditions other than

incorrect menstrual dates cause a

dierence between the duration o

pregnancy calculated rom menstrual

dates and the size o the uterus?

A uterus bigger than dates suggests:Multiple pregnancy.

Polyhydramnios.A etus which is large or thegestational age.Diabetes mellitus.

A uterus smaller than dates suggests:Intra-uterine growth restriction.Oligohydramnios.Intra-uterine death.Rupture o the membranes.

SIDE ROOM AND SPECIAL

INVESTIGATIONS

1-28 Which side room examinations

must be done routinely?

A haemoglobin estimation at the rstantenatal visit and again at 28 and 36 weeks.A urine test or protein and glucose is doneat every visit.

1-29 What special investigations

should be done routinely?

A serological screening test or syphilis. AnRPR card test or syphilis rapid test can beperormed in the clinic, i a laboratory is notwithin easy reach o the hospital or clinic.Determining whether the patient’s bloodgroup is Rh positive or negative. A Rh cardtest can be done in the clinic.A rapid HIV screening test afer healthworker initiated counselling and preerably afer written consent.

1.•

••

•2.

••••

1.

2.

1.

2.

3.

A smear o the cervix or cytology i it isindicated (as listed in 1-22).I possible, all patients should have amidstream urine specimen examined orasymptomatic bacteriuria. Te best test isbacterial culture o the urine.Where possible, an ultrasoundexamination when the patient is 18–22 weeks pregnant can be arranged

NOTE Ultrasound screening at 11 to 13 weeks

or nuchal thickness, or the triple test, is very

useul in screening or Down syndrome

and other chromosomal abnormalities.Written inormed consent or HIV testing

is not a legal requirement in South Arica,

but recommended as good practice.

1-30 Is it necessary to do an ultrasound

examination on all patients who book

early enough or antenatal care?

With well-trained ultrasonographers andadequate ultrasound equipment, it is o great value to:

Accurately determine the gestational

age i the rst ultrasound examination isdone at 24 weeks or less. With uncertaingestational age the undal height willmeasure less than 24 cm.Diagnose multiple pregnancies early.Identiy the site o the placenta.Diagnose severe congenital abnormalities.

I it is not possible to provide ultrasoundexaminations to all antenatal patients beore24 weeks gestation, the ollowing groups o patients may benet greatly rom the additionalinormation which may be obtained:

Patients with a gestational age o 14 to16 weeks:

Patients aged 37 years or more becauseo their increased risk o having a etuswith a chromosomal abnormality (especially Down syndrome). A patientwho would agree to termination o pregnancy i the etus was abnormal,should be reerred or amniocentesis.Patients with a previous history or amily history o congenital

4.

5.

6.

1.

2.3.4.

1.

•

•



21ANTENATAL CARE

abnormalities. Te nearest hospital witha genetic service should be contacted todetermine the need or amniocentesis.

Patients with a gestational age o 18 to22 weeks:

Patients needing elective delivery (e.g. those with 2 previous caesareansections, a previous perinatal death,a previous vertical uterine incision orhysterotomy, and diabetes).Gross obesity when it is ofen dicultto determine the duration o pregnancy.Previous severe pre-eclampsia orpreterm labour beore 34 weeks. Asthere is a high risk o recurrenceo either complication, accuratedetermination o the duration o pregnancy greatly helps in themanagement o these patients.Rhesus sensitisation where accuratedetermination o the duration o pregnancy helps in the management o the patient.

An ultrasound examination done ater 24 weeks

is too unreliable to be used to estimate theduration o pregnancy.

1-31 What is the assessment o

risk ater booking the patient?

Once the patient has been booked or antenatalcare, it must be assessed whether she or heretus have complications or risk actors present,as this will decide when she should be seenagain. At the rst visit some patients shouldalready be placed in a high-risk category.

1-32 I no risk actors are ound

at the booking visit, when should

the patient be seen again?

She should be seen again when the results o the screening tests are available, preerably 2 weeks afer the booking visit. However, i no risk actors were noted and the screeningtests done as rapid tests were normal thesecond visit is omitted.

2.

•

•

•

•

1-33 I there are risk actors notedat the booking visit, when should

the patient be seen again?

A patient with an underlying illness mustbe admitted or urther investigation andtreatment.A patient with a risk actor is ollowed upsooner i necessary:

Te management o a patient withchronic hypertension would beplanned and the patient would be seena week later.

An HIV-positive patient with anunknown CD4 count must be seena week later to obtain the result andplan what antiretroviral treatment sheshould receive.

1-34 How should you list risk actors?

All risk actors must be entered on the problemlist on the back o the antenatal card. Tegestational age when management is neededshould be entered opposite the gestational ageat the top o the card, e.g. vaginal examination

must be done at each visit rom 26 to 32 weeksi there is a risk o preterm labour.

Te clinic checklist (Fig1-III) or the rst visitcould now be completed. I all the open blocksor the rst visit can be ticked o, the visitis completed and all important points havebeen addressed. Te checklist should again beused during urther visits to make sure that allproblems have been considered (i.e. it shouldbe used as a quality control tool).

THE SECONDANTENATAL VISIT

1-35 What are the aims o the

second antenatal visit?

I the results o the screening tests were notavailable by the end o the rst antenatal visit, a second visit should be arranged 2weeks later to review and act on these results.It would then be important to perorm the

1.

2.

•

•




second screen or risk actors. I possible, allthe results o the screening tests should beobtained at the rst visit.

Assessing the results o the specialinvestigations

1-36 How should you interpret the results

o the screening tests or syphilis?

Te correct interpretation o the results is o the greatest importance:

I either the VDRL (Venereal Disease

Research Laboratory) or RPR (RapidPlasmin Reagin) or syphilis rapid test isnegative, then the patient does not haveantibodies against the spirochaetes whichcause syphilis. Tis means the patient doesnot have syphilis and no urther tests orsyphilis are needed.I the VDRL or RPR titre is 1:16 or higher,the patient has syphilis and must be treated.I theVDRL or RPR titre is 1:8 or lower(or the titre is not known), the laboratory should test the same blood sample by

means o the PHA (reponema PallidumHaemagglutin Assay) or FA (Fluorescentreponemal Antibody) test:

I the PHA (or FA or syphilis rapidtest) is also positive, the patient hassyphilis and must be ully treated.I the PHA (or FA or syphilis rapidtest) is negative, then the patient doesnot have syphilis and, thereore, neednot be treated.I a PHA (or FA or syphilis rapidtest) cannot be done, and the patienthas not been ully treated or syphilis inthe past 3 months, she must be given aull course o treatment.

A positive syphilis rapid test indicatesthat a person has antibodies against thespirochaetes which cause syphilis. Tismeans that the person either has active(untreated) syphilis or was inected in thepast and no longer has the disease.

A VDRL or RPR titre o less than 1 in 16 may be

caused by syphilis.

1.

2.

3.

•

•

•

4.

NOTE The VDRL, RPR or rapid syphilis test maystill be negative during the frst ew weeks

ater inection with syphilis as the patient has

not yet had enough time to orm antibodies.

1-37 How should the results o the

RPR card test be interpreted?

I the test is negative the patient does nothave syphilis.I the test is strongly positive the patientmost likely has syphilis and treatmentshould be started. However, a blood

specimen must be sent to the laboratory to conrm the diagnosis, and the patientmust be seen again 1 week later. Furthertreatment will depend on the result o thelaboratory test. It is important to explainto the patient that the result o the card testneeds to be checked with a laboratory test.I the test is weakly positive a bloodspecimen must be sent to the laboratory and the patient seen 1 week later. Any treatment will depend on the result o thelaboratory test.

1-38 What is the treatment o

syphilis in pregnancy?

Te treatment o choice is penicillin. I thepatient is not allergic to penicillin, she is givenbenzathine penicillin (Bicillin LA or PenilenteLA) 2.4 million units intramuscularly weekly or 3 weeks. At each visit 1.2 million unitsis given into each buttock. Tis is a painulinjection so the importance o completing theull course must be impressed on the patient.

Benzathine penicillin crosses the placenta and

also treats the etus.

I the patient is allergic to penicillin, she isgiven erythromycin 500 mg 6 hourly orally or14 days. Tis may not treat the etus adequately,however. etracycline is contraindicated inpregnancy as it may damage the etus.

1.

2.

3.



23ANTENATAL CARE

1-39 How should the results o therapid HIV test be interpretted?

I the rapid HIV test is NEGAIVE, there isa very small chance that the patient is HIVpositive. Te patient should be inormedabout the result and given counselling tohelp her to maintain her negative status.I the rapid HIV test is POSIIVE, asecond rapid test should be done with a kitrom another manuacturer. I the secondtest is also positive, then the patient isHIV positive. Te patient should be given

the result and post-test counselling or anHIV-positive patient should be provided.I the rst rapid test is positive and thesecond negative, the patient’s HIV statusis uncertain. Tis inormation should begiven to the patient and blood should betaken and sent to the nearest laboratory oran ELISA test or HIV:

I the ELISA test is negative, thereis only a very small chance that thepatient is HIV positive.I the ELISA test is positive, the patient

is HIV positive.

1-40 What should you do i the cervical

cytology result is abnormal?

A patient whose smear shows aninltrating cervical carcinoma mustimmediately be reerred to the nearestgynaecological oncology clinic (level 3hospital). Te duration o pregnancy is very important, and this inormation(determined as accurately as possible)must be available when the unit is phoned.

A patient with a smear showing a low grade CIL (cervical intra-epithelial lesion)such as CIN I (cervical intra-epithelialneoplasia), atypia or only condylomatouschanges is checked afer 9 months, or asrecommended on the cytology report.A patient with a smear showing a highgrade CIL, such as CIN II or III or atypicalcondylomatous changes, must get anappointment at the nearest gynaecology orcytology clinic.

1.

2.

3.

•

•

1.

2.

3.

Abnormal vaginal ora is only treated i the patient is symptomatic.

It is essential to record on the antenatal card the

plan that has been decided upon, and to ensure

that the patient is ully treated ater delivery.

1-41 What should you do i the patient’s

blood group is Rh negative?

Between 5 and 15% o patients are Rhesusnegative (i.e. they do not have the Rhesus

D antigen on their red cells). Te bloodgrouping laboratory will look or Rhesus anti-D antibodies in these patients. I the Rh cardtest was used, blood must be sent to the bloodgrouping laboratory to conrm the result andlook or Rhesus anti-D antibodies.

I there are no anti-D antibodies present,the patient is not sensitised. Bloodmust be taken at 26, 32 and 38 weeks o pregnancy to determine i the patient hasdeveloped anti-D antibodies since the rsttest was done.

I anti-D antibodies are present, thepatient has been sensitised to the RhesusD antigen. With an anti-D antibody titreo 1:16 or higher, she must be reerred to acentre which specialises in the managemento this problem. I the titre is less than 1:16,the titre should be repeated within 2 weeksor as directed by the laboratory.

1-42 What should you do i the

ultrasound fndings do not agree

with the patient’s dates?

Between 18 and 22 weeks:

I the duration o pregnancy, assuggested by the patient’s menstrualdates, alls within the range o theduration o pregnancy as given by theultrasonographer (usually 3–4 weeks), thedates should be accepted as correct. Tesame principle as explained in 1-25 applies.However, i the dates all outside the rangeo the ultrasound assessment, then thedates must be regarded as incorrect.

4.

1.

2.

1.

2.




I the ultrasound examination is done in therst trimester (14 weeks or less), the error indetermining the gestational age is only oneweek (range 2 weeks).

Remember, i the patient is more than 24weeks pregnant, ultrasonology cannot be usedto determine the gestational age.

1-43 What action should you take i

an ultrasound examination at 18 to 22

weeks shows a placenta praevia?

In most cases the placenta will move out o the lower segment as pregnancy progresses,as the size o the uterus increases more thanthe size o the placenta. Tereore, a ollow-upultrasound examination must be arranged at32 weeks, where a placenta praevia type II orhigher has been diagnosed, to assess whetherthe placenta is still praevia.

1-44 What should you do i the

ultrasound examination shows a

possible etal abnormality?

Te patient must be reerred to a level 3hospital or detailed ultrasound evaluation anda decision about urther management.

GRADING THE RISK

Once the results o the special investigationshave been obtained, all patients must be gradedinto a risk category. (A list o risk actors andthe level o care needed is given in Appendix1). A ew high-risk patients would have already

been identied at the rst antenatal visit.

1-45 What are the risk categories?

Tere are 3 risk categories:

Low (average) risk.Intermediate risk.High risk.

A low-risk patient has no maternal or etalrisk actors present. Tese patients can receiveprimary care rom a midwie.

1.2.3.

An intermediate-risk patient has a problemwhich requires some, but not continuous,additional care. For example, a grandemultipara should be assessed at her rst orsecond visit or medical disorders, and at 34weeks or an abnormal lie. She also requiresadditional care during labour and postpartum.She, thereore, is at an increased risk o problems only during part o her pregnancy,labour and puerperium. Most o the antenatalcare in these patients can be given by a midwie.

A high-risk patient has a problem which

requires continuous additional care. Forexample, a patient with heart valve diseaseor a patient with a multiple pregnancy. Tesepatients usually require care by a doctor.

SUBSEQUENT VISITS

General principles:

Te subsequent visits, e.g. the third andourth visits must be problem oriented.Te visits at 28, 34 and 41 weeks aremore important visits. At these visits,complications specically associated withthe duration o pregnancy are looked or.From 28 weeks onwards the etus is viableand the etal condition must, thereore, beregularly assessed.

1-46 When should a patient return

or urther antenatal visits?

I a patient books in the rst trimester, and isound to be at low risk, her subsequent visits

can be arranged as ollows:Every 8 weeks until 28 weeks.Te next visit is 6 weeks later at 34 weeks.Primigravids are then seen at 36 weeksand multigravidas at 38 weeks. However,multigravidas are also seen again at 36weeks i a breech presentation was presentat 34 weeks.Tereafer primigravidas are seen every 40and 41 weeks while multigravidas are seenat 41 weeks i they have not yet delivered.

1.

2.

3.

1.2.3.

4.



25ANTENATAL CARE

In some rural areas it may be necessary to seelow-risk patients less ofen because o the largedistances involved. Te risk o complicationswith less requent visits in these patients isminimal. Visits may be scheduled as ollows:afer the rst visit (combining the booking andsecond visit), the ollow-up visits at 28, 34 and41 weeks. I possible, primigravidas shouldalso be seen at 38 weeks.

1-47 Which patients should have

more requent antenatal visits?

I a complication develops, the risk gradingwill change. Tis change must be clearly recorded on the patient’s antenatal card.Subsequent visits will now be more requent,depending on the nature o the risk actor.

Primigravidas, whenever possible, must beseen every 2 weeks rom 36 weeks, even i it isonly to check the blood pressure and test theurine or protein, because they are a high-risk group or developing pre-eclampsia.

A waiting area (obstetric village), where

cheap accommodation is available orpatients, provides an ideal solution or someintermediate-risk patients, high-risk patientsand the above-mentioned primigravidas, sothat they can be seen more regularly.

THE VISIT AT 28 WEEKS

1-48 What important complications o

pregnancy should be looked or?

Antepartum haemorrhage becomes a very important high-risk actor rom 28 weeks.Early signs o pre-eclampsia may now bepresent or the rst time, as it is a problemwhich develops in the second hal o pregnancy. Tereore, the patient must beassessed or proteinuria and a rise in theblood pressure.Cervical changes in a patient who is athigh risk or preterm labour, e.g. multiplepregnancy, a history o previous pretermlabour, or polyhydramnios.

1.

2.

3.

I the symphysis-undal heightmeasurement is below the 10th centile,assess the patient or causes o poorundal growth.I the symphysis-undal heightmeasurement is above the 90th centile,assess the patient or the causes o a uteruslarger than dates.Anaemia may be detected or the rst timeduring pregnancy.Diabetes in pregnancy may present now with glycosuria. I so, a random bloodglucose concentration must be measured.

1-49 Why is an antepartum haemorrhage

a serious sign?

Abruptio placentae causes many perinataldeaths.It may also be a warning sign o placentapraevia.

1-50 How should you monitor the

etal condition?

All women should be asked about therequency o etal movements and warnedthat they must report immediately i themovements suddenly decrease or stop.I a patient has possible intra-uterinegrowth restriction or a history o a previousetal death, then she should count etalmovements once a day rom 28 weeks andrecord them on a etal movement chart.


1-51 Why is the 34 weeks visit important?

All the risk actors o importance at 28weeks (except or preterm labour) are stillimportant and must be excluded.Te lie o the etus is now very importantand must be determined. I the presentingpart is not cephalic, then an externalcephalic version must be attempted at 36weeks i there are no contraindications.A grande multipara who goes into labour

4.

5.

6.

7.

1.

2.

1.

2.

1.

2.




with an abnormal lie is at high risk o rupturing her uterus.Patients who have had a previous caesareansection must be assessed with a view to thesaest method o delivery. A patient with asmall pelvis, a previous classical caesareansection, as well as other recurrent causesor a caesarean section must be booked oran elective caesarean section at 39 weeks.Te patient’s breasts must be examinedagain or at or inverted nipples, oreczema o the areolae which may impairbreasteeding. Tese abnormalities shouldbe treated.


1-52 Why is the visit at 41 weeks important?

A patient, whose pregnancy extends beyond42 weeks, has an increased risk o developingthe ollowing complications:

Intrapartum etal distress.

Meconium aspiration.Intra-uterine death.

1-53 How should you manage a

patient who is 41 weeks pregnant?

A patient with a complication such as intra-uterine growth restriction (retardation) orpre-eclampsia must have labour induced.A patient who booked early and was sureo her last menstrual period and where,at the booking visit, the size o the uteruscorresponded to the duration o pregnancy

by dates must have the labour induced onthe day she reaches 42 weeks. Te sameapplies to a patient whose duration o pregnancy was conrmed by ultrasoundexamination beore 24 weeks.A patient who is unsure o her dates, orwho booked late, must have an ultrasoundexamination on the day she reaches42 weeks to determine the amount o amniotic uid present:

I the amniotic uid index is 5 or more(or the largest pool o liquor measures

3.

4.

1.

2.3.

1.

2.

3.

•

3 cm or more) and the patient reportsgood etal movement, she should bereassessed in one weeks time.I the amniotic uid largest pool o liquor measures less than 3 cm, thepregnancy must be induced.

NOTE The amniotic uid index measures the

largest vertical pool o liquor in the each o the 4

quadrants o the uterus and adds them together.

It is very important that the above problemsare actively looked or at 28, 34 and 41 weeks.It is best to memorise these problems and

check then one by one at each visit.

Remember that the commonest cause o being

postterm is wrong dates.

1-54 How should the history,

clinical fndings and results o

the special investigations be

recorded in low-risk patients?

Tere are many advantages to a hand-heldantenatal card which records all the patient’s

antenatal inormation. It is simple, cheap andeective. It is uncommon or patients to losetheir records. Te clinical record is then alwaysavailable wherever the patient presents orcare. Te clinic need only record the patient’spersonal details such as name, address and agetogether with the dates o her clinic visits andthe result o any special investigations.

On the one side o the card are recorded thepatient’s personal details, history, estimatedgestational age, examination ndings,results o the special investigations, plan o

management and proposed uture amily planning. On the other side are recorded allthe maternal and etal observations madeduring pregnancy.

It is important that all antenatal women have a

hand-held antenatal card.

•



27ANTENATAL CARE

1-55 What topics should youdiscuss with patients during the

health education sessions?

Te ollowing topics must be discussed:

Danger symptoms and signs.Dangerous habits, e.g. smoking or drinkingalcohol.Healthy eating.Family planning.Breasteeding.Care o the newborn inant.Te onset o labour and labour itsel mustalso be included when the patient is aprimigravida.Avoiding HIV inection or counselling i HIV positive.

1-56 What symptoms or signs,

which may indicate the presence

o serious complications, must

be discussed with patients?

Symptoms and signs that suggest abruptionplacenta:

Vaginal bleeding.Persistent, severe abdominal pain.Decreased etal movements.

Symptoms and signs that suggest pre-eclampsia:

Persistent headache.Flashes beore the eyes.Sudden swelling o the hands, eetor ace.

Symptoms and signs that suggest pretermlabour:

Rupture o the membranes.Regular uterine contractions beore theexpected date o delivery.

1.2.

3.4.5.6.7.

8.

1.

•••

2.

•••

3.

••

MANAGING WOMENWITH HIV INFECTION

1-57 How should women with

HIV inection be managed?

A thorough medical history must be takenand physical examination must be done todetermine the clinical stage o the disease.

All women ound to be HIV positive musthave their CD4 count determined.

1-58 What should be included

when taking a history?

A history o:

Painul lymph nodesWeight lossSkin rashes or itchy skinRecurrent sinusitisFever and rigors (shivering) extending overa period o more than 4 weeksPainul or dicult swallowing

Chronic cough or more than 2 weeksB treatment within the past yearSevere headaches

1-59 What should be included in

the physical examination?

Examine or:

Enlarged lymph nodes o more than 2 cmSkin rashesSigns o weight lossMouth ulcers or oral or pharyngeal thrush

Any abnormal physical nding o therespiratory system

I the history and physical examinationindicates stage 3 or 4 disease patients mustbe reerred urgently to an HIV or inectiousdiseases clinic or assessment and urthermanagement. Waiting or the CD4 result may result in an unnecessary delay with potentialdisastrous results. Early adherence counsellingand commencement withantiretroviraltreatment (HAAR) may be lie saving.

•••••

•

•••

••••

•




1-60 What is the importance o a CD4 count?

Te CD4 count and a ull clinical examinationare used to assess the state o the woman’simmune sysytem. Te normal CD4 countin adults is 700 to 1100 cells/μl. A CD4count below 350 indicates a damagedimmune system. Tese women need urgentantiretroviral treatment. Women with clinicalsigns o HIV disease also need antiretroviraltreatment even i their CD4 count has notyet dropped to below 350. Women who areHIV positive but appear clinically well with

a CD4 count above 350 need antiretroviralprophylaxis (dual therapy) only to preventHIV crossing to their unborn inant.

Most HIV positive women appear healthy (stage one or 2 disease). Tereore the CD4count determines whether antiretroviraltreatment (HAAR) or antiretroviralprophylaxis (dual therapy) should be used inthese women. A second visit afer ONE week must be arranged and every measure put inplace to ensure that the CD4 count will beavailable during that visit. Te most common

cause o a delay in starting antiretroviraltreatment is a delay in obtaining the result o the CD4 count.

All HIV-positive women must have a CD4 count

and the result must be available one week later.

NOTE The CD4 count used as an indication

or antiretroviral treatment varies between

dierent countries depending on their

capacity to provide antiretroviral care.

1-61 What is antiretroviral prophylaxis?

Antiretroviral prophylaxis consists o AZ(zidovudine) 300 mg orally twice daily whichis started at 28 weeks gestation. In addition.a single dose o nevirapine is given at theonset o labour. Tis is known as dual therapy and will reduce the risk o HIV transmissionrom mother to inant to 2% when ormulaeeding is provided, compared to 30% withoutprophylaxis.

1-62 What is antiretroviral treatment?

Antiretroviral treatment (HAAR) consistso taking three drugs every day. Te currentantiretroviral drugs used in pregnancy areusually AZ, 3C and nevirapine.

1-63 What is the management o women

already on antiretroviral treatment

when they book or antenatal care?

Management will depend on the gestationalage:

I 12 weeks or less eavirenze should bechanged to nevirapine.I already beyond 12 weeks the patient canstay on eavirenze

Tey should then continue on antiretrovira;ltreatment during the pregnancy, labour,delivery and the puerperium.

Eavirenze (EFV) should not be used duringthe rst trimester as a higher incidence o neural tube deects has been reported. Womenwho took eavirenze during the rst trimester

should be reerred or a detail ultrasound scanat 20 weeks to rule out the possibility o aneural tube deect.

CASE STUDY 1

A 36 year old gravida 4 para 3 patient presentsat her rst antenatal clinic visit. She does notknow the date o her last menstrual period.Te patient says that she had hypertension inher last 2 pregnancies. Te symphysis-undus

height measurement suggests a 32 week pregnancy. At her second visit, the report o the routine cervical smear states that she has alow grade cervical intra-epithelial lesion.

1. Why is her past obstetric history

important?

Because hypertension in a previous pregnancy places her at high risk o hypertension againin this pregnancy. She must be careully examined or hypertension and proteinuria

•

•



29ANTENATAL CARE

at this visit and at each subsequent visit.Tis case stresses the importance o a careulhistory at the booking visit.

2. How accurate is the symphysis-undus

height measurement in determining that

the pregnancy is o 32 weeks duration?

Tis is the most accurate clinical method todetermine the size o the uterus rom 18 weeksgestation. I the uterine growth, as determinedby symphysis-undus measurement, ollows thecurve on the antenatal card, the gestational age

as determined at the rst visit is conrmed.

3. Why would an ultrasound

examination not be helpul in

determining the gestational age?

Ultrasonology is accurate in determining thegestational age only up to 24 weeks. Tereafer,the range o error is virtually the same as thato a clinical examination.

4. What should you do about the

result o the cervical smear?Te cervical smear must be repeated afer 9months. It is important to write the result inthe antenatal record and to indicate what plano management has been decided upon.

CASE STUDY 2

At booking a patient has a positive VDRL testwith a titre o 1:4. She has had no illnessesor medical treatment during the past year.

By dates and abdominal palpation she is 26weeks pregnant.

1. What does the result o this

patient’s VDRL test indicate?

Te positive VDRL test indicates that thepatient may have syphilis. However, thetitre is below 1:16 and, thereore, a denitediagnosis o syphilis cannot be made withouta urther blood test.

2. What urther test is needed to confrmor exclude a diagnosis o syphilis?

I possible, the patient must have a PHA orFA or rapid syphilis test. A positive result o any o these tests will conrm the diagnosiso syphilis. I these tests are not available, thepatient must be treated or syphilis.

3. Why is the etus at risk o

congenital syphilis?

Because the spirochaetes that cause syphilis

may cross the placenta and inect the etus.

4. What treatment is required

i the patient has syphilis?

Te patient should be given 2,4 millionunits o benzathine penicillin (Bicillin LAor Penilente LA) intramuscularly weekly or3 weeks. Hal o the dose is given into eachbuttock. Benzathine penicillin will cross theplacenta and also treat the etus.

5. What other medical conditions is

this patient likely to suer rom?

She may have other sexually transmitteddiseases such as HIV.

CASE STUDY 3

A healthy primigravid patient o 18 yearsbooked or antenatal care at 22 weekspregnant. Her rapid syphilis and HIV testswere negative. Her Rh blood group is positiveaccording the Rh card test. She is classied asat low risk or problems during her pregnancy.

1. What is the best time or a pregnant

woman to attend an antenatal

care clinic or the frst time?

I possible, all pregnant women shouldbook or antenatal care within the rst 12weeks. Te duration o pregnancy can thenbe conrmed with reasonable accuracy onphysical examination, medical problems can




be diagnosed early, and screening tests can bedone as soon as possible.

2. When should this patient return

or her next antenatal visit?

She should attend at 28 weeks.

3. What important complications

should be looked or in this

patient at her 28 week visit?

Anaemia, early signs o pre-eclampsia, a

uterus smaller than expected (suggestingintra-uterine growth restriction), or a uteruslarger than expected (suggesting multiplepregnancy). A history o antepartumhaemorrhage should also be asked or.

4. When should she attend antenatal

clinic in the last trimester i she

and her etus remain normal?

Te next visit should be at 34 weeks, and thenevery 2 weeks until 41 weeks.

CASE STUDY 4

A 24 year old gravida 2 para 1 attends thebooking antenatal clinic and is seen by amidwie. Te previous obstetric history revealsthat she had a caesarean section at termbecause o poor progress in labour. She is sureo her last menstrual period and is 14 weekspregnant by dates. On abdominal palpation theheight o the uterine undus is halway betweenthe symphysis pubis and the umbilicus.

1. What urther important inormation

must be obtained about the

previous caesarean section?

Te exact indication or the caesarean sectionmust be ound in the patient’s hospital notes.In addition, the type o uterine incision mademust be established, i.e. whether it was atransverse lower segment or a vertical incision.

2. Why is it important to obtainthis additional inormation?

I the patient had a caesarean section or anon-recurring cause and she had a transverselower segment incision, she may be allowed atrial o labour.

3. In which risk category would

you place this patient?

She should be placed in the intermediatecategory.

4. How must you plan this

patient’s antenatal care?

Her next visit must be arranged at a hospital.I possible, the hospital where she hadthe caesarean section so that the requiredinormation may be obtained rom her older.Ten she may continue to receive her antenatalcare rom the midwie at the clinic until 36weeks gestation. From then on the patientmust again attend the hospital antenatalclinic where the decision about the method o

delivery will be made.

5. Which o the two estimations o the

duration o pregnancy is the correct one?

A undal height measurement midway betweenthe symphysis pubis and the umbilicus suggestsa gestational age o 16 weeks. According to herdates, the patient is 14 weeks pregnant. As thedierence between these two estimations isless than 3 weeks, the duration o pregnancy as calculated rom the patient’s dates must beaccepted as the correct one.



31ANTENATAL CARE

N A M E :

F O L D E R N O . :

B I R T H D A T E :

C L I N I C / D O C T O R :

T E L E P H O N E N O :

H I S T O R Y *

O b s t e t r i c h i s t o r y

Y e a r

G e s t a t i o n

( w e e k s )

D e l i v e r y

W e i g h t

S e x

C o m p l i c a t i o n s

D e s c r i p t i o n o f c o m p l i c a

t i o n s

A g e

P

G

M e d i c a l a n d g e n e r a l h i s t o r y

M e d i c a t i o n

O p e r a t i o n s

A l l e r g i e s

S m o k i n g : Y e s

N o

C o u n s e l l i n g

E X A M I N A T I O N *

D

D

M

M

Y

Y

D a t e

W e i g h t

H b

H e i g h t

B P

U r i n e

G e n e r a l

T h y r o i d

H e a r t

L u n g s

B r e a s t s

A b d o m e n

S F - M e a s u r e m e n t

O t h e r

V + V

V a g i n a l E x a m i n a t i o n

C e r v i x

U t e r u s

A b d o m e n

N A M E

S P E C I A L I N V E S T I G A T I O N S *

V D R L

T P H A

F T A - A b s

R x r e c e i v e d

1 s t

2 n d

3 r d

B l o o d g r o u p a n d R b

C y t o l o g y

M S U

O t h e r

R V D

T e s

t a c c e p t e d : Y e s

N o

P r e c a u t i o n s : Y e s

N o

P L A N

A n t e n a t a l C a r e

L a b o u r

G E S T A T I O N A L A G E

L M P D

D

M

M

Y

Y

D

D

M

M

Y

Y

Y e s

Y e s

N o N o

C e r t a i n

C o n t r a c e p t i o n

T y p e

C y c l e

S O N A R

D a t e

B P D

m m

m m

w e e k s

w e e k s

F L

P l a c e n t a

O t h e r

E D D

a c c o r d i n g t o : d a t e s / s o n a r / b o t h / u n c e r t a i n

D a y

D a y

M o n t h

M o n t h

Y e a r

Y e a r

F u t u r e f a m i l y

p l a n n i n g

* N o t e p r o b l e m s f r o m h i s t o r y , e x a m i n a t i o

s p e c i a l i n v e s t i g a t i o n s o n p r o b l e m l i s t

L I U D E N D

L N D I D

=

L i v e

=

i n t r a - u t e r i n e d e a t h

=

e a r l y n e o n a t a l d e a t h

=

l a t e n e o n a t a l d e a t h

=

i n f a n t d e a t h

Figure 1-I: The front of an antenatal record card




D a t e

D a t e

P R O B L E M L I S T

1 2 3 4 5

N O T E S ( e s s e n t i a l f a c t s o n l y )

G E S T A T I O N E S T .

B Y :

D a t e s

S o n a r

B o t h

S F - m e a s u r e m e n t

L W .

0 . = W e i g h t

x

= m e a s u r e m e n t

S I G N A T U R E :

D A T E :

G E S T A T I O N

1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3

G E S T A T I O N

1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4

3 5 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3

U t e r i n e s i z e u s i n g

a n a t o m i c a l

l a n d m a r k s

R e p e a t e x a m i n a t i o n o f b r e a s t s a t 3 4 w e e k s

R e p e a t e x a m i n a t i o n o f b r e a s t s a t 3 4 w e e k s

P R E S E N T I N G P A R T

H E A D A B O V E P E L V I S ( f i f t h s )

B L O O D -

P R E S S U R E

U r i n e

P S

O E D E M A

F e t a l m o v e m e n t s

H a e m o g l o b i m ( g / d l )

S y s t .

D i a s t .

P S R R T 2 / 0 1

A n t e n a t a l

c a r d B

E N G

4 5

4 0

3 5

3 0

2 5

2 0

1 5

1 0 5

4 5

4 0

3 5

3 0

2 5

2 0

1 5

1 0 5

S t a r t

S F m e a s u r e m e n t

S t a r t

S F m e a s u r e m e n t

Figure 1-II: The back of an antenatal record card



33ANTENATAL CARE

Clinic Checklist – Classiying (frst) visitName o patient______________________________ Clinic record

number

Address ___________________________________________ Telephone ________________

____________________________________________ Cell _____________________

INSTRUCTIONS: Answer all the ollowing questions by placing a cross mark in the corresponding box

Obstetric History No Yes

1. Previous stillbirth or neonatal loss?

2. History o three or more consecutive spontaneous abortions

3. Birth weight o last baby < 2500g?

4. Birth weight o last baby > 4500g?

5. Last pregnancy: hospital admission or hypertension

or pre-eclampsia/eclampsia?

6. Previous surgery on reproductive tract (Caesarean section, myomectomy,

Current pregnancy

7. Diagnosed or suspected multiple pregnancy

8. Age < 16 years

9. Age > 40 years

10. Isoimmunisation Rh (-) in current or previous pregnancy

11. Vaginal bleeding

12. Pelvicmass

13. Diastolic blood pressure 90 mmHg or more at booking

14. AIDS

General medical

15. Diabetes mellitus on insulin or oral hypoglycaemic treatment

16. Cardiac disease

17. Renal disease

18. Epilepsy

19. Asthmatic on medication

20. Tuberculosis

21. Known substance abuse (including heavy alcohol drinking)

22. Any other severe medical disease or condition

Please speciy ____________________________________________________

A yes to any ONE o the above questions (i.e. ONE shaded box marked with a cross) means that the woman is not

eligible or the basic component o antenatal care.

Is the woman eligible (circle) NoYes

I NO, she is reerred to ________________________________________________

Date_____________ Name_________________________ Signature_______________(Sta responsible or antenatal care)

cone biopsy, cervical cerclage,)

Figure 1-III: Clinic checklist




Clinic Checklist: Follow-up visits(Back page o frst visit checklist)

VISITS

First visit or all women at frst contact with clinics, regardless

o gestational age. I frst visit later than recommended, carryout activities up to that time

1 2 3 4 5

DATE :

Approximate Gest. Age.__

(20)

___

(26-28)

___

(32)

___

(38)

___

Classiying orm which indicates eligibility or BANCHistory takenClinical examinationEstimated date o delivery calculatedBlood pressure takenMaternal height/weightHaemoglobin testRPR perormedUrine testedRapid Rh perormedCounselled and voluntary testing or HIV

Tetanus toxoid givenIron and olate supplementation providedCalcium supplementation providedInormation or emergencies givenAntenatal card completed and given to woman

AZT and NVP given(i required) – Check each visit i AZT sucient

Clinical examination or anaemiaUrine test or proteinUterus measured or excessive growth (twins), poor growth (IUGR)

Instructions or delivery/transport to institutionRecommendations or lactation and contraception

Detection o breech presentation and reerralComplete antenatal card and remind woman to bring it when inlabourGive ollow-up visit date or 41 weeks at reerring institution

Initials o sta member responsible

Additional Visits

Date Reason Action/Treatment

Figure 1-IV: Back page of clinic checklist

Documents

primarymaternalcareantenatalcare-120417044447-phpapp02