COURSE: OBSTETRICS AND GYNAECOLOGICAL NURSING

COURSE CODE : NUS3105/CNS4101, 6 credits (40-10-10)

COURSE INSTRUCTOR: DR MOU EPSE CHE BRIDGET SEN
YEAR: NOVEMBER 2025
HANDOUT 2

Basics of Antenatal Care

Guiding Principles of Antenatal Care

Antenatal care focuses on both the medical and psychosocial needs of each pregnant woman,
within the context of the health care system and the culture in which the woman lives. WHO
defines ANC as “the care provided by skilled health care professionals to pregnant women
and adolescent girls in order to ensure the best health conditions for both mother and baby
during pregnancy.

The components of ANC include: risk identification; prevention and management of

pregnancy-related or concurrent diseases; and health education and promotion.” WHO’s
recommendations include results from its recent scoping review that reveal that women desire
a positive pregnancy experience that includes:

• Maintaining physical and sociocultural normality

• Maintaining a healthy pregnancy for mother and baby (including preventing and treating
risks, illness, and death)

• Having an effective transition to positive labor and birth

• Achieving positive motherhood (including maternal self-esteem, competence, and

autonomy) Also essential are:

• Placing the woman at the center of care

• Promoting innovative, evidence-based approaches to ANC

• Enhancing the woman’s experience of pregnancy and ensuring that babies have the best
possible start in life

• Aligning with the Sustainable Development Goals to expand care beyond survival,
prioritizing person centered health and wellbeing, not only the prevention of death and
morbidity

To improve perinatal outcomes and maternal satisfaction, WHO calls for a minimum of eight
contacts during pregnancy. It explicitly replaces the word “visit” with “contact,” to imply
active engagement between the pregnant woman and the service provider; “contact” is used
in this document. A contact can also take place in the community through outreach activities
by skilled service providers (i.e., midwives). In some geographic areas, auxiliary midwives
can also provide certain elements of care.
The first ANC contact should take place in the first trimester, two contacts should take place
in the second trimester and five in the third trimester. This new model aims to reduce the
incidence of stillbirths and increase the woman’s satisfaction with her care. The model should
be instituted within a framework of quality services that promotes empowerment and
engagement of women and families in their care.

To deliver quality ANC, lay providers (maternal and child health promoters, community
health workers [CHW]), community support groups, etc.) should support service providers by
acting as coordinators between providers and the community and educating women about the
importance of ANC. Equity of service provision is paramount to ensure that all women
receive quality and timely ANC. Evidence shows that women in low and middle-income
countries who are poor, less educated, and living in rural areas have lower ANC coverage and
worse pregnancy outcomes than more advantaged women do in the same countries. Thus,
ANC interventions can potentially reduce health differences among various groups of
women. Ensuring the quality of care must be an inherent and essential component of all
services to improve the health of mother and her unborn baby.

Principles of Quality Care

As important as equity in delivering ANC services is the quality of the services. Using the
WHO definition, quality of care is “the extent to which health care services provided to
individuals and patient populations improve desired health outcomes. In order to achieve this,
health care must be safe, effective, timely, efficient, equitable and people-centered. ”WHO
designed a quality of care framework by identifying domains that should be targeted to
assess, improve, and monitor care in health facilities in the context of the health system. The
process of care includes provision of care, use of evidence-based practices for routine and
emergency care, information systems in which record keeping allows review and auditing,
and functioning systems for referral between different levels of care. Experience of care
consists of effective communication with women and their families about the care provided,
their expectations and their rights; care with respect and preservation of dignity; and access to
the social and emotional support of their choice. The cross-cutting areas of the framework
include the availability of competent, motivated human resources and physical resources that
are prerequisites for good quality of care in health facilities.

The following are required for achieving quality care:

• Respectful maternity care including continuous communication with women and families
in the context of linguistically and culturally appropriate services

• Use of standard precautions for infection prevention and control

• Organization of services

• Clinic management and client flow

• Effective referral mechanisms Respectful Maternity Care Service providers should be aware
of the rights of women who receive maternity care services.

• Every woman receiving care has the right to information about her health.
 • Every woman has the right to discuss her concerns in an environment in which she feels
confident.

• A woman should know in advance the type of procedure that is going to be performed.

• A woman (or her family, if necessary) should give informed consent before the service
provider performs a procedure.

• A woman (or her family, if necessary) has the right to decline any treatment or procedure
offered.

• Procedures should be conducted in an environment in which the woman’s right to privacy

is respected.

• A woman has the right to determine how her health information is used and to whom her
information is disclosed by service providers.

• A woman should be made to feel as comfortable as possible when receiving care.

• A woman has the right to express her views about the services she receives.

Service providers should use basic communication techniques when talking to a woman
about her pregnancy or a complication. These techniques help the service provider establish
an honest, caring, and trusting relationship with the woman. If a woman trusts her service
providers and feels that they have her best interests at heart, she is more likely to return to the
facility.

All staff in the ANC clinic should understand how to make women and their companions
feel welcome, and treat them with kindness and respect. Service providers should speak the
local language or have a translator available and must use terms easily understood by the
woman. Opportunities should be given for the woman to ask questions (and have her
questions answered) throughout the visit.

Service providers should explain why exams and tests are being done and obtain permission
from the woman before performing them (informed consent). The woman has the right to
accept and refuse treatment and to be fully aware of the risks and benefits of accepting or
refusing the care. If treatments or medications are indicated, the woman should be informed
about the reason for them and understand how to use them (dose, timing, whether they may
be taken with food, possible side effects, etc.). Service providers must understand local
culture, norms, and taboos to improve communication and build trust with women and their
husbands, partners, or other support persons. Service providers should evaluate and revise
communication strategies to support informed decision making by women and their families
using evidence-based information.

The clinic space should be organized to provide visual and auditory privacy. All staff should
understand that women have the right to confidentiality and their personal information is
never shared with other service providers or outside the clinic. Client records and registers
must be kept where only responsible service providers have access to them.

Cultural background
Women from different culturally backgrounds have specific issues and concerns. Women’s
experiences also differ depending on residential status, educational level, and prior
experience of pregnancy and childbirth.

Women from different cultural backgrounds may perceive the social worker, interpreter,
and/or nurse to be in a position of authority, and thus are unwilling to divulge personal health
information. Even the perception of authority may have a negative impact on the clinical
consultation as women may have had previous unpleasant encounters with authorities.
Therefore, it is very important for people working with women from different cultures to find
a way to gain their trust at the outset. One approach is to be aware and talk about the
woman’s background and culture. This breaks down barriers between the woman and service
providers, and helps her open up about her health and concerns. In addition, service providers
should be mindful that the gender of the interpreter can have an impact on the outcome of the
consultation, especially where sensitive health issues are involved.

Variations in language can lead to misinterpretations if an unqualified interpreter is used.

For example, the service provider may not be aware that there are several versions of a
language (e.g., weh language), and may not ask an appropriate interpreter to assist. In
addition, family members may be fluent in different languages, which makes explaining even
simple concepts difficult. A situation may arise where the husband can speak both weh
language and English , but his wife can understand only weh language. An interpreter who
speaks only weh language must explain what the service provider is saying to the husband,
which makes his wife reliant on him to relay the message to her in weh.

Hence, service providers are encouraged to develop an understanding of the issues facing
women and babies from the culturally and linguistically diverse groups that they regularly
work

Use of Standard Precautions for Infection Prevention and Control

All clinical services should use infection prevention and control practices to protect service
providers and the women they serve.

These include:

• Washing hands with soap and water, or using alcohol-based hand rub, before and after
seeing a client, donning and doffing gloves, and whenever hands are visibly soiled

• Wearing exam gloves for non-sterile procedures such as drawing blood or inspection of
external genitalia

• Wearing exam gloves for procedures such as vaginal exams, unless ruptured membranes
are suspected

• Using single-use syringes, needles, and lancets when giving injections or drawing blood and
disposing of them after each use, avoiding re-capping needles

• Disposing of needles and other sharps in puncture-proof containers and incinerating them
when threequarters full
• Disposing of used gloves and other contaminated items in leak-proof receptacles that will
be buried or burned

• Wiping down exam tables and other equipment daily, or when soiled, with 0.5% chlorine
solution

Organization of Services, Clinic Management and Client Flow, and Effective Referral
Mechanisms Effective organization of services and management of clinics, facilities, and
client flow and effective referral protocols and mechanism that followed are critical to
ensuring that women receive equitable and quality services. See Part B: Providing Antenatal
Care for guidance on these areas.

Populations with Special Needs

Women with special needs require care in addition to the core components of basic care. An
important goal in caring for women with special needs during pregnancy is to determine
whether their needs require special care/referral or whether the nurse can address them
appropriately during the ANC contact. It is the nurses’s responsibility to ensure that all
relevant information is made available to other providers in the same health facility or in
another level of care if she is referred.

This may include:

• Providing all information related to the special needs that have been identified.

• Making special recommendations about the woman’s care during the antenatal, labor/birth,
and postpartum periods, referral to special care, or supportive services as indicated.

• Facilitating linkages as appropriate with local sources of support (adolescent/youth corners,

one stop crisis center, social welfare, public health agencies, peer support groups, community
service organizations, etc.)

In these guidelines, women with special needs include:

• Adolescents (10—19 years old)

• Women living with HIV

• Women encountering gender-based violence (GBV)

• Those in remote areas because of their greater vulnerabilities and health care needs

Adolescents (10–19 years old)

While assessing and caring for adolescents, use good interpersonal skills. Important goals in
providing care to adolescents are to:
• Provide them with the information they need to meet immediate challenges; for example,
knowledge of and linkage to services for antenatal, delivery and new-born care; basic
parenting skills; and postpartum care, including family planning.

• Support them to identify and overcome obstacles and receive quality care through linkages
for services like transportation and social support from the local community.

• Advocacy/counselling to parents, caregivers, and family members about pregnant

adolescents’ special needs. Perform basic assessments with the following additions and/or
emphases:

• Determine the circumstances surrounding the pregnancy.

• If the pregnancy is the result of any form of sexual abuse, see the section on Populations
with Special Needs, Women Encountering Gender-Based Violence for additional information
about assessment and provision of care.

• Identify physically and mentally challenged adolescents and refer them to specialized
services.

• Focus on identifying barriers to care as well as harmful behaviors and practices.

• Confirm pregnancy through history, physical examination, and investigation (urine or

serum pregnancy tests and ultrasound exam), and provide appropriate ANC and counselling.

Women Living with HIV

Women living with HIV/AIDS should be offered quality care during the pregnancy, birth,
and the postpartum period, including prevention of mother-to-child transmission (PMTCT),
family planning, and HIV-related treatment, prevention, and care. Support for women living
with HIV includes:

• Initiation of antiretroviral therapy (ART) as early as possible and life-long treatment,

regardless of clinical stage or CD4 count, according to global and national recommendations
(WHO 2016, National AIDS Program 2017).

• Assistance in choosing an appropriate contraceptive method. Whatever method is chosen,

transmission of HIV and other sexually transmitted infections (STIs) warrants special
consideration during family planning counselling, including dual protection.

• Linkages to international nongovernmental organizations (NGOs) and other NGOs for

support services they may need.

Women Encountering Gender-Based Violence

Special consideration should be given to women who may be encountering violence.

Intimate partner violence affects women’s physical and mental health, including their
reproductive health. While not all service providers are trained to deal with this problem,
unexplained bruises and other injuries may be indications of abuse. The following are
recommendations on how to respond and support women living with violence.
• Help her recognize her right to high-quality care: be sure that she feels welcome, knows
what services are available, and understands how to access these services.

• Demonstrate sympathy and understanding.

• Help her feel safe by ensuring a pleasant environment and using a kind, non-judgmental
approach to communication.

• Provide a space where the woman can speak in privacy where her partner or others cannot
hear. Do all possible to guarantee confidentiality, and reassure her of this.

• Gently encourage her to tell you what is happening to her. Ask indirect questions to help
her tell her story.

• Listen to her in a sympathetic manner. Listening can often be of great support. Do not
blame her or make light of the situation. She may defend her partner’s action. Reassure her
that she does not deserve to be abused in any way.

• Help her to assess her present situation. If she thinks she or her children are in danger,
explore together the options to ensure her immediate safety (e.g., can she stay with her
parents or friends? Does she have, or could she borrow, money?)

• Explore options with her. Help her identify local sources of support, either within her
family, friends, and local community or through NGOs, shelters, or social services, if
available. Remind her that she has legal recourse, if relevant.

• Suggest that she keep a bag packed with money, clothes, and important papers—in case it is
necessary to leave home quickly, and plan and rehearse an “escape route”.

Offer her an opportunity to see you again. Violence by partners is complex, and she may be
unable to resolve her situation quickly.

• Document any forms of abuse identified or concerns in the file.

• Be aware of, and gently responsive to, a possible fear of vaginal examinations or any
invasive procedure.

• If she is suspected or reported to be a survivor of sexual assault, follow the national 2017
GBV guideline 2017.

Women Living in Hard-to-Reach Areas

In rural and remote areas, the rate of maternal deaths is higher than in urban areas. Women
living in hard-to-reach areas may have difficulties accessing appropriate ANC due to limited
availability and/or accessibility of services. They may incur extra costs, and experience lack
of practical and emotional support, inappropriate or culturally unsafe health care, and
temporary separation from family members. Support for women living in hard-to-reach areas
includes:

• Provision of information about ANC and promotion of health literacy

• Linkages to services providing quality care

• Establishment of a community-based referral system

Content of First and Return ANC Contacts

Main ANC Goals
The ultimate goal of all ANC is a healthy outcome for the mother and her new-born, as well
as a positive experience with the health system. In ANC, this is accomplished through the
following:
• Risk identification
• Prevention and management of pregnancy-related or concurrent diseases
• Heath education and health promotion
Risk Identification
An important component of ANC is identifying women at risk for problems that can
complicate their pregnancy. ANC promotes targeted assessment, during which the service
provider interviews, examines, and tests the woman to determine her risk of developing
pregnancy-related complications and her risk of conditions that are common in the population
served.
One way of establishing risk is by taking a thorough history to determine if the woman has
had hypertension in previous pregnancies, which could increase her risk of complications in
the current pregnancy. It underscores the need to take a woman’s blood pressure at every
ANC visit to screen for existing hypertension or hypertension that develops later pregnancy.
A list of the risks that should be identified are given below under “Diagnosis” in “How to
Conduct the First ANC Contact”.
Prevention and Management of Pregnancy-Related or Concurrent Diseases
Another component of targeted assessment is detection of signs and symptoms of pregnancy
complications (such as abruptio placenta) and pre-existing diseases (such as diabetes). The
service provider should manage complications or provide initial management and
stabilization, including life-saving measures as needed. Facilitating management or referral to
a higher level of care is an important role of the ANC provider. Health Education and Health
Promotion Antenatal care should promote discussions of important health issues at each visit.
The service provider should ensure that the woman and her family have the information they
need to make healthy decisions during pregnancy, childbirth, and the postpartum/new-born
period—as well as sufficient guidance in applying that information in their specific situation.
This includes, but it not limited to, healthy eating during and after pregnancy, exercise,
counselling about exclusive breastfeeding, healthy timing and spacing of pregnancies, and
methods of postpartum family planning. Specific components of the first and subsequent
ANC contacts are described in Table 2. How to Conduct the First ANC Contact Objectives •
Perform risk assessment and detect signs/symptoms of complications or diseases
• Calculate estimated date of delivery (EDD)/gestational age by last menstrual period (LMP)
and physical exam
• Provide health education and health promotion
• Initiate development of the birth plan and complication readiness plan.
Performing risk assessment and detecting signs/symptoms of complications or diseases
perform adequate risk assessment, the following need to be done
History:
ASK her name, age, address, phone number, occupation, marital status
• Menstrual history: date of first day of LMP; current or previous breastfeeding, and
contraception; calculation of EDD and gestational age
• Obstetric history: number of previous pregnancies and outcome of each; previous cesarean
sections; problems and complications including bleeding and high blood pressure
• Gynecological history
• Medical history including hypertension, convulsions, diabetes, tuberculosis, and other past
and current medical problems; current medications including use of medications and
herbal/traditional remedies, drug history including allergies
• History of present pregnancy including any complications to date
• Surgical history (including presence of uterine scar)
• Family history (e.g., genetic disorders)
• Nutrition history: how many meals/day, usual content of meals
• Social history including use of alcohol, tobacco, exposure to second-hand smoke, betel
chewing, caffeine in large quantities (>300 mg/day), or other harmful substances; screening
for intimate partner violence as appropriate
Physical exam
• Vital signs: weight, height, calculate body mass index (BMI)7 (Appendix 2), pulse rate,
respirations, and temperature. Blood pressure should be taken in sitting position, feet flat on
floor, with apparatus at heart level, and the correct size blood pressure cuff.
• General condition and level of consciousness
• Presence of conjunctival and palmar pallor or jaundice; facial edema
• Condition of breasts and nipples (lesions or inverted nipples)
• Extremities for presence of varicosities, calf tenderness
• Abdominal inspection for tenderness and scars
• Obstetric examination: assessment of uterine size to confirm gestational age; fetal
movement; fetal heart sounds; fetal position after 36 weeks
• Inspection of external genitalia for lesions or discharge as indicated
Then a complete laboratory investigation.
 Diagnosis/Risk identification from all of the above.
Risk factors, present or potential with reference to the current pregnancy.
Some risk factors for pregnancy complications are present before women become pregnant.
All women need to be assessed for:
 Certain physical characteristics, such as age and weight
 Problems in a previous pregnancy, including the need to have a cesarean delivery
 Certain disorders present before pregnancy
 Exposures that can harm the fetus
Physical characteristics

The following characteristics of women affect risk during pregnancy.

Age : less than 18 years or more than 40 years

About 13% of all pregnancies occur in adolescents (see also Adolescent Pregnancy).
Adolescents are at increased risk of having the following conditions, which often leads
to babies who are born underweight (small-for-gestational age):

 Preeclampsia (a type of high blood pressure that develops during pregnancy)

 Preterm labor
 Anemia
 Part of the reason for these risks is that adolescents are less likely to get medical
care during pregnancy. Also, they are more likely to smoke cigarettes or use other
substances, and they have higher rates of sexually transmitted infections. (Using
condoms can help prevent sexually transmitted infections.)
 Older age is also a factor in pregnancy complications. Women aged 35 and older
are at increased risk of having the following:
 A preexisting disorder that increases risk during pregnancy, such as high blood
pressure or diabetes
 Problems related to the pregnancy, such as preeclampsia, gestational
diabetes (diabetes that develops during pregnancy), chromosomal
abnormalities in the fetus, and stillbirth
 Complications during labor, such as difficult labor or a placenta that detaches too
soon (placental abruption) or is mislocated (placenta previa)
 Children of women aged 35 or older are more likely to have birth defects, such
as heart defects. a narrowed esophagus (esophageal atresia), a defect of the
urethra called hypospadias, or a defect of the skull called craniosynostosis.

As women age, genetic counselling and testing for chromosomal and genetic
abnormalities becomes more important. In older pregnant women, ultrasonography may
be done to help determine whether the fetus has birth defects.

Weight

Women with a body mass index (BMI) of less than 19.8 before becoming pregnant are
considered underweight and are more likely to have

 Small, underweight babies

Women with a BMI of 25 to 29.9 before pregnancy (overweight) and women with a BMI
of more than 30 (obese) are more likely to have the following problems:

 Very large babies (large-for-gestational age), which may be difficult to deliver

 Babies who are born underweight (small-for-gestational age)
 Babies with birth defects
 Miscarriages and stillbirth
 Gestational diabetes
 Gestational hypertension (high blood pressure that first develops after 20 weeks
of pregnancy)
 Preeclampsia (gestational hypertension accompanied by protein in the urine)
 A pregnancy that lasts 42 weeks or longer (postterm pregnancy)
 Need for a cesarean delivery

Nurses/midwives encourage most women to exercise at least 3 times a week for a total of
150 minutes a week. Women should talk to their care providers about appropriate weight
gain, diet, and exercise at the initial prenatal visit and periodically throughout the
pregnancy.

History of:

• Heart or kidney disease

• Prior delivery by cesarean section

• Assisted delivery

• More than 5 previous births

• Obstetric complication such as heavy bleeding, convulsions, 3rd degree laceration, stillbirth
or early new-born death, low birthweight/preterm birth

Reproductive organ abnormalities

Structural abnormalities in the uterus or cervix increase the risk of the following:

 A difficult labor
 A miscarriage during the second trimester and preterm labor
 A fetus in an abnormal position
 Preterm labor or a preterm baby
 Need for a cesarean delivery

Structural abnormalities include

 a double uterus,
 fibroids in the uterus, and a weak cervix (cervical insufficiency) that tends to
open (dilate) as the fetus grows.
 Fibroids occasionally cause the placenta to be
 mislocated (called placenta previa), labor to begin too early (preterm labor),
 and miscarriages to occur.
  Cervical insufficiency increases the risk that a baby will be delivered too soon
(preterm delivery).

Problems in a Previous Pregnancy

Women who have had a problem in one pregnancy are more likely to have the same
problem in subsequent pregnancies. Such problems include any of the following:

 Miscarriage
 Ectopic pregnancy
 Preterm birth
 Postterm delivery (after 42 weeks of pregnancy)
 Stillbirth
 Birth defects
 Hemolytic disease of the fetus and new-born that required a blood transfusion to
the fetus
 Too much or too little amniotic fluid in the uterus
 Small-for-gestational age or large-for-gestational age new-born
 Cerebral palsy in the baby
 Abnormal position of the fetus, such as buttocks first (breech)
 Gestational diabetes
 Preeclampsia (high blood pressure during pregnancy)
 Shoulder dystocia: Baby whose shoulder gets caught in the birth canal during
delivery, which sometimes injures the nerves in the baby's shoulder (brachial
plexus injury)
 Women who had a baby with a genetic disorder or birth defect are more likely to
have another baby with a similar problem. Genetic testing of the baby, even if
stillborn, and of both parents may be appropriate before another pregnancy is
attempted. If these women become pregnant again, tests such as high-
resolution ultrasonography, chorionic villus sampling, and amniocentesis may
help determine whether the fetus has a genetic disorder or birth defect. These
women may be referred to a specialist.
 Having had 5 or more pregnancies increases the risk of very rapid labor and
excessive bleeding after delivery.

Disorders Present Before Pregnancy

Before becoming pregnant, women may have a disorder that can increase the risk of
problems during pregnancy. These disorders include

 High blood pressure

 Diabetes
 Kidney disorders
 Kidney infections
 Heart failure
 Sickle cell disease
 Sexually transmitted infections
 Abnormalities of the fallopian tubes
Women who have one of these disorders should talk with a doctor and try to get in the
best physical condition possible before they become pregnant. After they become
pregnant, they may need special care, often from an interdisciplinary team. The team
may include an obstetrician (who may also be a specialist in the disorder), a specialist in
the disorder, and other health care practitioners (such as nutritionists).

Disorders During Pregnancy

In current pregnancy:

• Current or history of vaginal bleeding

• High blood pressure

• Transverse lie or other malpresentation after 36 weeks

• Suspected/confirmed multiple pregnancy

• Desires postpartum IUD or implants

During pregnancy, a problem may occur or a disorder may develop to make the
pregnancy high risk.

Some disorders that occur during pregnancy are related to (are complications of)
pregnancy. Other disorders are not directly related to pregnancy. Certain disorders are
more likely to occur during pregnancy because of the many changes pregnancy causes in
a woman's body.

Pregnancy complications are problems that occur during pregnancy. They may affect the
woman, the fetus, or both and may occur at different times during the pregnancy. For
example, complications such as a mislocated placenta (placenta previa) or premature
detachment of the placenta from the uterus (placental abruption) can cause bleeding
from the vagina during pregnancy. Women who have heavy bleeding are at risk of
losing the baby or of going into shock and, if not promptly treated, of dying during labor
and delivery.

Other pregnancy complications include

 A previous miscarriage or stillbirth

 An abnormally located pregnancy (ectopic pregnancy)
 Severe nausea and vomiting during pregnancy (hyperemesis gravidarum)
 A weak cervix (cervical insufficiency) that tends to open (dilate) as the fetus
grows
 Hemolytic disease of the fetus and new-born (when a pregnant woman has Rh-
negative blood and the fetus has Rh-positive blood)
 Problems with amniotic fluid (the fluid that surrounds the fetus in the uterus)
 An infection of the tissues around the fetus, such as the amniotic fluid (intra-
amniotic infection)
 Preeclampsia (a type of high blood pressure that develops during pregnancy)
Multiple Gestation

Being pregnant with twins or more fetuses (multiple gestation) increases the risk of the
following:

 Underweight babies
 Preterm (premature) delivery
 A placenta that detaches too soon (placental abruption)
 Birth defects
 Stillbirth or death of the new-born
 After delivery, vaginal bleeding in the mother
 Multiple gestation is usually detected with ultrasound in the first trimester.
Incidence of multiple gestations has been increasing; use of assisted reproductive
technologies have contributed substantially to this increase.

Women with one or more of the conditions should give birth at hospital level with
appropriate explanation and development of birth and complication readiness plans.

TREAT/ADVISE

• Administer tetanus diphtheria (Td) immunization, two doses at least one month apart in
each pregnancy if there is no evidence of previous Td immunization. A new-born is protected
against neonatal tetanus if the mother has received any of the following:

• Two Td injections during the present pregnancy

• Two or more injections, the last one within three years of the current pregnancy

• Three or more injections, the last one within five years of the current pregnancy

• Four or more injections, the last one within 10 years of the current pregnancy

• Five or more injections at any time prior to the current pregnancy

• When the mother has active immunity, the antibodies pass through the placenta, protecting
the new-born. A woman is protected when she has received two vaccine doses at least four
weeks apart, with an interval of at least four weeks between the last vaccine dose and
pregnancy termination. Women who last received a vaccination series (five injections) more
than 10 years before the present should be given a booster. In most women, a booster is
recommended in every pregnancy.

• Folic acid 0.4 mg daily starting in first trimester and up to 37 completed weeks, and then
twice daily up to delivery. Criteria for taking higher doses of folic acid (a daily dose of 5
milligrams) prior to pregnancy and in the first trimester:

• History of a previous pregnancy affected by spina bifida

• History of spina bifida in one of the couple (woman or her partner)

• History of taking certain medications for epilepsy

• History of coeliac disease or diabetes

• BMI is 30 or more

• History of sickle-cell anemia or thalassemia

• Vitamin B1 10 mg daily one month before pregnancy, during pregnancy, and three months
after delivery

• Preventive anthelminthic treatment after the first trimester

• Provide insecticide-treated net (ITN) or long-lasting insecticide-treated net (LLIN) if

woman does not have one, or explain where she can obtain one and how to use it

• Treat or advise about relief of common physiological symptoms during pregnancy (refer to
Part C) Health Education and Health Promotion.

Messages appropriate to gestational age should be discussed, such as a birth preparedness and
complication readiness plans, healthy eating and physical activity, tobacco and substance use,
limiting caffeine, healthy timing and spacing of pregnancies, use of ITNs or LLINs, if
available (where to access and how to use them), and danger signs and what to do if they
occur.

Exposures During Pregnancy

Substances and conditions that increase the risk of birth defects are called teratogens.
Birth defects are most likely to result if women are exposed to a teratogen 2 to 8 weeks
after they become pregnant (4 to 10 weeks after their last menstrual period) because the
fetus's organs are forming during this time. The risk of having a miscarriage is also
increased.

During pregnancy, being exposed to the following can increase the risk of having a baby
with a birth defect:

 Certain infections
 Certain substances and medications
 Radiation and certain chemicals (such as carbon monoxide, lead, gasoline,
and mercury)
 Infections that are particularly dangerous during pregnancy include
 Chickenpox
 Hepatitis
 Herpes simplex
 Rubella (German measles)
 Syphilis
 Toxoplasmosis
 Infections with cytomegalovirus, coxsackievirus, or parvovirus B19
 Zika virus infection
 Substances and medications that may increase the risk of birth defects include
 Alcohol
 Tobacco
  Cocaine
 Bath salts (cathinones)
 Some prescription medications (see table Some Medications and Risk of
Problems During Pregnancy)
 Exposure to high temperatures (> 102° F [39° C ]), such as in a sauna or hot tub,
during the first trimester has been linked to the development of spina bifida.

Mercury in seafood
Consuming too much mercury in seafood may harm the fetus. However, seafood
contains nutrients that are important for growth and development of the fetus and
for breastfed infants. Thus, the Food and Drug Administration (FDA)
recommends the following for women who are pregnant, who may become
pregnant, or who are breastfeeding:

 Do not eat tilefish from the Gulf of Mexico, shark, swordfish, big-eye tuna,
marlin, orange roughy, and king mackerel.
 Limit the amount of albacore or yellowfin tuna eaten to 4 ounces (one average
meal) a week.
 Before eating fish caught in local lakes, rivers, and coastal areas, check
local advisories about the safety of such fish, and if mercury levels in the fish are
not known to be low or if no advice is available, limit the amount eaten to 4
ounces (one average meal) a week and do not eat other high-mercury seafood
during that week.
 Each week, eat 8 to 12 ounces (2 or 3 average meals) of a variety of seafood that
is lower in mercury.

Dangers signs during pregnancy

Identifying danger signs and referring variations from normal during the course of
pregnancy such as: headaches,
vaginal bleeding fever oedema, dizziness, epigastric pain, severe vomiting, reduced
foetal
movements etc.
Headaches
Headaches are a common neurological presentation during pregnancy. Though the
majority of headaches pregnant women experience (for example, migraine and
tension-type headache) can be managed in primary care, some headaches, especially
when associated with other neurological or visual symptoms, require urgent
investigation to exclude more sinister causes. Pregnancy is an independent risk factor
for secondary headaches due to unique physiological changes that occur, such as
hypercoagulability. This can be further exacerbated by nausea, vomiting, and
dehydration, particularly in the first trimester. Therefore, preferably, all pregnant
women with new-onset or worsening headache should be reviewed face-to-face. This
allows for neurological examination, a blood pressure reading, and fundoscopy. Urine
should always be dipped for protein. Patients who look systemically unwell or display
new focal neurological deficits in the context of new headache should be referred for
urgent assessment to secondary care.
Vaginal bleeding during pregnancy
 Vaginal bleeding during pregnancy can be a concerning symptom for many expectant

mothers. While it can occur for various benign reasons, especially in the first trimester, it is

important to understand its potential causes, implications, and the necessary steps for

management.

Causes of Vaginal Bleeding During Pregnancy:

First Trimester:

 Implantation bleeding: Light spotting as the embryo implants into the uterus lining.

 Miscarriage: Loss of pregnancy within the first 20 weeks, often accompanied by bleeding.

 Ectopic pregnancy: Where the embryo implants outside the uterus, a medical emergency.

 Cervical changes: Increased blood flow can cause light bleeding after intercourse or a pelvic

exam.

Second and Third Trimester:

 Placenta previa: The placenta covers the cervix, causing painless bleeding.

 Placental abruption: The placenta detaches from the uterine wall, a serious condition.

 Preterm labor: Bleeding can be a sign of labor starting before 37 weeks of pregnancy.

 Uterine rupture: A rare but serious condition where the uterus tears, requiring immediate

medical attention.

 Cervical insufficiency: A weakened cervix opens too early, leading to potential pregnancy

loss.

Symptoms Accompanying Vaginal Bleeding:

 Cramping or Abdominal Pain

 Back Pain

 Weakness or Fainting

 Fever or Chills
 Passing Tissue or Clots

Diagnosis of Vaginal Bleeding During Pregnancy:

 Medical History and Physical Examination: Including a pelvic exam to check the cervix.

 Ultrasound: To assess the health of the fetus and placenta.

 Blood Tests: To check hormone levels and blood count.

 Speculum Examination: To examine the cervix and vagina for sources of bleeding.

Management of Vaginal Bleeding During Pregnancy:

 Immediate Medical Consultation: Essential for any bleeding during pregnancy.

 Bed Rest: May be recommended in some cases.

 Monitoring: Regular check-ups and ultrasounds to monitor the health of the pregnancy.

 Medications: In cases of threatened miscarriage, progesterone supplements might be

prescribed.

 Hospitalization: For severe cases like placental abruption or preterm labor.

Prevention and Precautionary Measures:

 Regular Prenatal Care: To monitor the health of the pregnancy.

 Avoiding Certain Activities: Such as heavy lifting or strenuous exercise if advised by a

healthcare provider.

 Healthy Lifestyle: Balanced diet, adequate hydration, and avoiding smoking and alcohol.

Vaginal bleeding during pregnancy, while sometimes benign, always warrants medical

attention to ensure the safety of both the mother and the fetus. Understanding the potential

causes and appropriate management strategies is crucial. Pregnant women experiencing any

form of vaginal bleeding should seek immediate medical consultation for proper evaluation

and care.
Warning signs
In pregnant women with vaginal bleeding during early pregnancy, the following symptoms
are cause for concern:
 Fainting, light-headedness, or a rapid heart rate—symptoms that suggest very low blood
pressure
 Loss of large amounts of blood or blood that contains tissue or large clots
 Severe abdominal pain that worsens when the woman moves or changes positions
 Fever, chills, and a vaginal discharge that contains pus mixed with the blood.
Fever during pregnancy
Symptoms of Fever in Pregnancy
In addition to an elevated temperature, you might experience:
 Chills and sweating
 Headaches
 Muscle aches
 Fatigue
 Dehydration
What are the Risks of Fever During Pregnancy?
Fever can pose risks depending on the stage of pregnancy:
First Trimester: High fever can increase the risk of birth defects like neural tube and heart
abnormalities.
Second and Third Trimesters: Fever may lead to complications like preterm labor or low
birth weight if not managed promptly.
Safe Ways to Treat Fever During Pregnancy
When managing fever while pregnant, safety is a top priority. Here are some effective ways:
 Stay Hydrated: Drink water, broths, and electrolyte solutions to prevent dehydration.
 Rest: Ensure you get plenty of rest to help your body recover.
 Medications: Acetaminophen (Tylenol) is usually safe, but always check with your doctor
before taking any medication. Avoid NSAIDs like ibuprofen, especially in the third trimester.
 Cool Compresses: Apply a cool, damp cloth to your forehead to reduce temperature.
When to Seek Medical Attention
Call your doctor if:
 Your fever is higher than 100.4°F and doesn't respond to acetaminophen
 The fever lasts more than 24-48 hours
 You have difficulty breathing, chest pain, or a rash
 You notice signs of dehydration, like dark urine or dizziness
 You experience reduced fetal movements
Preventing Fever During Pregnancy
While some fevers can't be prevented, here are steps to reduce your risk:
 Practice Good Hygiene: Regular hand washing helps prevent infections.
 Stay Vaccinated: Get vaccines like the flu shot, which are safe during pregnancy.
 Avoid Risky Foods: Steer clear of unpasteurized dairy and undercooked meats.
 Regular Prenatal Care: Attending your check-ups allows your healthcare provider to monitor
your health. today!
While fever during pregnancy can be concerning, understanding its causes and managing it
safely will reduce risks for you and your baby. Always consult your healthcare provider for
any concerns, and seek immediate care if symptoms persist or worsen. Stay informed, stay
safe and protect your pregnancy health.
Epigastric pain during pregnancy

However, if you experience pain below the ribs in your upper abdomen, call your doctor.
Although rare, epigastric pain can be a sign of fatty liver disease or preeclampsia, a serious
blood pressure disease that can arise suddenly during pregnancy

.
Danger sign epigastric pain during pregnancy and referral

Epigastric pain during pregnancy can be concerning and may indicate a few serious
conditions. Here are some potential danger signs and when you should seek medical referral:

Danger Signs:

 High Blood Pressure: Epigastric pain combined with high blood pressure could
indicate preeclampsia, a serious condition that needs immediate medical attention.
 Severe Pain: Persistent or severe pain in the upper abdomen should not be ignored.
 Other Symptoms: Accompanying symptoms like headache, vision changes, nausea,
vomiting, or swelling in hands and face can also be red flags.

When to Seek Referral:

 Immediate Referral: If you experience any of the danger signs mentioned above, seek
immediate medical attention
 Consult Your Healthcare Provider: Even if the pain is mild but persistent, it's always a
good idea to consult your healthcare provider for a thorough evaluation.

It's important to stay in close contact with your healthcare provider throughout your
pregnancy to ensure both your health and the baby's health are monitored closely. Do you
have any other symptoms or concerns you'd like to discuss?

Severe vomiting during pregnancy

There is no evidence that mild to moderate nausea and vomiting have a harmful effect on
your baby. Women with severe nausea and vomiting or with hyperemesis gravidarum may
have a baby with a lower than expected birthweight. You may be offered scans to monitor the
growth of your baby:

Danger sign severe vomiting during pregnancy and referral

Severe vomiting during pregnancy, also known as hyperemesis gravidarum, can be a

serious condition that requires medical attention. Here are some danger signs and when you
should seek a referral:

Danger Signs:
  Persistent Vomiting: Vomiting that doesn't improve or worsens over time.
 Dehydration: Symptoms like dizziness, light-headedness, dark urine, and infrequent
urination.
 Weight Loss: Losing more than 5% of your pre-pregnancy weight.
 Severe Pain: Abdominal pain or discomfort.
 Other Symptoms: Headaches, rapid heart rate, confusion, or jaundice (yellowing of
the skin and eyes).

When to Seek Referral:

 Immediate Referral: If you experience any of the danger signs mentioned above, seek
immediate medical attention.
 Consult Your Healthcare Provider: Even if the vomiting is less severe but persistent,
it's important to consult your healthcare provider for a thorough evaluation and
appropriate treatment.

Hyperemesis gravidarum can lead to complications if not treated properly, so it's crucial to
get help early. Do you have any other symptoms or concerns you'd like to discuss?

Summarize the main points on this page

The page discusses the potential danger signs of epigastric pain and severe vomiting during
pregnancy, emphasizing the importance of seeking medical attention. Here are the key points:

Oedema (swelling) during pregnancy is quite common, especially in the later stages.
However, there are certain signs that might indicate a more serious condition, such as
preeclampsia2. Here are the key points:

Danger Signs of Oedema During Pregnancy

 Pitting Edema: When you press your thumb into your skin, an indentation
remains for a few seconds.
 Severe Swelling: Swelling in the hands, face, and around the eyes.
 Rapid Increase in Swelling: Sudden swelling that wasn't there before.
 Other Symptoms: High blood pressure, headaches, vision changes, nausea, or
vomiting.

When to Seek Referral

 Noticeable Swelling: If you notice swelling in your hands, face, or around your eyes,
contact your healthcare provider.
 Pitting Edema: If you experience pitting edema, it's important to notify your
healthcare provider immediately.
 Other Symptoms: If you have any of the accompanying symptoms like high blood
pressure, headaches, or vision changes, seek medical attention right away.

It's always better to be cautious and consult your healthcare provider if you're concerned
about swelling during pregnancy. They can perform necessary tests to ensure everything is
okay.
Dizziness during pregnancy can be common, especially in the first trimester, due to
hormonal changes and increased blood volume. However, there are certain danger signs that
warrant immediate medical attention:

Danger Signs of Dizziness During Pregnancy

 Persistent Dizziness: Ongoing dizziness that doesn't improve with rest or hydration.
 Fainting: If you faint or pass out.
 Severe Shortness of Breath: Difficulty breathing or shortness of breath.
 Other Symptoms: Accompanying symptoms like severe headache, vision changes, or
chest pain.

When to Seek Referral

 Persistent or Severe Dizziness: If dizziness continues despite rest and hydration,

contact your healthcare provider.
 Fainting: Seek immediate medical attention if you faint.
 Shortness of Breath: If you experience severe shortness of breath, contact your
healthcare provider right away.
 Other Symptoms: If you have any accompanying symptoms like severe headache,
vision changes, or chest pain, seek medical attention immediately.

It's always better to be cautious and consult your healthcare provider if you're concerned
about dizziness during pregnancy. They can help determine the cause and ensure both you
and your baby are safe.

Reduced fetal movements can be a concerning sign during pregnancy and may indicate
potential issues such as fetal distress, placental insufficiency, or even stillbirth. Here are the
key points:

Danger Signs

 Significant Decrease: A noticeable reduction in the baby's usual movement

pattern.
 No Movement: If you haven't felt any movement for a period of time.
 Change in Pattern: Any sudden change in the pattern of movements.

When to Seek Referral

 Less than 24 Weeks Pregnant: Contact your midwife or local maternity unit for an
assessment.
 Between 24 and 28 Weeks Pregnant: Contact your midwife or local maternity unit to
check the baby's heartbeat.
 Over 28 Weeks Pregnant: Contact your midwife or local maternity unit immediately.

It's always better to err on the side of caution and get checked out if you're worried about your
baby's movements. Your healthcare provider can perform necessary tests to ensure everything is
okay.
Screening tests during initial antenatal visits and ongoing visits.
Urine tests
Urine is checked at antenatal checks using a simple dipstick test to detect:
 Protein. Protein in the urine may indicate early pre-eclampsia.
 Sugar (glucose) as an initial check for diabetes.
 Germs (bacteria). During pregnancy you can have an infection of the urine without
symptoms (asymptomatic bacteriuria). This can increase the risk of problems later in
pregnancy, such as early childbirth. It can be treated with antibiotic medication.

Blood tests

A sample of blood is taken early on in pregnancy and put into several tubes. These are sent to
the laboratory to check for:
 Anaemia. The common reason for anaemia is lack of iron, which can usually be
treated easily with iron tablets.
 Blood group including rhesus D status and red cell antibodies. If you are rhesus D
negative and your baby is rhesus positive then you may form anti-D antibodies in
your bloodstream. These are not dangerous in the first pregnancy but can attack the
blood cells of a baby who is rhesus D positive in any future pregnancy. To prevent
this you will usually be offered anti-D injections later in your pregnancy.
 Rubella status. This test checks for antibodies to German measles (the rubella virus).
If antibodies are present it means that you are immune to this infection. If you are not
immune, when you are pregnant you should keep away from anyone who may have
rubella and consider being immunised.
 Haemoglobin disorders. The blood test can detect if you're a carrier of sickle
cell, thalassaemia or another haemoglobin disorder.
 Infections. Some uncommon but serious infections are checked for. These are:
o HIV. You can be infected with HIV for years before it causes symptoms. The
risk of passing this virus on to your baby can be greatly reduced with
treatment during pregnancy, and delivery by caesarean section.
o Hepatitis B. Many people are carriers of the hepatitis B virus but have no
symptoms. In some cases it can cause serious liver damage. If you have this
virus, it may be prevented from affecting your baby if the baby is immunised
at birth.
o Syphilis. This is an uncommon sexually transmitted infection. Again, you can
be infected with this germ (bacterium) without realising and pass it on to your
baby. It can develop into a serious illness. It can be treated with antibiotics.
 Diabetes. If you have had a history of diabetes in a previous pregnancy (gestational
diabetes) then you will be tested for diabetes by a blood test in future pregnancies. In
addition, you may be offered a test for diabetes if you have risk factors for diabetes;
for example, if you:
o Are very overweight.
o Have had a heavy baby in the past (≥4.5 kg).
o Have a close family relative with diabetes.
o Are from certain ethnic groups.

Initial Lab Tests

Shortly after registration, initial laboratory tests are ordered. Later in pregnancy, other tests
are usually performed. Physician preference and patient population guide some of the choice
of these tests, but commonly-ordered tests include:

 Hemoglobin and hematocrit (HGB/HCT)

  White blood cell count (WBC)
 Urinalysis (UA)
 Blood type and Rh
 Hepatitis B Screen
 Rubella Titer
 Atypical antibody screen
 Thyroid Stimulating Hormone (TSH)
 Serologic test for syphilis (RPR or VDRL)
 HIV
 Gonorrhea
 Chlamydia
 Pap
 Other lab tests as indicated by individual circumstances. For example, Sickle
screening for black patients, Tay-Sachs screening for Ashkenazi Jewish patients, and
thalassemia screening for patient's of Mediterranean extraction.

Subsequent Lab Tests

 Serum AFP at 15-18 weeks

 Targeted (Level II) ultrasound scan for women at high risk at 16-20 weeks
 Hbg/Hct at about 28 weeks
 Glucose screening at about 28 weeks (50 g oral load with 1-hour glucose test)
 Antibody screen and Rhogam for Rh negative women at 28 weeks
 Vaginal/rectal culture for Group B Strep at about 36 weeks

A repeat blood test at about 28 weeks is usually offered to check again for anaemia and red
cell antibodies.

Ultrasound scans
An ultrasound scan is a safe and painless test which uses sound waves to create images of
structures inside your body, such as an unborn baby. Two scans are normally offered:
 An early pregnancy scan works out when your baby is due. The scan is usually done at
around 10-13 weeks. This early scan confirms your baby's heart is beating and how
many babies are growing inside your womb (uterus).
 A fetal anomaly scan is offered later in your pregnancy. The scan is usually done at
around 20 weeks. This looks for any developmental problems with your baby. If an
earlier scan using sound waves (an ultrasound scan) indicates that you may have a
placenta praevia, a repeat scan at 36 weeks of pregnancy may be advised. This is to
clarify the position of your placenta before delivery.

uring the first prenatal visit, a healthcare provider typically covers several important topics to
ensure both the mother and baby's health. Here's a summary of what you can expect:

Health Information Given During the First Visit

 Medical History Review: Discussion about your medical history, any previous
pregnancies, and family health history.
 Physical Exam: A general physical exam, including checking your weight, blood
pressure, and possibly a pelvic exam.
  Urine Test: To check for protein, glucose, white blood cells, blood, and bacteria.
 Blood Tests: To determine blood type and Rh factor, check for anemia, and screen for
certain infections or conditions.
 Genetic Carrier Screening: To identify if you are a carrier for certain genetic
conditions.
 STD Tests: Screening for sexually transmitted infections.
 Blood Sugar Test: To check for gestational diabetes.
 Ultrasound: Sometimes an early ultrasound is done to confirm the pregnancy and
check for the baby's heartbeat.
 Prenatal Vitamins: Discussion about the importance of taking prenatal vitamins,
especially folic acid.
 Lifestyle Advice: Guidance on diet, exercise, and avoiding harmful substances like
alcohol and tobacco.
 Questions and Answers: Time to ask any questions and address concerns you might
have.

This visit is comprehensive and sets the stage for ongoing prenatal care throughout your
pregnancy. It's a great opportunity to establish a relationship with your healthcare provider
and ensure you have all the information you need for a healthy pregnancy

Health topics to include in the HP and HE activities in all settings are the following:

 Nutrition (e.g. own nutrition, breastfeeding);

 Birth spacing and contraception;
 Lifestyle issues (e.g. smoking, substance use, physical activity);
 Safe sex and sexually transmitted infections, including HIV;
 Mental health;
 New-born care and parenting.

 Adherence to medical treatment or lifestyle changes;

 Specific types of infectious diseases (e.g. hepatitis B and C, malaria, dengue and TB)
and how to avoid or treat them. Attention to certain emerging infectious diseases may
also be needed;
 Harmful cultural practices (e.g. herbal concoctions to induce or accelerate labor,
female genital mutilation).

In certain contexts, the same midwife or group of midwives supports a woman throughout her
reproductive life cycle.

HP and HE are an integral part of their day-to-day functioning.

In the context where you work: Health education on antenatal care include
definition, aim, objectives, registration, antenatal check-up, immunization, iron & folic acid,
diet, bowel care, cleanliness, clothing, shoes, dental care, care of breast, sleep, exercise,
coitus, travel, smoking & alcohol, family support & dangers signs during pregnancy.

 What are the challenges in addressing general health topics like nutrition,
contraception and lifestyle issues? What are possible solutions?
 How are specific types of infectious diseases included in HP and HE activities? How
consistent are current health messages? How could they be improved?
 What are harmful practices in your context? Are they addressed adequately in HP and
HE activities?

The objectives of Antenatal Care are:

 To ensure a normal pregnancy and delivery of a healthy baby.

 To monitor the progress of pregnancy and recognize deviation from the normal
 To provide psychological support to a woman by allaying her fear and anxiety
 To prepare her for delivery and care of the new-born
 To offer the family advices on planned parenthood

Counselling and Health Promotion

A critical component of effective ANC services is the provision of counselling to provide
women with proper knowledge and psychosocial support to improve their health behaviors
and attitudes. Counselling for maternal and new-born health is an interactive process between
the service provider and the woman and her partner/family. During counselling, information
is exchanged and support is provided so that the woman can make decisions, design a plan,
and take action to improve her health. To counsel and help women successfully, the
counselling process should encompass six components: assessing the situation; defining
problems, needs, and information gaps; generating alternative solutions; prioritizing
solutions; developing a plan; and reviewing and evaluating the plan at subsequent contacts. It
is necessary to engage women and partners/families in interactive discussion, asking
questions for better understanding of individual needs and challenges. Service providers
should then review situations that might prevent the woman and her family from carrying out
the plan, including lack of resources and support. Discuss selection of potential alternative
solutions taking into account the advantages and disadvantages of each and review the agreed
upon plan during the next ANC contact. Counselling can build trust while helping to ensure
positive pregnancy outcomes. This section discusses key points to include in counselling on
nutrition, hygiene, physical activity and rest; early and exclusive breastfeeding; healthy
timing and spacing of pregnancy; tobacco, alcohol, and substance use; safer sex; and danger
signs of pregnancy.

Health promotion refers to any activity that aims to achieve better health in a community or
a country. It includes the health education of individuals to enable them to control and
change their lifestyles so that their health is improved, health promotion activities go far
beyond this focus on individual behaviour, and include a wide range of social and
environmental interventions that increase health and wellbeing in populations as well as
individuals. Health promotion also includes disease prevention — actions taken to prevent a
disease from developing, and health screening — the routine testing of individuals to see if
they are at risk of developing a health problem.

Antenatal care provides a key entry point for a broad range of health promotion and disease
prevention services. It is essential for healthcare providers and women to talk about important
issues affecting the woman’s health and her pregnancy.

During the antenatal period, you can promote the health of the women in your care and the
health of their babies before and after birth, by educating mothers about the benefits of good
nutrition, adequate rest, good hygiene, family planning and exclusive breastfeeding, and
immunization and other disease prevention measures. Your aim is to develop women’s
knowledge of these issues so they can make better informed decisions affecting their
pregnancy outcome — but you should never lose sight of the difficulties some women will
face in being able to improve their lifestyles.

Learning Outcomes

When you have studied this session, you should be able to:

 Describe the major dietary constituents for good health in a pregnant woman, advise
women on eating well with little money, and explain the problems resulting from a
poor diet.
 Explain the benefits of good hygiene and other self-care activities in pregnancy.
 Explain the benefits of immunization against tetanus.
 Explain the benefits of early and exclusive breastfeeding for the mother and for her
baby.
 Explain the benefits of family planning to achieve birth spacing and discuss
postpartum contraception with pregnant women.

Nutrition during pregnancy

In this section (the biggest in this study session) we describe the nutritional requirements in
pregnancy in detail and explain how you can advise women about eating well, even if they
have very little money for additional [Link] nutritional status of a woman before and
during pregnancy plays a vital role in fetal growth and development. In pregnancy, increased
nutrient requirements for energy, protein, iron, calcium, etc., mean the woman needs an
additional 300 calories, 10 g of protein, and 1,000 mg of calcium daily, including the foods
from three main groups:

• Energy providing foods

• Body building foods

• Disease preventing foods

Healthy Eating during Pregnancy and Breastfeeding Consuming a variety of nutritious foods
is particularly important during pregnancy and breastfeeding. Meals should include foods
from three main groups to ensure a balanced diet and appropriate nutrition. The three groups
are:

• Cereals, grains, vegetable oils (energy providing foods)

• Varieties of meat and fish, eggs, milk, peas and beans (body building foods)

• Vegetables and fruits (disease preventing foods) Pregnant women should consume iron and
folate rich foods such as liver, beef, poultry, bean curd, dark green vegetables, and leafy
vegetables to prevent deficiencies. Wholegrain foods (e.g., brown rice, corn, whole wheat)
are also valuable sources of iron and zinc and fiber. Vegetable and fruit consumption before
and during pregnancy makes an important contribution to health outcomes for women and
their children. Vegetables should be cooked together with meat, fish, or prawns.

Fruits and vitamin C-enriched juices should be taken after meals in order to ensure the
absorption of iron. Iodized salt should be used in cooking to fulfill the requirement for iodine
during pregnancy. Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and
legumes/beans: Lean red meat and chicken are a good source of protein, iron, and zinc.
Maternal consumption of fish during pregnancy is likely to have a number of health benefits
but the fish should be low in mercury. Nuts, seeds, and legumes/beans are important foods for
people who choose vegetarian or vegan diets as they can provide an alternative source of
nutrients. For several nutrients, including iron, calcium, and vitamin B12, animal foods are
highly bioavailable sources and care should be taken to ensure a variety of alternatives if
these foods are excluded. Vitamin B1 is essential during pregnancy and lactation to prevent
beriberi—B1 deficiency. Varieties of beans, whole grain, lean meat, and steamed rice with
the shell are rich B1 sources. To avoid B1 deficiency, rice should be steamed and should not
be heavily rinsed. Eating only fish, fried chicken, and plain soup in the antenatal or
postpartum period will lead to vitamin B1 deficiency. Milk, yogurt, cheese, and their
alternatives are good sources of calcium. Reduced-fat milk, yogurt, and cheese products are
recommended during pregnancy. Water: Pregnant women have an increased water
requirement because of expanding extracellular fluid space and the needs of the baby and
amniotic fluid. Foods that should be limited: Foods containing saturated fat, added salt, added
sugars: Intake of these foods should be limited in general and during pregnancy. The
additional energy requirements of pregnancy should be met through additional portions of
foods from the three food groups. Caffeine: WHO recommends limiting intake to less than
300 mg of caffeine during pregnancy (not more than 2 cups of coffee or six cups of tea a day)
to reduce the risk of pregnancy loss and low birth weight. Other caffeinated beverages (e.g.,
colas, energy drinks, green tea) should also be limited.

Dietary Taboos and Family Participation

Discuss dietary taboos and encourage a variety of food groups using fresh, hygienic foods
and safe water. Include partners and other family members so they understand the need for
adequate nutrition in pregnancy and during breastfeeding. To avoid the reduced absorption of
iron, drinking tea and eating tea leaf salad need to be avoided 1 hour before and 2 hours after
a meal.

Nutritional supplements

There is evidence to support routine supplementation with folic acid preconception and in
the first trimester. Iron supplementation may prevent iron deficiency in women with limited
dietary iron intake. Vitamin B12 supplementation may be needed if a woman has a vegetarian
or vegan diet. Multivitamin and mineral supplements may be needed for women who are
vegetarian, drink alcohol, use cigarettes or drugs, have been on a weight-loss program, and
adolescents with poor nutrition. Other nutritional supplements do not appear to be of benefit
unless there is an identified deficiency.

Health education and counselling method: Group and individual sessions—health talk,
discussion, demonstration, counselling with information, education, and communication
(IEC). Special considerations: spend more time with adolescents, women living with HIV,
underweight women, and women not gaining weight.

Assignment

What is a balance diet?

Eating well

Eating well means eating a variety of healthy foods and also eating enough food. This
combination helps a pregnant woman and her baby stay healthy and strong because it:

 Helps a woman resist illness during her pregnancy and after the birth
 Keeps a woman’s teeth and bones strong
 Gives a woman strength to work
 Helps the baby grow well in the mother’s uterus
 Helps a mother recover her strength quickly after the birth
 Supports the production of plenty of good quality breast milk to nourish the baby.
Eating a variety of foods
It is important for pregnant women (like everyone else) to eat different kinds of food, energy
foods (carbohydrates), grow foods (proteins), glow foods (vitamins and minerals), and go
foods (fats, oils and sugar), along with plenty of fluids.

Eating well means eating a variety of foods to get all the right nutrients, especially during
pregnancy and breastfeeding, and eating enough food for good health.

Eat more food

Pregnant women and women who are breastfeeding need to eat more than usual. The extra
food gives them enough energy and strength, and helps their babies grow. They need
to increase their usual food intake by at least 200 calories per day, or even more than this if
they were underweight before they became pregnant. There are many ways to increase daily
food intake by this amount: for example, one more serving of maize porridge and 12
groundnuts a day would meet this additional requirement.

Some pregnant women feel nauseated and do not want to eat. But pregnant women need to
eat enough — even when they do not feel well. Simple foods like injera or rice can be easier
for these women to eat. For women who suffer from nausea, encourage small and frequent
meals.

Problems from poor nutrition

Poor nutrition can cause

tiredness, weakness,

difficulty in fighting infections and other serious health problems.

Poor nutrition during pregnancy is especially dangerous.

It can cause miscarriage or cause a baby to be born very small or with birth defects.

It also increases the chances of a baby or a mother dying during or after the birth.

Talking to women about food

When you see pregnant women for antenatal care, or at village meetings and celebrations, in
the market, try to find ways to enquire sensitively about the food they eat. The earlier
pregnant women start eating healthier foods, the better chance they have to stay healthy, to
have normal births and to have healthy babies.

To find out whether a woman is eating well, ask her what she usually eats, and how much.
For example, ask her: ‘What did you eat yesterday?’ Be sure to tell her what is healthy about
what she eats, reinforce the positive efforts she is making to eat well. Then, if it is
appropriate, make a suggestion for how she could eat better.

Remember that education about food is not enough on its own to change eating behaviour.
Even if a woman knows the best foods for health, she may not eat them. Many families
cannot afford to buy enough food or a wide variety of foods. Some women may simply not
like the taste of some healthy foods. To help a woman eat better, suggest healthy foods that
she can afford and will choose to eat.

Eating well with little money

The biggest cause of poor nutrition is poverty. A very poor family can eat better by spending
money wisely and not wasting what little they have. A father who buys alcohol, tobacco and
‘chat’ (or khat) could instead buy nutritious food or he could buy a hen to lay eggs. A mother
who buys her children sweets or soda pop could instead buy eggs, beans or other low-cost,
healthful foods. Here are some ideas that families can use to eat better with little money.

Beans, peas and lentils

Beans, peas and lentils belong to a family of vegetables called legumes. All legumes have a
lot of protein and vitamins, and they usually do not cost much. They have even more vitamins
if they are sprouted before being eaten. Planting legumes makes soil richer. Other crops such
as maize will grow better in a field where legumes once grew.

Less expensive meats and animal products

Blood and organ meats like liver, heart and kidney have a lot of iron and may cost less than
other meats. Fish and chicken are as healthy as other meats, and usually cost less —
especially for a family that fishes or raises their own chickens. Eggs have a lot of protein,
iron, and vitamin A. Eggs give more protein for less money than almost any other food.

Whole grains
Grains like teff, wheat, rice and corn are more nutritious when they have not been refined
(processed to take out the colour). Taking out the colour takes out healthy things too. White
bread and white rice have fewer vitamins, minerals and proteins than brown bread or brown
rice. Dark teff and brown injera are more nutritious than the light-coloured ones.

Vegetables and fruits

When vegetables are boiled or steamed, some of the vitamins from the foods go into the
cooking water. Use this water to make soups.

The outside leaves of plants are usually thrown away, but sometimes they can be eaten. The
leaves of the cassava plant have more vitamins and protein than the root. Many wild fruits
and berries are rich in vitamins and natural sugars that give energy.
Breast milk
Breast milk costs nothing, and has all the nutrition a baby or young child needs. Young
children who are on exclusive breastfeeding do not need fortified milks or other foods until
after the age of 6 months.

Food groups and their nutrients

Main foods (carbohydrates)

In most parts of the world, people eat one main food at each meal. This main food may be
injera, rice, maize, wheat, millet, cassava, plantain, kocho, bulla, godere, shenkora, gishta,
breadfruit or another low-cost, starchy food which is rich in carbohydrates. These foods give
the body energy. But to grow and stay healthy, the body needs other types of food too.

proteins

Meat, fish and cheese are nutritious foods but they can carry parasites or disease when they
are eaten raw. Pregnant women should eat fish, meat or cheese only when it is well cooked or
pasteurised.
Foods contain protein, which is needed for the growth of muscles, bones, and strong blood.
Everyone needs protein to be healthy and to grow. Some grow foods that are high in proteins
are:
 Legumes (beans, peas, soybeans, and lentils)
 Eggs
 Cheese, milk and yogurt
 Nuts and seeds
 Cereal, wheat, corn and rice
 Meat, poultry and fish.

sugars and fats

contain sugars and fats, which give the body energy. Everyone needs these foods to be
healthy. Some healthy foods that are high in sugars are:
 Fruits
 Honey.

Some ‘go foods’ that are high in fats are:

 Some nuts (e.g. peanuts) and some seeds (e.g. sunflower)

 Avocados
 Vegetable oils, butter and lard
 Fatty meat
  Milk and cheese
 Eggs
 Fish.

These days, many people eat more sugars and fats than they need. That is because more
people drink sugary soda pop, or eat foods that come from packages instead of foods made at
home. These packaged, sugary and fatty foods are expensive and not as healthy as fresh
products. They also damage the teeth. It is better to eat go foods that are natural, not
packaged.

Vitamins and minerals

vitamins and minerals, which help the body fight infection and keep the eyes, skin and bones
healthy and strong. Vitamins and minerals are known as micronutrients because they are
very small. Fruits and vegetables are high in vitamins and minerals. It is important for
pregnant women to eat as many different fruits and vegetables as they can. In the next
section, we discuss the five most important vitamins and minerals that pregnant and
breastfeeding women should eat every day.

The five most important vitamins and minerals

Pregnant and breastfeeding women need more of these five vitamins and minerals than other
people do — iron, folic acid, calcium, iodine and vitamin A. They should try to get these
vitamins and minerals every day.

 Why do you think that a pregnant woman needs more of these vitamins and minerals?

Iron
Iron helps make blood healthy and prevents anaemia (you will learn about diagnosing and
treating anaemia in Study Session 18 of this Module). A pregnant woman needs a lot of iron
to have enough energy, to prevent too much bleeding at the birth, and to make sure that the
growing baby can form healthy blood and store iron for the first few months after birth. It is
also important in the production of good breast milk.

Pregnant and breastfeeding women should try to eat at least one iron-rich food every day.

These foods contain a lot of iron:

 Poultry (chicken)
 Fish
 Sunflower, pumpkin and squash seeds
 Beans, peas and lentils
 Dark leafy green vegetables
  Yams
 Hard squash
 Meat (especially liver, kidney and other organ meats)
 Whole grain products
 Dried fruit
 Nuts
 Iron-fortified bread
 Egg yolk.

Taking iron pills

It can be difficult for a pregnant woman to get enough iron, even if she eats iron-rich foods
every day. She should also take iron pills (or liquid iron drops) to prevent anaemia. These
medicines may be called ferrous sulfate, ferrous gluconate, ferrous fumerate or other names
(ferrous comes from the Latin word for iron).

Iron pills or drops can be obtained from pharmacies and health institutions, but throughout
you will give iron pills routinely to pregnant women as part of focused antenatal care. She
should receive 300 to 325 mg (milligrams) of ferrous sulphate once a day taken by mouth,
preferably with a meal. This dosage is usually supplied in a single tablet combined with folate
(see below).

The iron pills may cause nausea, make it hard for the woman to pass stool (constipation), and
her stool may turn black, but it is important for the woman to keep taking the iron pills
because anaemia can cause complications during pregnancy, during delivery, and after the
baby is born. It is helpful for the woman to take the iron pill with a meal, drink plenty of
fluids, and eat plenty of fruits and vegetables to avoid nausea and constipation. The black
colour of the stool is a normal side-effect from the iron and is not harmful.

Folate (folic acid)

Lack of folate can cause anaemia in the mother and severe birth defects in the baby. To
prevent these problems, it is important if possible for a woman to get enough folic acid in her
diet before she becomes pregnant and she should certainly do this in the first few months of
pregnancy.

Foods rich in folate that pregnant and breastfeeding women should try to eat every day
include:

These foods contain a lot of folate.

 Dark green, leafy vegetables
 Whole grains (brown rice, whole wheat)
  Meat (especially liver, kidney and other organ meats)
 Fish
 Peas and beans
 Eggs
 Sunflower, pumpkin and squash seeds
 Mushrooms.

As well as eating as many of these foods as she can, all pregnant women should also take 400
mcg (micrograms) of folic acid tablets orally every day during pregnancy. She should be able
to get these tablets from you as part of Focused Antenatal Care.

Calcium
Calcium-rich foods.

A growing baby needs a lot of calcium to make new bones, especially in the last few months
of pregnancy. Women need calcium for strong bones and teeth. These foods contain a lot of
calcium:

 Yellow vegetables (hard squash, yams)

 Lime (carbon ash)
 Milk, curd, yogurt and cheese
 Green, leafy vegetables
 Bone meal and egg shells
 Molasses and soybeans
 Sardines.

Women can also get more calcium in these ways:

 Soak bones or eggshells in vinegar or lemon juice for a few hours. Then use the liquid to
make soup or eat with other foods.
 Add lemon juice, vinegar or tomatoes when cooking bones.
 Grind eggshells into a fine powder and mix into food.
 Soak maize in lime (carbon ash) before cooking it.

Iodine
Iodized salt is the easiest way to get enough iodine in the diet.

Iodine prevents goitre (swelling of the neck) and other problems in adults. Lack of iodine in a
pregnant woman can cause her child to have cretinism, a disability that affects thinking and
physical features.
The easiest way to get enough iodine is to use iodized salt instead of regular salt. It is
available in packet form labelled ‘Iodized salt’ in many market places.

Vitamin A
Vitamin A prevents poor vision at night or when light intensity is low and helps to fight
infections. Lack of vitamin A also causes blindness in children. A woman needs to eat plenty
of vitamin A-rich food during pregnancy and while breastfeeding. Dark yellow and green
leafy vegetables and yellow fruits contain lots of vitamin A. Name some of these vegetables
and fruits. Other sources of vitamin A are liver, fish liver oil, milk, eggs and butter.

Fluids
Along with eating healthy foods, women should drink plenty of clean water and other healthy
fluids every day. Fruit juices, animal milks and many herbal teas are all healthy fluids to
drink.

Hygiene during pregnancy

Hygiene and oral health during pregnancy

During pregnancy, women should be especially careful about personal hygiene. Pregnant
women, Dry, scaly skin, sweat more and have more vaginal discharge than non-pregnant
women (due to hormonal changes), and they may be more vulnerable to infection by germs in
the environment.

Keeping the body clean helps prevent infection. Hand washing with soap is the most
important hygiene action she can take, especially before preparing food and after going to the
toilet. If possible, a pregnant woman should wash her body every day with clean water
especially her genital area.

Encourage:

• Regular bathing and clean clothes, address taboos about bathing in pregnancy

• Hand washing after using the bathroom and before preparing food and eating

• Hand washing before touching the baby and after touching/handling the baby’s waste

• Preparation of clean clothes for mother to use during labor and after birth, including
sanitary cloths; prepare clothes for new-born.

Health education and counselling method: Group and individual sessions—health talk,
discussion, demonstration, counselling with IEC.

Special considerations: spend extra time with women who have diarrheal disease, skin lesions
 Good hygiene during your pregnancy will help prevent infections, keep you comfortable and
make you feel more refreshed.
Here are some basic hygiene tips:
 Apply lotions or creams immediately after bathing or showering to soothe and soften your
skin
 Good hygiene will help prevent vaginal infections, but never douche during pregnancy unless
your provider specifically tells you to.
 Put a rubber mat in the tub or shower to prevent slipping. Tub baths may become more
difficult near the end of pregnancy when your center of balance shifts. You may want to
switch to showers or have someone help you in and out of the tub safely.
 Keep the water temperature warm when you bathe or shower because hot water may make
you feel dizzy or lightheaded.
 Avoid hyperthermia (high body temperature). There is some evidence that hyperthermia in
early pregnancy may cause damage to the fetus. You may be able to tolerate short stretches in
a sauna or hot tub, but the temperature should not exceed 102°F and your exposure should
not exceed 10 minutes.

Cleanliness During Pregnancy: Importance & Tips to Maintain It

Maintaining personal hygiene during pregnancy is just as important as having a nutritional
diet and proper exercise to keep yourself healthy. Most women believe that staying away
from dirty areas and washing their hands is equivalent to being hygienic. While those might
be good starting points, that isn’t enough to cover all aspects of personal hygiene during
pregnancy. Plus, with the weakened immune system during pregnancy, it becomes imperative
that you take proper measures to keep hygiene in check. The importance of cleanliness during
pregnancy cannot be stressed enough, and there are numerous aspects related to your body
that you should focus on during this phase.
Importance of Hygiene in Pregnancy
Be it during pregnancy or after delivery, every decision that you make which affects your
body and your mind affects the well-being of your child. Even the most straightforward
choices of keeping yourself clean are connected to the baby’s health as well.
Having poor hygiene can put the pregnant woman at risk of being exposed to numerous
bacteria and microbes, all of which can get you infected since the immune system is not as
strong as before. Certain infections can reach and affect the baby as well, at his most
vulnerable stage of growth, causing the possibility of long-term defects.

How to Maintain Hygiene during Pregnancy

There are a bunch of areas you ought to focus on when attempting to maintain proper hygiene
in pregnancy.
Hair & Skin Hygiene
A lot of nutrients are taken from the pregnant woman body to help the child grow, which
affects her skin in different ways. Furthermore, the secretion of oil within the glands of the
hair gets a kick as well, causing oily hair to be a recurring situation in most pregnant women.
Hence, shampooing the hair on a regular basis is essential to rid them of the excess oil and
maintain hair texture. Since the skin can react quickly to any extremities, don’t spend
extended hours in bathtubs or water. A shower is a better choice. When choosing soaps and
shampoos, pregnant women should choose the mild ones made from natural oils and
substances since they are safer and gentler on the skin. However, bathing is the easiest and
safest way to the maintenance of hygiene.
Clothing
When organising wardrobe for better clothes or purchasing newer ones, the pregnant woman
keep a few ideas in mind to help choose better. Opt for clothes that you can wash with
detergents that have antibacterial qualities. When choosing clothes, go for ones that are a bit
loose and can be worn easily. Choose cotton clothes that can absorb sweat and change them
as soon as they get sweaty. When purchasing a maternity bra, go for the one with pads that
can absorb milk leaks from your nipples.
Personal Hygiene
Taking care of your own body, and specifically, your intimate regions, is a necessity at this
stage to keep personal hygiene in pregnancy optimal. Bathe daily and pay extra attention to
the pubic region to keep it clean and free from any infection. Choose soaps that are plain and
natural. Experts usually recommend not using any harsh soaps or chemicals to clean the
around near your vagina so that it doesn’t disturb its natural pH balance. Washing the genital
area with cleaning water, in most cases, is enough. Washing hands with soap and water
before and after handling food, using the toilet, and after touching animals is extremely
important.
Breast Care
Most women observe colostrum leaks towards the end of the first trimester. This needs to be
cleaned regularly, for damp breasts can easily get itchy and unhygienic. Change bra pads
regularly after they get wet, and use lotions to treat nipple cracks, as suggested by your
 doctor. After your daily bath, make sure there is no soap left on your nipples. Leftover soap
residue on nipples can make them dry and crack, making them vulnerable to infections.
Dietary Hygiene
Bathing daily and wearing clothes isn’t enough to protect yourself from harmful germs. You
need to include strict dietary hygiene in your routine as well. Remember to wash your hands
with antibacterial soap for at least 20 seconds before preparing and eating food, and keep
a sanitiser handy whenever you are out and need to have some snacks. Make sure to wash the
front and back of your hands, between your fingers, and your fingernails. Nails house dust
and multitude of germs, therefore, nails should be clipped and cleaned. Wash your hands
after handling raw foods, cleaning kitchen surfaces, and wiping up any spillage. Most of all,
avoid food, juices, and drinks from outside vendors and restaurants as the chances of food
contamination are high, and any food handled or prepared poorly can jeopardise your and
your baby’s health. Avoid eating food that smells unusual or off and always have properly
cooked and hot food as it destroys bacteria and pathogens.
Hygiene is one factor that is important in every stage of life. Its importance increases

Oral Hygiene Care during Pregnancy

Counsel women about maintaining good oral hygiene by avoiding sugary drinks and foods,
regular brushing, and use of a dental stick. Routine dental care during pregnancy is safe, as is
treatment of periodontal problems. Women should inform the service provider if their gums
are red, bleed easily, or if tooth or gum pain is noted. Women should be aware that improved
oral health can decrease transmission of cavity-causing bacteria to their infants and thus
reduce their chance of dental caries. Dental hygiene is especially important during pregnancy
because increased oestrogen levels can cause swelling and increased sensitivity in gum
tissues. Whether she cleans her teeth with a dental stick or a toothbrush and toothpaste, the
pregnant woman should do so regularly. Health education and counselling method: Group
and individual sessions—health talk, discussion, demonstration, counselling with IEC.
Special considerations: Women with active periodontal disease should be advised to seek
dental care as soon as possible to avoid/treat infections that could compromise nutrition and
general health. Dental health is an important part of your total health. Dental disease can
increase your risk of certain pregnancy complications. Here are some helpful pointers to
make sure that you have the best oral health:

 See your dentist as early as possible in your pregnancy to be checked for tooth decay, gum
disease and other dental problems, and to get the necessary treatment
 You require special care and attention when you’re pregnant, so be sure to tell your dentist
that you are pregnant
 Discuss the benefits and risks of x-rays, anesthetic agents, pain medications, and other drugs
with your dentist. Your dentist may recommend alternative procedures and treatments
 If drinking water is not fluoridated, ask the dentist or provider about fluoride supplements
 Brush and floss your teeth at least once a day. This prevents tooth decay and will help
maintain healthy gums, gums may bleed more easily during pregnancy
 An early dental examination followed by necessary treatment, good oral hygiene practices
and a well-balanced diet will help maintain bright and healthy teeth
 Avoid sweets such as caramels, hard candies, sticky foods, and soft drinks. If you have some
of these occasionally, brush your teeth, or at least rinse with water afterward. Sugar build-up
in your mouth, even for a few hours, can contribute to tooth decay

Living a healthy lifestyle

As well as eating well and keeping clean, pregnant women need to get enough sleep and rest
every day. This will help her to avoid developing high blood pressure and oedema (swelling
of the feet and ankles due to fluid collecting in the tissues). Good rest also helps her to stay
strong and gives the fetus a better chance of being born healthy.

Families who encourage a pregnant woman to rest often are helping her and the baby to be
healthy.

Many women have to work throughout their pregnancy in the fileds, factories or shops, as
well as in their own homes. This can be especially hard for women during pregnancy,
because they get more tired than usual — especially in the last few weeks. Explain to them
and their families that the woman should try to rest for a few minutes every 1 to 2 hours. This
will also help her to enjoy her pregnancy. Whatever a mother puts into her body passes to
her baby.

Make sure that women know that whatever they put into their body will pass across the
placenta and into the baby. Cigarette smoke, alcohol and illegal drugs such as opium, heroin,
cocaine and barbiturates are dangerous for anyone, but especially harmful to the developing
fetus. Even one or two alcoholic drinks a day during pregnancy can result in the baby being
born too small, or with birth defects or disabilities that affect the brain.

She should also be advised to avoid:

 Lifting heavy things

 People who are sick, especially if they have vomiting, diarrhoea or rashes
 Strong chemicals or their fumes (e.g. chemicals used to kill pests in the fields)
 Non-essential medicines
 Medicines such as cough syrups, laxatives and pain relievers that have not been
prescribed for her by a health worker (Figure 14.9).
Pregnant women should take only medicines that are safe in pregnancy and that are truly
needed.
Physical Activity and Rest
Physical activity is defined as any body movement that involves the use of one or more of
the large muscle groups and raises the heart rate. This includes sports, exercise, and
recreational and incidental activity that accrue throughout the day (e.g., walking to do errands
and shopping, climbing stairs).
• At least 30 minutes/day or at least 150 minutes/week of moderate-intensity physical
activity on most, preferably all days, are recommended for all adults.
• Moderate-intensity activity causes a slight, but noticeable, increase in breathing and heart
rate (e.g., brisk walking, working in the garden, or medium-paced swimming).
• Vigorous activity during pregnancy, such as heavy lifting and prolonged standing or
bending, is not recommended.
• A pregnant woman should take an hour-long nap daily and rest when fatigued.
• The partner and family should be encouraged to assist women with their duties as
necessary. Health education and counselling method: Group and individual sessions—health
talk, discussion, demonstration, counselling with IEC.
Immunization against tetanus

Tetanus is a very serious, life-threatening infection, which damages the nervous system and is
caused by bacteria in the environment, for example in soil. Tetanus toxoid immunization is
the best protection against tetanus for the woman and her baby. Therefore, it
is very important for her to be immunized according to the schedule on her card, and to bring
her card to every antenatal care visit.

Make sure all pregnant women are immunized against tetanus. , the stump of the baby’s
umbilical cord should be kept clean and dry after birth and until it falls off. This is one reason why it
is so important for the woman and her family to plan and prepare for a clean and safe childbirth
attended by a skilled health provider such as you.

Benefits of early and exclusive breastfeeding

Breastfeeding positions and good attachment of the baby are described during your antenatal
care visits with pregnant women — especially those having their first baby. Whether the
mother chooses to breastfeed her baby or she feeds a substitute for human milk, you should
respect her decision. But she cannot make this choice if she has not been well informed by
you about the benefits of early and exclusive breastfeeding. Explain to her that it:

 Provides the best nutrition for the new-born

 Is easily digested and efficiently used by the baby’s body
 Protects against infection and other illnesses
 Offers some protection against allergies
 Is cost-effective and affordable
 Promotes mother-baby bonding
  Provides the woman with a degree of contraceptive protection (though less than 100%
effective) if she is exclusively breastfeeding until her first menstrual period returns after
the birth.
Unhealthy beliefs and practices about feeding new-borns

In some countries, there are beliefs about feeding new-born babies that are dangerous to the
baby’s health. For example, in some places the baby is given food or liquids, such as water
with sugar, honey, herbs, spices and animal milks, during the first 3 days after the birth
before the woman begins breastfeeding. The thin, watery fluid called colostrum that her
breasts produce during these 3 days may be thrown away because it is considered unclean.

 What are the benefits of feeding colostrum to new-borns?

 Even after the woman’s breastmilk begins to flow, some people go on feeding other liquids
and honey to the baby, in addition to breastfeeding.

 What do you think are the reasons for this and what are the risks in doing so?
 General principles of early and exclusive breastfeeding

For mothers who are HIV-negative:

 Babies should begin breastfeeding as soon as possible after birth (preferably within the
first hour) and continue for at least the first 6 months of life.
 Colostrum, the first milk should be given to the baby, not thrown away.
 The baby should be breastfeed exclusively for the first 6 months of life. Nothing else
should be given to the baby to drink or eat during that time.
 The baby should be breastfeed whenever s/he wants, day and night (on demand), which
stimulates the breasts to produce an adequate supply of breast milk.
Postpartum family planning

During the antenatal period, discussions should begin concerning postpartum contraception
options. Family planning information and services are important components of good quality
antenatal care. These occasions provide an opportunity for health providers to discuss with
women the benefits of birth spacing (leaving at least 2 years between births) for their health
and the health of their current and future children. Help pregnant women and new mothers
decide how they will avoid pregnancy after childbirth.

Breastfeeding and contraception

The return of fertility after birth is not entirely predictable, and conception can occur before
the woman resumes her first menstrual period. A woman who is not fully and exclusively
breastfeeding is able to become pregnant again as soon as 4 to 6 weeks after childbirth, and
she should plan to begin some sort of contraception before starting to have sexual intercourse
again. Full and exclusive breastfeeding gives good protection against conception, but cannot
be relied on as 100% effective. A breastfeeding woman is usually protected from
pregnancy only if:

 She is no more than 6 months postpartum

 She is breastfeeding exclusively (8 or more times a day, including at least once at night;
no daytime feedings more than 4 hours apart and no night feedings more than 6 hours
apart; no complementary foods or fluids given to the baby)
 Her menstrual cycle has not returned.

Numerous safe methods of contraception are available for the breastfeeding woman.

Benefits of birth spacing

For maximum protection, women after childbirth should not wait until the return of monthly
bleeding to start a contraceptive method, but start as soon as safe guidance for her chosen
method allows.

Intervals of at least 2 years have health benefits for both the woman and baby

Appropriate birth spacing lowers the risk of:

 Maternal mortality

 Fetal death (miscarriage or stillbirth), neonatal mortality

 Anaemia in the mother during subsequent pregnancies
 Postpartum inflammation of the endometrium lining the uterus
 Premature rupture of the amniotic membranes surrounding the fetus
 Premature birth
 Intrauterine growth retardation and a low birth-weight baby
 Malnutrition of new-borns and infants due to insufficient breastmilk.

Coordinate your family planning visits with an infant’s immunization schedule. And
remember that optimal breastfeeding offers triple value: important improvements in child
survival and health, better health for mothers, and temporary contraception.

Effective counselling, so you can communicate the health promotion messages to pregnant
women sensitively during antenatal care, and address their concerns and beliefs about
pregnancy and childbirth.

Prophylaxis in pregnant women

Albendazole is the recommended drug of choice for deworming of PW. Deworming should
be done after the 1st trimester of pregnancy (preferably during the 2nd trimester). A single
dose of Tablet Albendazole (400 mg) IP is recommended.
Daily iron and folic acid supplementation during pregnancy

It is estimated that more than 40% of pregnant women worldwide are anaemic. At least half
of this anaemia burden is assumed to be due to iron deficiency.

Pregnant women require additional iron and folic acid to meet their own nutritional needs as
well as those of the developing fetus. Deficiencies in iron and folic acid during pregnancy can
potentially negatively impact the health of the mother, her pregnancy, as well as fetal
development.

Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron* and
400 µg (0.4 mg) folic acid is recommended for pregnant women to prevent maternal anaemia,
puerperal sepsis, low birth weight, and preterm birth.

The equivalent of 60 mg of elemental iron is 300 mg ferrous sulfate heptahydrate, 180 mg

ferrous fumarate or 500 mg of ferrous gluconate.

Iron supplementation is crucial during pregnancy to support the increased blood volume and
the needs of the growing baby. Here are the key points:

When to Give Iron During Pregnancy

 Early Pregnancy: It's recommended to start iron supplementation as soon as

pregnancy is confirmed.
 Second and Third Trimesters: The need for iron increases significantly during these
stages due to the growing baby and placenta.
 Throughout Pregnancy: Continue taking iron supplements throughout the entire
pregnancy to prevent anemia and support fetal development.

Recommended Dosage

 Daily Oral Iron and Folic Acid Supplementation: The World Health Organization
(WHO) recommends 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic
acid daily.

Importance of Iron

 Increased Blood Volume: Your body produces more blood during pregnancy,
requiring more iron to make hemoglobin.
 Supporting Baby's Development: Iron is essential for the baby's growth and
development, especially in the second and third trimesters.

It's always best to consult with your healthcare provider to determine the appropriate dosage
and type of iron supplement for your specific needs. They can also monitor your iron levels
and adjust the supplementation if necessary.

Calcium supplementation in pregnancy

Calcium supplementation during pregnancy is recommended by the World Health
Organization (WHO) from 20 weeks’ gestation until the end of pregnancy. It's best to
start taking calcium supplements around the third trimester. The recommended daily
intake is 1,000 mg for pregnant patients aged 19-30, and 1,300 mg for those aged
31-. Some experts suggest starting prenatal vitamins at least three months before
conception.
Calcium supplementation during pregnancy is important, especially for those with low
dietary calcium intake, to reduce the risk of hypertensive disorders like pre-eclampsia. Here
are the key points:

When to Start Calcium Supplementation

The third trimester is when your baby's bone development is at its peak and during this time,
250 to 350 milligrams of your body's calcium is transferred to your developing baby.
Being aware of your calcium intake and whether maternal calcium supplementation is needed
is particularly important during the third trimester.

1. Early Pregnancy: It's recommended to start calcium supplementation as soon as

pregnancy is confirmed, especially if your dietary intake is low.
2. Throughout Pregnancy: Continue taking calcium supplements throughout the entire
pregnancy to support maternal bone health and fetal development.

Recommended Dosage

 Daily Supplementation: The World Health Organization (WHO) recommends 1.5 g

to 2.0 g of oral elemental calcium daily for pregnant women in populations with low
dietary calcium intake.

Importance of Calcium

 Preventing Hypertensive Disorders: Adequate calcium intake can help reduce the
risk of developing pre-eclampsia and other hypertensive disorders during pregnancy.
 Supporting Bone Health: Calcium is essential for maintaining maternal bone health
and supporting the baby's skeletal development.

It's always best to consult with your healthcare provider to determine the appropriate dosage
and type of calcium supplement for your specific needs. They can also monitor your calcium
levels and adjust the supplementation if necessary.

Vitamin supplements in pregnancy

Major development happens in the first trimester, those first 12 weeks,” she says. “The
spinal cord and brain are developing so those vitamins help with that.” Additionally, mothers
who are breastfeeding are encouraged to continue taking prenatal vitamins to keep providing
those nutrients via breast milk.

Multivitamin supplementation is important during pregnancy to ensure both the mother and
baby receive all necessary nutrients. Here are the key points:

When to Start Multivitamin Supplementation

 1. Before Conception: Ideally, start taking multivitamins before you become pregnant.
This helps build up nutrient reserves for the early stages of pregnancy.
2. As Soon as Pregnancy is Confirmed: If you haven't started multivitamins before
conception, begin as soon as you find out you're pregnant.
3. Throughout Pregnancy: Continue taking multivitamins throughout the entire
pregnancy to support ongoing fetal development and maternal health.

Important Nutrients in Prenatal Multivitamins

 Folic Acid: Helps prevent neural tube defects and is crucial in the early weeks of
pregnancy.
 Iron: Supports the development of the placenta and fetus, and helps prevent anemia.
 Calcium and Vitamin D: Promote the development of the baby's teeth and bones.
 Vitamin C, Vitamin A, Vitamin E, B Vitamins, Zinc, and Iodine: Support overall
health and development.

It's always best to consult with your healthcare provider to determine the appropriate
multivitamin and dosage for your specific needs. They can also monitor your nutrient levels
and adjust the supplementation if necessary

when you are pregnant, and it works to your benefit in focusing on the specifics of it. Pretty
soon, you will be holding your child in your own hands and feeding him off your breasts, so
it is best you stay clean and healthy to have him the same way.

STIs and pregnancy

Sexually transmitted infections (STIs) can spread from one person to another through sexual

contact. STIs are common, and many are easy to treat. However, STIs can cause

complications in those who are pregnant.

 In addition to the usual health risks associated with STIs, pregnant women have
complications, including premature labor or stillbirth. The baby may also
experience health problems.
 STIs transmit when a person has unprotected vaginal, anal, or oral sex with
someone who already has the infection.
 Some STIs, such as HIV, can transmit through other ways, such as sharing
unsterilized needles.
 Some STIs can also pass to the baby during pregnancy, childbirth, or
breastfeeding.
 According to the office on womens health, having an STI while pregnant can
cause an infection in the uterus after birth.
 STIs, such as chlamydia and gonorrhea, increase the risk of ectopic pregnancy,
which can be life threatening. Without treatment, these infections can also lead
to infertility.
Passing an STI to a baby can have harmful effects. These may include:

 low birth weight – less than 5 pounds

 pneumonia
 blindness
 deafness
 acute hepatitis
 chronic liver disease, which can lead to cirrhosis
 Stillbirth
Symptoms of STIs
STI is a blanket term for several infections spread through unprotected sexual activity. They
can affect anyone.

Some of the symptoms of an STI are:

 unusual discharge from the penis or vagina

 abnormal vaginal odor

 sores or warts on the genital area

 itching and redness in the genital area

 painful or frequent urination

 blisters or sores in or around the mouth

 anal itching, soreness, or bleeding

 fever

 abdominal pain

A person should speak with a doctor if they experience any of these symptoms.

Many STIs have no symptoms, so a person may not realize they have one. It is important for
a person to test regularly, especially if they are, or are planning to be, pregnant.

Use of unprescribed drugs and alcohol in pregnancy

Taking drugs (including tobacco and alcohol) when you’re pregnant, even in small
quantities, can put your baby’s health at serious risk. It increases the risk they’ll be stillborn
or will die in the first few weeks and months of life

Use of Drugs and Alcohol During Pregnancy

 Using drugs, alcohol, and tobacco can be harmful at any time during your life. But they pose
a double danger if you’re pregnant, jeopardizing your health and that of the unborn baby.

Bad timing

Drugs and alcohol are dangerous at any stage of pregnancy. They’re likely to affect the fetus
differently depending on what’s used, when, how much, and how often.

Many parts of a fetus’ body begin to form in the first few weeks of pregnancy. Substance use
at this point can lead to birth defects and miscarriage. Later in pregnancy, illegal drug use can
interfere with the fetus’ growth, cause premature delivery, and even result in fetal death.

Understanding the health risks of taking any kind of drug during pregnancy may help you
avoid using them. You can also get help from a healthcare professional if you have trouble
stopping on your own.

Alcohol

You shouldn’t drink any amount of alcohol during any stage of your pregnancy, according to
the CDC.

Drinking alcohol while pregnant can cause miscarriage, stillbirth, and fetal alcohol spectrum
disorders (FASDS). Children with FASDS may develop:

 Learning and intellectual disabilities

 Facial abnormalities
 Vision and hearing problems
 Problems with their heart, kidneys, or bones

Tobacco

Smoking before or while pregnant raises your risk of having a preterm birth or a low-birth-
weight baby. It also increases your likelihood of having a pregnancy outside the womb,
which can cause your fallopian tube to rupture. Even if you smoke after the baby is born, this
increases the baby’s risk for developing asthma and sudden infant death syndrome.

Marijuana

Even though it is legal in some states, marijuana should not be used in any form during
pregnancy. People who use marijuana while pregnant have an increased risk of delivering a
stillborn or low-birth-weight baby. Using marijuana during pregnancy is also associated with
learning and behavioral challenges in children.

Cocaine

Using cocaine during pregnancy increases the risk for placental abruption, which is when the
placenta separates from the uterus. In addition, cocaine use can sometimes lead to
spontaneous miscarriage and preterm labor. Babies who have been exposed to cocaine before
they’re born also face an increased risk for congenital, urinary, and brain defects.
 Opioids

When taken under a healthcare professional’s supervision, prescription opioids can be safe
for you and your child. However, misusing opioids during pregnancy can increase the risk for
fetal growth problems, preterm birth, stillbirth, and neonatal abstinence syndrome––when the
baby goes through withdrawal upon birth.

Medicine

Some prescriptions, over-the-counter medicines, vitamins, and herbal supplements aren’t safe
to take during pregnancy. Check with your healthcare provider before taking any of these
substances when you’re pregnant.

Pregnancy: Exercise During Pregnancy

 Why Should You Exercise During Pregnancy?

 Who Should Not Exercise?
 Safe Exercises During Pregnancy
 Exercises To Avoid During Pregnancy

Why Should You Exercise During Pregnancy?

Maintaining a regular exercise routine throughout your pregnancy can help you stay healthy
and feel your best. It can also improve your posture and decrease some common discomforts
such as backaches and fatigue. There is evidence that it may prevent gestational diabetes
(diabetes that develops during pregnancy), relieve stress, and build more stamina needed for
labor and delivery.
If you were physically active before your pregnancy, you should be able to continue your
activity with modifications as needed. But some exercises are not a good idea when you're
pregnant. Knowing the difference can help keep you and your growing baby safe.
You can exercise at your former level as long as you are comfortable and have your doctor's
approval. Low-impact aerobics are encouraged over high-impact ones. Do not let your heart
rate exceed 140 beats per minute. If you're a competitive athlete, follow your obstetrician's
advice.
If you have never exercised regularly before, you can safely begin an exercise program
during pregnancy after consulting with your doctor. Do not try a new, strenuous activity.
Walking and swimming are considered safe to begin when pregnant. The CDC recommends
at least 30 minutes of moderate exercise per day for 5 days a week unless you have a medical
or obstetric complication.
If you are at high risk for complications, your doctor may recommend that you put your
exercise plans on hold until after you give birth. Or they may suggest that you cut back on
exercising at around 20 to 24 weeks.
Before considering any exercise program, talk with your doctor about your specific risks and
concerns, especially what types of exercises are best to avoid.
Who Should Not Exercise?

If you have a medical problem, such as asthma, heart disease, or type 1 diabetes that is
uncontrolled, exercise may not be advisable. Exercise may also be harmful if you have an
obstetric condition such as:

 Bleeding or spotting
 A weak cervix

Avoid aerobic exercise during pregnancy if you have:

 Hemodynamically significant heart disease

 Restrictive lung disease
 Incompetent cervix/cerclage
 Multiple gestation at risk for premature labor
 Persistent second- or third-trimester bleeding
 Placenta previa after 26 weeks of gestation
 Premature labor during current pregnancy
 Ruptured membranes
 Preeclampsia/pregnancy-induced hypertension

Take precautions with aerobic exercise during pregnancy if you have:

 Severe anemia
 Unevaluated maternal cardiac arrhythmia
 Chronic bronchitis
 Poorly controlled type 1 diabetes
 Extreme morbid obesity
 Extreme underweight (BMI <12)
 History of an extremely sedentary lifestyle
 Intrauterine growth restriction in current pregnancy
 Poorly controlled hypertension
 Orthopedic limitations
 Poorly controlled seizure disorder
 Poorly controlled hyperthyroidism
 A habit of heavy smoking

Consult your doctor before beginning an exercise program. They can offer personalized
exercise guidelines based on your medical history.

Safe Exercises During Pregnancy

Most exercises are safe to perform during pregnancy as long as you exercise with caution and
do not overdo it.
The safest and most productive activities are swimming, brisk walking, indoor stationary
bicycling, low-impact aerobics (taught by certified aerobics instructor), yoga or Pilates, and
strength training with light weights. These activities carry little risk of injury, benefit your
entire body, and can be continued until birth.
Contact sports that could cause injury to your stomach should be avoided, according to the
American College of Obstetricians and Gynecologists. Other activities such as jogging can be
done in moderation.
You may want to choose exercises or activities that do not require great balance or
coordination, especially later in pregnancy.
 Neck rotation. Relax your neck and shoulders. Drop your head forward. Slowly
rotate your head to your right shoulder, back to the middle, and over the left shoulder.
Complete four slow rotations in each direction.
 Shoulder rotation. Bring your shoulders forward and then rotate them up toward
your ears and back down. Do four rotations in each direction.
 Swim. Place your arms at your sides. Bring your right arm up, extend your body
forward, and twist to the side, as if swimming the crawl stroke. Follow with your left
arm. Do the sequence 10 times.
 Thigh shift. Stand with one foot about 2 feet in front of the other, toes pointed in the
same direction. Lean forward, supporting your weight on the forward thigh. Change
sides and repeat. Do four on each side.
 Leg shake. Sit with your legs and feet extended. Move the legs up and down in a
gentle shaking motion.
 Ankle rotation. Sit with your legs extended and keep your toes relaxed. Rotate your
feet, making large circles. Use your whole foot and ankle. Rotate four times on the
right and four times on the left.

When to Stop Exercising

Take a break if you have any of the following:

Shortness of breath. A growing baby can push against your lungs and make it harder to take
a full breath, especially in your last few months. Even earlier in pregnancy, the hormonal
changes that affect your lungs can make you feel short of breath. But if you have increased
shortness of breath or any other breathing changes that are unusual, call your doctor or
midwife right away.
Overheating. If you feel yourself getting hot, slow down. Getting overheated can cause some
serious problems for your growing baby, including birth defects. Make sure you drink plenty
of water while exercising. Stay safe and take it easy when you're exercising on hot days.
Dizziness. You're more likely to feel dizzy when you’re pregnant, especially early in your
second trimester. Dizziness during exercise, though, could cause you to fall. Don't risk it. If
you feel dizzy, take a break and lie down on your side. Call your doctor or midwife if the
symptoms persist.
Pain in your back or hips. This is another sign your body's had enough for the time being.
Stop what you're doing and take it easy.
You should also stop exercising if you:

 Have a headache unrelieved by rest and Tylenol

 Feel cold or clammy
 Have sudden swelling in your ankles, hands, or face or calf pain
 Have difficulty walking
Safe Sex in Pregnancy
Pregnant woman should be informed that sexual intercourse in pregnancy is not known to be
associated with any adverse outcomes. However, some conditions such as placenta previa
require abstinence and genital infections in partners carry risks for both mother and fetus.
Protection against STIs, including HIV/AIDS, is a concern for many women. Counsel women
and their partners about their options for protection against STIs. Issues for women and their
partners to consider are:
• People with multiple partners are at higher risk of acquiring STIs.
• Often people do not know if they or their partners have an STI as they may have no
symptoms.
• A person with an STI, including HIV, can look and feel healthy.
• Those at risk of STI should know that screening tests are available.
• If the woman is sexually active (and not 100% sure that her partner is not infected) then
consistent and correct condom use is the only way to protect against most STIs.

Educating pregnant women for hospital delivery

Empowering women through education to choose facility deliveries is an innovative

approach to improving maternal health access in Africa. This strategy focuses on providing
women with the knowledge and confidence to seek skilled birth attendants and healthcare
facilities during childbirth, ultimately reducing maternal and infant mortality rates.

Benefits
1. Improved Maternal and Child Health: Educated women are more likely to
understand the importance of skilled birth attendance and facility deliveries, leading
to better health outcomes for both mothers and babies.
2. Increased Use of Health Services: Education empowers women to seek and utilize
maternal health services, increasing the demand for and quality of healthcare
facilities.
3. Enhanced Decision-Making: Women with education are better equipped to make
informed decisions regarding their health and that of their children.
4. Economic Growth: Educated women can contribute more effectively to their
communities’ economic development, creating a positive cycle of health and
prosperity.
Application
The application of this innovation involves integrating educational programs into existing
maternal health initiatives. This can be achieved through:
1. Community-Based Education Programs: Workshops and seminars in local
communities to educate women about the benefits of facility deliveries.
2. School Curricula: Incorporating maternal health education into the school
curriculum for girls.
3. Mass Media Campaigns: Utlising radio, television, and social media to spread
awareness about the importance of facility deliveries.

Danger Signs during Pregnancy

 If any of the following signs occur, the woman should be taken immediately to the
hospital or health center.
• Loss of consciousness/fainting
Convulsions
• Respiratory distress
• Vaginal bleeding
• Acute abdominal pain
• Severe headaches, blurred vision, and vomiting
• Fever
• Contractions (signs of labor)
• Leaking of liquor (rupture of membranes)
All pregnant women, their partners and families should be aware of the signs of
complications and emergencies and know when to seek care from a service provider.
Actions on Danger Signs It is important to ensure that women and family members
act without delay when problems occur. Explain in familiar terms (using local words)
the danger signs, so that the woman, her family, and others in the community can
recognize them if they should occur. Ensure they know where to go in case of an
emergency. Refer to the section on birth and emergency plans, as many elements,
including transport, where the nearest health facility is located, and logistical details
regarding persons to support the family, should be discussed and planned before the
third trimester. Health education and counselling method: Group and individual
sessions—health talk, discussion, demonstration, counselling with IEC. Special
considerations: Adolescents; women who live far from health facilities; women from
different cultural and language [Link] ensure both the mother and baby's
health. Here's a summary of what you can expect:

Pregnant Women and Violence

Given the sensitive nature of intimate partner violence, ensure privacy and confidentiality
before discussing issues of violence. Explore this issue with women whom you suspect are
experiencing domestic violence (such as inadequately explained injuries, bruises,
miscarriage, vaginal bleeding in pregnancy, STIs, persistent aches and pains without a clear
cause, and psychological issues such as anxiety, depression, and substance abuse). It is
important to do so in a supportive way. Service providers can offer initial support by paying
attention to women’s concerns with respect and empathy. It is important to reassure the
woman continuously that the situation is not her fault and reinforce her self-esteem. Never
ask about abuse within earshot of the woman’s husband/partner, or his relatives and do not
write anything down about the abuse unless it can be kept confidential. Following are
questions that can be used to explore the situation:

• How is the relationship with your husband (or partner)?

• Has your husband (or partner) or someone at home ever threatened to hurt you or physically
hurt you in some way? If yes, when did it happen?

• Were you ever forced into sex or to have sexual contact you did not want?

Does your husband (or partner) or someone at home bully you, try to control you, put you
down, or stop you doing things you want to do? • Are you afraid of your husband (or
partner)? • Has your husband (or partner) threatened to kill you? If a woman answers “yes” to
any of these questions, you should use open-ended questioning and active listening skills to
encourage her to give you a full account of what happened (or happens). Refer to GBV
section, also carefully review the November 2017 National GBV Guidelines. Individual
Counselling: understand and become familiar with local availability of support services for
women encountering violence, and how women can access these services. Special
considerations: Take time to discuss potential violence with women of any age, especially
those who appear to be in immediate danger.

Explore the local resources to which you can refer women encountering violence.

Prevention of Mother-to-Child Transmission of HIV Counselling and Testing

The aim of offering or recommending HIV testing to a client or a group of clients is to

provide clear and concise information including:

• The benefits of HIV testing

• The services available in case of an HIV-positive diagnosis, including where antiretroviral

therapy (ART) is provided

• The potential risks of transmitting HIV to the infant

• Measures that can be taken to reduce mother-to-child transmission, including the provision
of ART to benefit the mother and prevent HIV transmission to the infant

Health education and counselling method: Group and individual sessions—health talk,
discussion, demonstration, counselling with IEC. Special considerations: Adolescents and
women who do not know if their partners are monogamous; those who fear stigma.

Birth Preparation and Complication Readiness

Birth preparedness and complication readiness is an intervention included by WHO as an

essential element of the ANC package. If a woman is well prepared for normal childbirth and
possible complications, she is more likely to receive the timely and life-saving care from a
service provider. As part of ANC, the service provider assists the woman and her family in
developing her birth plan at every contact. The birth plan helps to ensure that necessary
preparations for normal childbirth are made well in advance of the estimated delivery date.
And since every woman and her family must be prepared to respond appropriately in an
emergency, the service provider should also address complication readiness. The main
components of a birth plan include:

• Desired place of birth and the preferred provider; explain that even for low-risk women
giving birth at the facility is preferable as complications can arise at any time.

• A facility will have skilled staff, equipment, supplies, and drugs that will not be available at
a home birth and referrals can be made rapidly.

• For a home birth, a skilled service provider should be present.

• Location of the closest facility for birth and referral in case of complications
• Funds for any expenses related to birth and in case of complications

• Transport to a facility for birth or in the case of a complications

• A selected decision-maker in case of complications or need for transport

• A family member to act as labor and birth companion

• Support persons to look after the home and other children while the woman is away

• Identification of compatible blood donors in case of complications

• Supplies and materials to bring to the facility

• Knowledge of signs of labor and danger signs Skilled service provider Assist the woman in
arranging for a service provider to attend the birth and obtain a clean delivery kit; this person
should be trained in supporting normal labor and childbirth, managing complications if they
arise, and making rapid referrals to a higher level of care. Make sure the woman knows how
to contact the service provider or health care facility at the appropriate time. Record the
woman’s phone number on her clinic card, and give her a contact number for the health
facility. Place of birth Support the woman in arranging the place of birth based on her risk
status—whether it is a referral hospital or primary health care facility, or home delivery with
a skilled health worker. Depending on her individual needs and risks, you may have to
recommend a specific level of health care facility as the place of birth, or simply support the
woman in her choice of where to give birth. Referral to a higher level of care in case of
complications Transportation/emergency transportation Make sure that the woman knows
what her transportation system will be and that she has made specific arrangements for:

• Transportation to the place of birth (if not the home)

• Emergency transportation to an appropriate health care facility if she experiences danger

signs or is referred by a health worker in a facility. If applicable, discuss emergency means of
transportation available through national, district, community, and/or facility programs.

Funds/emergency funds Ensure that the woman has personal savings or other funds that she
can access when needed to pay for care during normal birth and/or an emergency. If relevant,
discuss emergency funds that are available through the community and/or facility. Decision
making Discuss who usually makes decisions in her family and decide:

• How decisions will be made when labor begins or if danger signs arise (who is the key
decision-maker?)

• Who else can make decisions if that person is not present? Support Assist the woman in
deciding on and arranging for necessary support, including:

• A family member of her choice to stay with her during labor and childbirth and accompany
her during transport, if needed

• Someone to care for her house and children during her absence Blood donor In areas where
adequate blood transfusion services are not available, ensure that the woman has identified an
appropriate blood donor and that this person will be accessible in case of an emergency.
Items needed for a clean and safe birth and for the new-born

Make sure the woman has gathered necessary items for a clean and safe birth including a
clean delivery kit. Discuss the importance of keeping items together for easy retrieval when
needed. Advise the woman to bring her home-based maternal and child health handbook to
the facility where she will deliver or to other facilities where she may be referred to in an
emergency.

• For the birth: bucket for clean water and a way to heat the water; perineal pads/cloths;
soap; clean bed clothes; placenta receptacle; new, unused razor blade; waterproof/plastic
cover; cord ties; etc.

• For the new-born: clean cloths for drying the baby and wrapping the baby; blankets,
nappies, hat, clothes; chlorhexidine digluconate 7.1% for cord care. Note: Items needed
depend on the individual requirements of the intended place of birth, whether in a facility or
in the home.

Signs of labor and danger signs

Signs of labor include a bloody, sticky discharge; painful contractions at least every 20
minutes; and/or waters have broken. Ensure that the woman knows the danger signs that
indicate that the complication readiness plan must be put into action:

• Loss of consciousness/fainting

• Convulsions

• Respiratory distress Vaginal bleeding

• Acute abdominal pain

• Severe headaches, blurred vision, and vomiting

• Fever

• Contractions (signs of labor)

• Leaking of liquor (rupture of membranes) Fever, headache, convulsions, and loss of

consciousness can also be signs of malaria; headache and convulsions (fits) can indicate
severe malaria.

Health Information Given During the First Visit

 Medical History Review: Discussion about your medical history, any previous
pregnancies, and family health history.
 Physical Exam: A general physical exam, including checking your weight, blood
pressure, and possibly a pelvic exam.
 Urine Test: To check for protein, glucose, white blood cells, blood, and bacteria.
  Blood Tests: To determine blood type and Rh factor, check for anemia, and screen for
certain infections or conditions.
 Genetic Carrier Screening: To identify if you are a carrier for certain genetic
conditions.
 STD Tests: Screening for sexually transmitted infections.
 Blood Sugar Test: To check for gestational diabetes.
 Ultrasound: Sometimes an early ultrasound is done to confirm the pregnancy and
check for the baby's heartbeat.
 Prenatal Vitamins: Discussion about the importance of taking prenatal vitamins,
especially folic acid.
 Lifestyle Advice: Guidance on diet, exercise, and avoiding harmful substances like
alcohol and tobacco.
 Questions and Answers: Time to ask any questions and address concerns you might
have.

This visit is comprehensive and sets the stage for ongoing prenatal care throughout your
pregnancy. It's a great opportunity to establish a relationship with your healthcare provider
and ensure you have all the information you need for a healthy pregnancy.

Do you have any specific concerns or questions about your first prenatal visit?

Provide

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when to give iron to pregnant women

Iron supplementation is crucial during pregnancy to support the increased blood volume and
the needs of the growing baby. Here are the key points:

 When to Give Iron During Pregnancy

 Early Pregnancy: It's recommended to start iron supplementation as soon as
pregnancy is confirmed.
 Second and Third Trimesters: The need for iron increases significantly during these
stages due to the growing baby and placenta.
 Throughout Pregnancy: Continue taking iron supplements throughout the entire
pregnancy to prevent anemia and support fetal development.

Recommended Dosage

 Daily Oral Iron and Folic Acid Supplementation: The World Health Organization
(WHO) recommends 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic
acid daily.

Importance of Iron

 Increased Blood Volume: Your body produces more blood during pregnancy,
requiring more iron to make hemoglobin.
  Supporting Baby's Development: Iron is essential for the baby's growth and
development, especially in the second and third trimesters.

It's always best to consult with your healthcare provider to determine the appropriate dosage
and type of iron supplement for your specific needs. They can also monitor your iron levels
and adjust the supplementation if necessary.

Do you have any other questions or concerns about pregnancy?

when to start calcium in pregnancy

Calcium supplementation during pregnancy is important, especially for those with low
dietary calcium intake, to reduce the risk of hypertensive disorders like pre-eclampsia. Here
are the key points:

When to Start Calcium Supplementation

 Early Pregnancy: It's recommended to start calcium supplementation as soon as

pregnancy is confirmed, especially if your dietary intake is low.
 Throughout Pregnancy: Continue taking calcium supplements throughout the entire
pregnancy to support maternal bone health and fetal development.

Recommended Dosage

 Daily Supplementation: The World Health Organization (WHO) recommends 1.5 g

to 2.0 g of oral elemental calcium daily for pregnant women in populations with low
dietary calcium intake.

Importance of Calcium

 Preventing Hypertensive Disorders: Adequate calcium intake can help reduce the
risk of developing pre-eclampsia and other hypertensive disorders during pregnancy.
 Supporting Bone Health: Calcium is essential for maintaining maternal bone health
and supporting the baby's skeletal development.

It's always best to consult with your healthcare provider to determine the appropriate dosage
and type of calcium supplement for your specific needs. They can also monitor your calcium
levels and adjust the supplementation if necessary.

Do you have any other questions or concerns about pregnancy?

when to give multivitamine suppliment to pregnant women

Multivitamin supplementation is important during pregnancy to ensure both the mother and
baby receive all necessary nutrients. Here are the key points:

When to Start Multivitamin Supplementation

 Before Conception: Ideally, start taking multivitamins before you become pregnant.
This helps build up nutrient reserves for the early stages of pregnancy2.
  As Soon as Pregnancy is Confirmed: If you haven't started multivitamins before
conception, begin as soon as you find out you're pregnant.
 Throughout Pregnancy: Continue taking multivitamins throughout the entire
pregnancy to support ongoing fetal development and maternal health.
 Important Nutrients in Prenatal Multivitamins

 Folic Acid: Helps prevent neural tube defects and is crucial in the early weeks of
pregnancy.
 Iron: Supports the development of the placenta and fetus, and helps prevent anemia.
 Calcium and Vitamin D: Promote the development of the baby's teeth and bones.
 Vitamin C, Vitamin A, Vitamin E, B Vitamins, Zinc, and Iodine: Support overall
health and development.

It's always best to consult with your healthcare provider to determine the appropriate
multivitamin and dosage for your specific needs. They can also monitor your nutrient levels
and adjust the supplementation if necessary.

educating women to deliver in facilities

Educating women about the benefits of delivering in healthcare facilities is crucial for
improving maternal and infant health outcomes. Here are some key strategies and benefits:

Strategies for Educating Women

 Community-Based Education Programs: Conduct workshops and seminars in local

communities to inform women about the importance of facility deliveries.
 School Curricula: Incorporate maternal health education into school curricula for
girls to build awareness from a young age.
 Mass Media Campaigns: Use radio, television, and social media to spread awareness
about the benefits of delivering in healthcare facilities.
 Partnerships with NGOs and Governments: Collaborate with non-governmental
organizations and government bodies to expand the reach of educational programs.
 Leveraging Technology: Utilize mobile technology and e-learning platforms to
deliver educational content to women in remote areas.
 Empowering Local Leaders: Train community leaders to advocate for maternal
health education and facility deliveries.

Benefits of Educating Women

 Improved Maternal and Child Health: Educated women are more likely to
understand the importance of skilled birth attendance and facility deliveries, leading
to better health outcomes for both mothers and babies.
 Increased Use of Health Services: Education empowers women to seek and utilize
maternal health services, increasing the demand for and quality of healthcare
facilities.
 Enhanced Decision-Making: Women with education are better equipped to make
informed decisions regarding their health and that of their children.
 Economic Growth: Educated women can contribute more effectively to their
communities' economic development, creating a positive cycle of health and
prosperity.
Challenges and Mitigations

 Cultural Barriers: Overcome traditional beliefs that discourage facility deliveries

through community engagement and education.
 Geographical Barriers: Improve access to healthcare facilities by building better
roads and increasing the number of health facilities in remote areas.
 Perceived Quality of Care: Ensure that healthcare facilities provide high-quality care
to build trust among pregnant women.

By implementing these strategies, we can empower women to make informed decisions about
their health and ensure safer deliveries for both mothers and babies.

Signs of labor

These are reliable signs that you're in real labor:

Regular contractions

Once you're having regular, persistent contractions, you're considered to be in labor.

When your uterus contracts, your abdomen feels tight or hard, and you have a sensation of
cramping. When the uterus relaxes between contractions, the sensation dissipates. Labor
contractions will grow stronger, longer, and more frequent as they cause your cervix to
dilate. True labor contractions are too painful to talk through, and they may bring tears to
your eyes.

You'll want to start timing your contractions – how far apart they are and how long they
last. (Time contractions starting from the beginning of one until the beginning of the next.)
Your doctor or midwife probably gave you directions about when to head to the
hospital based on the timing of the contractions. If not, give them a call and ask.

Back pain or pelvic pressure

You may feel increased pressure in your pelvis as your baby continues to move down.
Contractions can also cause a feeling of pressure, along with abdominal pain.

If you're having lower back pain along with contractions, it may signal that you're
having back labor. The pain from back labor continues between contractions, though it may
get stronger during contractions.

Back pain usually means that your baby's head is pressing against your lower back, though
one theory suggests that the pain may be "referred" from your uterus to your lower back.

Water breaking

When the fluid-filled amniotic sac surrounding your baby ruptures, fluid leaks from your
vagina. This is called rupture of membranes. It may come out in a large gush or a small
trickle, or anything in between.
 Labor usually follows soon after your water breaks – regular contractions often start before
this, but in some cases, the water breaks first.

If your water breaks when you're full term but you're not in labor (not having contractions),
it's called premature rupture of membranes (PROM).

If you don't start having contractions on your own within six to 24 hours of your water
breaking, your provider will most likely recommend that labor be induced. That's because
your baby is more likely to get an infection without the amniotic sac's protection against
germs. Most providers will offer you an immediate induction but give you the option to
postpone if you want to give labor a chance to start on its own.

If you're leaking amniotic fluid before 37 weeks, it's called preterm premature rupture of
membranes (PPROM), and it may mean your baby will need to be
delivered prematurely due to the increased risk of infection.

Regardless of contractions, if you're group B strep positive you'll need to start on

antibiotics as soon as your water breaks to prevent an infection in your baby.

Whenever your water breaks, call your doctor or midwife. (Call them even if you think
your water broke but aren't sure.)

Signs of preterm labor

If you start having regular contractions that cause your cervix to begin to open before you
reach 37 weeks of pregnancy, you're in preterm labor. (It's also known as premature labor.)

It can be difficult to tell whether you're having preterm labor or not, because some of the
symptoms (like Braxton Hicks and low back pain) may be things you've experienced
throughout your pregnancy.

Still, call your doctor or midwife right away if you're having any of the following
symptoms before 37 weeks:

 More vaginal discharge than usual

 A change in the type of discharge – if you're leaking watery fluid or your discharge
becomes watery, mucus-like, or bloody (even if it's pink or just tinged with blood)

 Any vaginal bleeding or spotting

 Abdominal pain, menstrual-like cramping, or six or more contractions in one hour (even if
they don't hurt)

 More pressure in the pelvic area (a feeling that your baby is pushing down)
 Low back pain, especially if it's dull or rhythmic, or you didn't previously have back pain

 Your water breaks, either in a gush or a trickle

If you are – or might be – in preterm labor, your doctor or midwife may give you steroids to
help your baby's lungs mature and to protect their brain. You may also receive medicine to
stop or slow early contractions. Getting these medications early can improve outcomes for
your baby, so be sure to call if you think you may be in preterm labor.

Braxton Hicks vs contractions

It can be hard to tell the difference between Braxton Hicks and "real" contractions at first.
Use this chart to help figure out whether you're in true labor or false labor (in other words,
just having Braxton Hicks contractions).

False labor contractions

True labor contractions
(Braxton Hicks)

Happen at regular intervals

Are irregular and don't get
Timing and get closer together
closer together over time
over time

Vary in length and don't get

Start to last longer with
longer over time (fewer than
Length each contraction (about 30
30 seconds or up to 2 minutes
to 70 seconds each)
each)

Are weak and don't get

Grow stronger and more
stronger with time (may be
Intensity painful with each
weak then strong, then weak
contraction
again)

May start in the back and

Are felt at the front of the move to the front, or
Location
abdomen radiate down into the
thighs

Effect of Contractions continue

Contractions stop when you
moving or even when you change
change position, walk, or rest
resting position, walk, or rest
No matter how well informed you are about the signs of labor, it's normal to have a false
alarm. Don't be embarrassed about calling your doctor or midwife – or showing up at the
hospital – because you think you're in labor when you're not.

If you're assessed at the hospital and sent home because you're not in labor yet, your care
team will give you specific instructions about changes to look for in the next few days or
weeks and when to call or come back.

Routine follow up visits

Following an initial visit that ideally occurs in the first trimester, regular follow-up visits are
scheduled every 4 weeks in the second trimester (ie, from 14 to 28 weeks gestation) and more
frequently in the third trimester (ie, from 28 weeks to delivery), increasing to every 2 weeks
from 28 to 36 weeks gestation, then every week from 36 weeks until birth.

Regular prenatal visits are crucial for monitoring both the mother's and baby's health
throughout pregnancy.:

Prenatal Visit Schedule

 First Trimester:
o Initial Visit: Ideally in the first trimester (up to 12 weeks), this visit includes a
comprehensive medical history, physical exam, and necessary tests.
 Second Trimester (14 to 28 weeks):
o Every 4 Weeks: Regular check-ups to monitor the baby's growth, the mother's
health, and to conduct any necessary screenings.
 Third Trimester (28 weeks to delivery):
o Every 2 Weeks: From 28 to 36 weeks, visits become more frequent to closely
monitor the pregnancy as the due date approaches.
o Every Week: From 36 weeks until birth, weekly visits help ensure that both
the mother and baby are ready for delivery.

During these visits, healthcare providers typically check the mother's blood pressure, weight,
and urine; monitor the baby's heartbeat and growth; and discuss any concerns or symptoms
the mother may have.

These regular visits help identify and address any potential issues early, ensuring a healthy
pregnancy and a safe delivery.

Responding to an Emergency

Responding to an emergency promptly and effectively requires that members of the clinical
team know their roles and how the team should function. Team members should also know:

• Clinical situations and their diagnoses and treatments.

• Medicines and how they are used, administered, and their side effects

• Emergency equipment and how it functions When managing an emergency:

• Introduce yourself.

• Ask the woman her name; if she is unconscious, ask for the woman’s name from her
companion.

• Encourage the companion to stay with the woman.

• Explain all procedures; ask permission and keep the woman informed as much as you can
about what you are doing. If the woman is unconscious, talk to her companion.

• Ensure and respect the woman’s privacy during examination and discussion.

• Do not leave the woman unattended.

• Ensure that the emergency transport that the woman used to get to the health facility is
retained at the facility until a clear plan of management is in place. The ability of a facility to
deal with emergencies should be assessed and reinforced by frequent practice emergency
drills.