By the end of this you will be able to:
Explain the routine management of a pregnant
Differentiate the physiological changes from the
minor disorders of pregnancy
Identify & treat minor disorders in pregnancy
3. Explain FANC it is meaning , objectives and
Explain preconception care
Identify and manage nutrition needs of a
Understand the national protocol on TT
immunization of a pregnant woman
4. Definition of common terms in pregnancy
Trimester refers to a three month calendar period.
Gravidity is the number of times a woman has been
pregnant regardless of the outcome of the pregnancies.
Parity refers to the delivery of a child that grew
beyond 28 weeks (the age of viability) irrespective of
whether the baby was born alive or dead.
5. A Primigravida is a woman who is pregnant for the first time.
A Primipara is a woman who has had only one delivery.
A Multigravida is a woman who has had two or more pregnancies.
Multipara refers to a woman who has had two or more deliveries.
Nullipara is a term that refers to a woman who has never delivered.
A Grand multipara is a woman who has had six or more deliveries.
6. The average duration of pregnancy is 266 days. This
is counting from the time the pregnancy started, which
is after ovulation and approximately two weeks after
the first day of the Last Normal Menstrual Period
(LNMP). If the counting is made from the first day of
the LNMP, then the duration is 280 days or forty
7. The duration of pregnancy can also be expressed in
months. These can be calendar months or lunar
months. A lunar month is the time from one new moon
to the next.
It is equal to four weeks or exactly 28 days. A
calendar month is longer, usually 30 or 31 days.
Therefore, on average, pregnancy lasts 40 weeks, that
is, ten lunar months or approximately nine calendar
8. It is important to remember that the EDD as
determined by Naegele’s rule is only a best guess of
when a baby is likely to be born. Two factors influence
the accuracy of naegeles
Regularity of a woman’s menstrual cycles
Length of a woman’s menstrual cycles
Results may not be accurate if menstrual cycles are
not regular or are greater than 28 days apart.
9. Most women give birth within the time period of 3 weeks
before to 2 weeks after their EDD.
The length of pregnancy is approximately 280 days or 40
weeks from the first day of the LMP.
In recent years there has been conflicting or inconsistent
information on the definition of a “term” pregnancy.
The window for term gestation has traditionally been
defined as between the 5 weeks from 37 to 42 weeks from the
10. According to the American Academy of Pediatrics
(AAP) and the American College of Obstetricians and
Gynecologists (ACOG) (2007)
neonates born prior to 37 completed weeks (<37 6/7
weeks or <259 days) of pregnancy are referred to as
preterm, and those delivered after 42 weeks (>42 6/7
or >294) are classified as post term (AAP & ACOG,
Gravida refers to the total number of times a
woman has been pregnant, without reference to
how many fetuses there were with each
pregnancy or when the pregnancy ended.
It is simply how many times a woman has been
pregnant, including the current pregnancy.
12. • Para refers to the number of births after 20 weeks’ gestation
whether live births or stillbirths.
• There is no reference to number of fetuses delivered with this
system, so twins count as one delivery, just like a singleton
• A pregnancy that ends before the end of 20 weeks’gestation is
considered an abortion, whether it is spontaneous
(miscarriage) or induced (elective or therapeutic), and is not
counted using the G/P system.
13. GTPAL (meaning gravida, term, para, abortion, and
living) is a more comprehensive system that gives
information about each infant from prior pregnancies.
This system designates numbers of infants as follows:
G = total number of times pregnant (same as G/P
T = number of term infants born (after 37 completed
or 37 6/7 weeks’gestation)
14. P = number of preterm infants born between 20
and 37 completed weeks’ gestation or 37 6/7
A = number of abortions (either spontaneous or
induced) before 20 weeks’ gestation (or <500
grams at birth)
L = the number of children currently living.
15. Diagnosis of pregnancy
The diagnosis of pregnancy is made on the basis of
symptoms, signs and investigations of pregnancy.
These can be conveniently divided into those of the
first, second and third trimester.
The main symptoms and signs during the first
trimester include: Amenorrhea Enlargement and
tenderness of the breasts Nausea Excessive salivation
( ptyalism )
16. Frequency of micturition due to the pressure of the
gravid uterus on the urinary bladder
Constitutional symptoms (that is tiredness, weakness
and sometimes depression)
Enlargement of the Breasts The nipple and the areola
increase in size. Small nodules, known as
Montgomery's tubercles, develop around the nipple.
The areola darkens.
17. The Cervix The cervix becomes bluish in colour, which is
referred to as Jacquemier's sign, because of the increased
vascularity and congestion with blood.
It also becomes softer. When you perform a bimanual
vaginal examination with two fingers inserted in the anterior
fornix of the vagina, and the other hand placed behind the
uterus abdominally, the fingers of both hands almost meet
because of the softness of the isthmus.
18. This is known as Hegar's sign. It is most marked between the
6th and 12th week of pregnancy.
There is also an increased pulsation felt in the lateral
fornices, which is known as Osiander's sign. The uterus is
Quickening This is when a mother feels the first
movements. Primigravida recognize these movements at
about the 20th week, and the multipara at about the 16th
19. Uterus Enlargement This occurs around the 12th week. You should
be able to feel the enlarged uterus abdominally just above the
symphysis pubis. The fundus reaches the level of the umbilicus at
about the 22nd week, and the xiphisternum by the 36th week.
Foetal Identification You should be able to feel the foetal parts, for
example, the head, from the 24th week onwards. You might be able to
feel foetal movements while palpating the fundus. Foetal heart sounds
can be heard around the 24th week. The rate varies from 120 to 160
beats per minute.
Pregnancy Test This depends on the Human Chorionic
Gonadotrophins (HCG) secreted in the mother's urine. It is
more likely to be certain when the urine is concentrated, that
is, a fresh, clean, early morning specimen. With a sensitive
test, HCG can be detected in maternal plasma or urine by
eight to nine days after ovulation.
The Ultrasound This is a scanner, which enables you to see
the foetus and its cardiac activity, particularly if performed by
the 6th week of pregnancy.
21. X-ray Method By the 16th week, if an x-ray is
performed, it will show foetal bones.
This is an undesirable method of diagnosing
pregnancy because in early or mid-pregnancy,
the foetus is very susceptible to the adverse
effects of radiation.
22. Presumptive symptoms of pregnancy
Possible (presumptive) signs are Early breast changes (unreliable in
the multigravida). Amenorrhoea ,Morning sickness ,Bladder irritability
Probable Signs are Presence of hCG in Blood & Urine
Softened isthmus (Hegar's sign) Blueing of vagina (Jacquemier's sign)
Pulsation in fornices (Osiander's sign)
Uterine growth Braxton Hicks contractions
Ballottement of foetus
23. Physiological changes in pregnancy
Physiological changes in pregnancy take place in the
The reproductive organs &The cardiovascular system
The respiratory system &The renal system
The gastrointestinal system &Maternal weight
Musculo-skeletal system & The skin
25. Changes in the Reproductive Organs
Changes in the Uterus The uterus provides a
nutritive and protective environment in which the
foetus will develop and grow.
The uterine muscle fibre increases in size
(hypertrophy) and in number (hyperplasia). The uterus
continues to grow this way for the first 20 weeks,
thereafter, it stretches to accommodate its contents. It
increases in size from 60 grams - 900 grams.
26. By the eighth week of gestation it begins to generate small
waves of contractions known as Braxton Hicks contractions,
which are painless and continue throughout pregnancy.
The blood supply to the uterus increases to keep pace with its
growth and also to meet the needs of the placenta.
In early pregnancy the uterus becomes globular in shape to
accommodate the foetal growth, liquor amnii and placental
tissue. This causes pressure on other pelvic organs.
27. Changes in the Cervix The cervix acts as an effective
barrier against infection. It also protects the pregnancy.
Under the influence of progesterone, the endocervical cells
secrete mucus, which becomes a cervical plug known as
This plug provides protection from ascending infection. In
late pregnancy, the cervix softens in response to increasing
painless contractions. Prostaglandins are thought to have a
role in cervical softening in readiness for the onset of
28. • Changes in the Vagina Oestrogen causes the vagina
to become more elastic.
• These changes will allow dilatation during the second
stage of labour to receive the descending foetal head.
There is an increased amount of the normal white
vaginal discharge called leucorrhoea.
• The vaginal ph becomes more acidic to provide
protection to some micro-organisms but also increases
susceptibility to others such as candida albicans.
29. Changes in the Breast
•The breast enlarges due to increased tissue
growth, blood supply and fat deposition.
Deposition of melanin toughens the nipple area
in preparation for breastfeeding.
30. Changes in the Cardiovascular System
The cardiac output increases from 5 litres to 7 litres per
minute by late pregnancy.
This is caused by an increase in resting heart rate of about 15
beats per minute by the end of pregnancy and an increase in
blood volume. The red cell mass increases by about 18% by
the end of the pregnancy.
The plasma volume increases from the tenth week of
pregnancy and reaches its maximum level of 50% above non-
pregnant values by the 32nd to 34th week, and maintains this
31. As the plasma increase is greater than that of the red
cell mass, there is haemodilution effect. This results in
lowered haemoglobin level. This effect is referred to
as physiological anaemia.
The mean acceptable HB level in pregnancy is 10 - 12
g/dl of blood. Despite these changes the blood pressure
remains normal. The increased cardiac output does not
affect the blood pressure. It may drop slightly by mid-
trimester and towards term it returns to the level of the
32. Respiratory system & renal system
Changes in the Respiratory System The respiratory
rate does not alter but the amount of air inhaled per
minute increases from 7 to 1 litres.
Changes in the Renal System Progesterone relaxes
the walls of the ureters and allows dilation and
kinking. This tends to result in a slowing down or
stasis of urinary flow, making infection a greater
33. Changes in the Gastrointestinal Tract
There is increased salivation. Women often
experience changes in their sense of taste,
leading to dietary changes and food cravings.
Craving for substances such as bricks/soil is
known as pica.
34. Progesterone relaxes the smooth muscles. Gastric
emptying and peristalsis are reduced in order to
maximise the absorption of nutrients.
Heartburn is common and is associated with gastric
reflux due to relaxation of the cardiac sphincter.
Constipation is also common due to sluggish gut
motility. Nausea and vomiting occur mainly during
early pregnancy as a result of raised hormonal levels.
35. •Changes in Maternal Weight There is
continuous weight increase during pregnancy,
which is due to the foetus and fat deposition.
•The expected weight gain is approximately 2
kilograms in the first 20 weeks followed by an
average of 0.5 kilogram per week until term
leading to 12 kilograms in total.
36. Changes to the Musculo-Skeletal System
Progesterone encourages relaxation of ligaments
and muscles. This increases the capacity of the
pelvis in readiness for labour.
The unstable pelvic joints result in the rolling
gait sometimes seen in pregnant women. In the
multigravidae, this is likely to cause backaches
and ligamental pain especially in the hip joint.
37. Changes to the Skin
During pregnancy, there is increased activity of the melanin-
stimulating hormone causing deeper pigmentation.
Some women develop deeper, patchy colouring on the face
known as chloasma. Many develop a pigmented line running
from the pubis to the umbilicus known as linea nigra.
Others may develop thin stretch marks called striae
gravidarum. The increased blood supply to the skin leads to
sweating. Women often feel hotter possibly due to
progesterone-induced rises in temperature of 0.45°C together
38. Minor disorders in pregnancy
Nausea and Vomiting (Morning Sickness)
• This is mainly caused by a rise in hormonal levels. It
occurs between four and sixteen weeks, usually in the
morning hours, but it can occur at any time of the day.
Advise the woman to take carbohydrate snacks at
bedtime and in the morning before rising. At this point,
it is important to rule out other causes of vomiting.
39. • Heartburn This refers to a burning sensation that is
felt at the medistinal region due to reflux of gastric
contents into the oesophagus through the cardiac
sphincter that is relaxed by the increased levels of
• It is prevalent between 30 to 40 weeks.
• Advise the affected woman to avoid bending over, to
take small meals, to sleep with several pillows and to
lie on her right side in a semireclining position. If this
condition persists, give anti-acids and refer.
40. • Backache
• Backache occurs due to softening of the ligaments that
is caused by hormones. Advise the woman what causes
this problem and reassure her that it will be over after
41. • Fatigue (first and third trimesters)
• Reassure the woman of the normalcy of her response.
• Encourage the woman to plan for extra rest during the day
and at night; focus on “work” of growing a healthy baby.
• Enlist support and assistance from friends and family.
Encourage the woman to eat an optimal diet with adequate
caloric intake and iron-rich foods and iron supplementation if
42. Insomnia (throughout pregnancy
Instruct the woman to implement sleep hygiene measures (regular
bedtime, relaxing or low-key activities pre-bedtime).
Encourage the woman to create a comfortable sleep environment
(body pillow, additional pillows).
Teach breathing exercises and relaxation techniques/measures
[progressive relaxation, effleurage (a massage technique using a very
light touch of the fingers in two repetitive circular patterns over the
gravid abdomen), warm bath or warm beverage pre-bedtime].
Evaluate caffeine use.)
43. Emotional lability (throughout pregnancy)
Reassure the woman of the normalcy of response.
Encourage adequate rest and optimal nutrition.
Encourage communication with partner/significant
Refer to pregnancy support group.
44. Supine hypotension (mid-pregnancy onward)
Instruct the woman to avoid supine position from mid
pregnancy onward. Advise her to lie on her side and rise
slowly to decrease the risk of a hypotensive event.
Advise woman to keep feet moving when standing and avoid
standing for prolonged periods. Instruct to rise slowly from a
lying position to sitting or standing to decrease the risk of a
45. Dependent edema lower extremities and/or vulva
Instruct the woman to: Wear loose clothing
Use a maternity girdle (abdominal support), which may help
reduce venous pressure in pelvis/lower extremities and
Avoid prolonged standing or sitting
Dorsiflex feet periodically when standing or sitting
Elevate legs when sitting
Position on side when lying down)
46. Hemorrhoids (later pregnancy)
• Avoid constipation Instruct the woman to avoid bearing
down with bowel movements.
• Instruct the woman in comfort measures (e.g., ice packs,
warm baths or sitz baths, witch hazel compresses).
• Elevate the hips and lower extremities during rest periods
throughout the day.
• Gently reinsert into the rectum while doing Kegel exercises.
47. Preconception Anticipatory Guidance and Education
• Anticipatory guidance is the provision of information
and guidance to women and their families that enables
them to be knowledgeable and prepared as the process
of pregnancy and childbirth unfolds.
• Anticipatory guidance and education in the
childbearing-aged population spans topics from health
maintenance, self-care, and lifestyle choices to
contraception and safety behaviors.
48. Preconception Education
When a woman seeks care specifically because she is
planning for a future pregnancy, more emphasis is placed on
counseling and anticipatory guidance related to preparation
and planning for a pregnancy.
Preconception anticipatory guidance and education topics:
Nutrition Prenatal vitamins Exercise ,Self-care ,
Contraception cessation Timing of conception & Modifying
behaviors to reduce risks
49. Nursing Actions in Preconception Care
Provide comfort and privacy. Use therapeutic communication
techniques. Obtain the health history.
Conduct a review of systems. Provide teaching about procedures
Assist with physical and pelvic exams.
Assist with obtaining specimens. Provide anticipatory guidance and
education related to plan of care and appropriate follow-up.
Assess the patient’s understanding.
Provide education, recommendations, and referrals to help women
make appropriate behavioral, lifestyle, or medical changes based on
history or physical examination.
50. Focused Antenatal Care
Definition of antenatal care Antenatal care (ANC) is health care
given to a pregnant woman from conception to the onset of labour.
Women can benefit from just a few antenatal visits, as long as those
visits are thorough.
Focused or targeted ANC refers to a minimum number of four
comprehensive personalised antenatal visits, each of which has
specific items of client assessment, education and care to ensure
prevention or early detection and prompt management of
51. The objectives of focused antenatal care
Early detection and treatment of problems
Prevention of complications using safe, simple
and cost-effective interventions
Birth preparedness and complication readiness
Health promotion using health messages and
Provision of care by a skilled attendant
52. Schedule of Visits
It is recommended that the pregnant woman should attend a
minimum of four comprehensive personalized antenatal visits
spread out during the entire pregnancy during which specific
focused activities are carried out to guide the woman along the
path of survival, as follows:
First visit less than 16 weeks
Second visit 16 - 28 weeks
Third visit 28-32 weeks
Fourth visit 32 – 40 weeks
54. The first visit:
Content of the first visit are
a) History taking
b) Perform physical examination
c) Perform investigative tests:
d) Implement the preventive measures
e) Assess the need for specialised care
f) Development of an individual birth plan
g) Advice on complications and danger signs
h) Health promotion, questions and answers, and scheduling the next
i) Maintain complete records
55. A. Full history taking
Name Age (date of birth) Physical address and
telephone number Marital status Educational
level: primary, secondary, university Economic
resources: employed? Type of work, position of
patient and husband/guardian Tobacco use
(smoking or chewing habit) or use of other
56. History of present pregnancy
Date of last menstrual period (LMP); certainty of dates (by regularity,
accuracy of recall and other relevant information including contraceptive
Determine the expected date of delivery based on LMP and all other
relevant information. Use 280-day rule (LMP + 280 days). Some women
will refer to the date of the first missed period when asked about LMP,
which may lead to miscalculation of term by four weeks Quickening if
Any unexpected event (pain, vaginal bleeding, other: specify) Malaria
attacks Habits: smoking/chewing tobacco, alcohol, drugs (frequency and
57. Obstetric history
Number of previous pregnancies (Gravida and Parity)
Date (month, year) and outcome of each event (live birth,
stillbirth, neonatal death, abortion, ectopic, hydatidiform mole)
Specify (validate) preterm births
Specify type and gestation of any abortion, and management if
possible (MVA, D&C)
Birth weight of previous pregnancies (if known) Sex of the
baby / babies Puerperium (eventful or uneventful) Periods of
exclusive breast-feeding: when? For how long?
58. Special maternal complications and events in previous
Specify which pregnancy, validate by records (if possible):
recurrent early abortion induced abortion and any
thrombosis, embolus hypertension, pre-eclampsia or
eclampsia placental abruption placenta praevia breech or
transverse presentation obstructed labour, including
dystocia third-degree tears third stage excessive bleeding
puerperal sepsis Gestational diabetes.
60. Special perinatal (foetal, newborn) complications
Special perinatal (foetal, newborn) complications and
events in previous Pregnancies; specify which pregnancy,
validate by records (if possible):
twins or higher order multiples low birth weight: <2500 g
intrauterine growth restriction (if validated) rhesus-antibody
malformed or chromosomally abnormal child macrosomic
(>4500g) newborn resuscitation or other treatment of
newborn perinatal, neonatal or infant death (also: later
61. Medical history
Specific diseases and conditions: tuberculosis, heart disease,
chronic renal disease, epilepsy, diabetes mellitus RTIs HIV
status, if known other specific conditions depending on
prevalence in the region,
e.g. hepatitis, malaria, sickle cell trait operations other than
caesarean section blood transfusions Rhesus D negative
antibodies current use of medicines: specify Period of
infertility: when? duration, cause(s) Any other diseases, past
or chronic; allergy
62. B. Perform physical examination
General appearance Head to toe examination
Measure blood pressure, pulse, temperature
Record weight (kilograms) and height (metres)
to assess the mother's nutritional status Check
for signs of anaemia: pale complexion,
fingernails, conjunctiva, oral mucosa, tip of
tongue and shortness of breath
63. Examine the chest, including breast exam and heart
Measure uterine size (fundal height) Signs of previous
caesarean section (scar)
Foetal presentation and heart sounds if applicable
Inspection of the external genitalia to assess for
abnormalities: FGM status: - If type III discuss the
possibility of de-infibulation (opening up either antenataly
or during labour) Varicosities, warts, discharge
64. C. Perform the following tests
Urine: multiple dipstick test for proteinuria, acetone
and sugar for all women and urinalysis for bacteriuria
Blood: syphilis (VDRL or RPR)
Blood-group typing (ABO and rhesus)
Counselling and testing for HIV
Sputum for AFB if indicated
65. D. Implement the following interventions
Iron and folic acid supplements to all women
If test for syphilis is positive: treat
Refer woman when complications arise that cannot
be managed at that facility, e.g.: Severe anaemia, Hb
<7.0 g/ml Antepartum Haemorrhage High blood
pressure (>140/90 mm Hg) Intra-uterine growth
restriction / IUCD
66. Underweight, use mid upper arm
Polyhydramnios Tuberculosis Opportunistic
infections / AIDS If the first visit is after 16 weeks,
give: In malaria endemic areas:
sufadoxine/pyrimethamine (IPT), three tablets once to
be taken at the facility under supervision(DOT)
Mebendazole 500mg stat
67. E. Assess the need for specialised care
•Determine whether the woman is in need of
special care and/or referral to a specialized clinic
• The following conditions might require
• Diabetes Heart disease Renal disease Epilepsy
Drug abuse Family history of genetic disease
68. E. Development of an individual birth plan
Assist the pregnant woman to develop an Individual Birth Plan
(IBP). Encourage the male partner to be involved in the health care of
the mother-to-be and his baby and they should know:
The Expected Date of Delivery (EDD)
The danger signs in pregnancy, childbirth and the postpartum period.
The danger signs for the newborn.
She should decide on who will be the skilled attendant at her delivery
and where She should be advised to identify a birth companion
69. What transport she will use before, during labour and after
delivery if complications arise
How she will raise funds for transport, delivery charges and
for essential items/supplies
Identification of possible blood donors in case of
Her postpartum contraception plans and subsequent
A decision maker is identified in case of emergency
70. Where women have a bad obstetric history like previous
caesarean section, stillbirth, retained placenta / PPH, the
woman should be advised to deliver at a facility that can
provide Comprehensive Emergency Obstetric and Newborn
Where multiple pregnancy has been diagnosed, the woman
should be referred immediately to a CEONC facility for
confirmation of the multiple pregnancy and planning for the
71. Birth Plan and emergency preparedness checklist
Is the EDD known?
Has a skilled professional birth attendant been identified?
Has a facility been identified?
Has a birth companion been identified?
Has a decision maker been identified? Are emergency funds
Who is the custodian of the emergency funds? Has financial support
Has means of transport been identified? Has a blood donor been
72. G. Advice on complications and danger signs
Counsel on possible complications during pregnancy,
labour and postpartum period
Danger signs in pregnancy
Bleeding per vagina Bleeding
Drainage of liquor
Severe abdominal pains
Generalized body swelling
Reduced foetal movements Convulsions
73. Danger signs in labour
Labour pains for more than 12 hours (sun rise to
Excessive bleeding Ruptured membranes without
labour for more than 12 hours
Convulsions during labour
Loss of consciousness
Cord, arm or leg prolapse
74. Danger signs in postpartum period (mother)
Fever Foul smelling discharge
Abdominal cramps or pains
Painful breasts or cracked nipples
Facial or hand swelling
Painful calf muscles
75. Danger signs in postpartum period (newborn)
Fast breathing(more than 60 breaths/minute) Slow
breathing less than 30 breaths per minute
Severe chest in-drawing – Grunting
Umbilicus draining pus /redness extending to skin
Floppy or stiff Fever(temp 38 degree c and above
More than 10 skin pustules Bleeding from stump/cut
76. H. Health promotion, questions and answers, and scheduling the next
Advice on personal hygiene, rest, nutrition, family planning,
malaria, worm infestations, HIV/AIDS and PMTCT. Give advice
on safer sex.
Emphasize the risk of acquiring or transmitting HIV or STIs
without the use of condoms
Advise women to stop the use of tobacco (both smoking and
chewing), alcohol and other harmful substances
Counsel on breast-feeding of the last born child; when to stop
breast-feeding, generally until seven months gestation (but avoid
breastfeeding if there is history of habitual abortion)
77. Advice on personal hygiene, rest, nutrition, family planning,
malaria, worm infestations, HIV/AIDS and PMTCT.
Give advice on safer sex. Emphasize the risk of acquiring or
transmitting HIV or STIs without the use of condoms
Advise women to stop the use of tobacco (both smoking and
chewing), alcohol and other harmful substances
Counsel on breast-feeding of the last born child; when to stop
breast-feeding, generally until seven months gestation (but avoid
breastfeeding if there is history of habitual abortion)
78. Advise the woman to bring her partner (or a family
member or friend) to later ANC visits so that they can
be involved in the activities and can learn how to
support the woman throughout her pregnancy,
childbirth and postnatal period
Schedule appointment as per recommendations (state
date, and hour). This should be written in the woman’s
antenatal card and in the clinic’s appointment book.
79. I. Maintain complete records
Complete clinic record. Give the ANC card/ mother child booklet to
the patient and advise her to bring it with her to all appointments she
may have with any health services.
Although every pregnancy is at risk, the following conditions
require careful monitoring:
Poor obstetrical history Strikingly short stature Very young maternal
age (below 15 years) - Nulliparity and grandmultiparity Size-date
discrepancy - Unwanted pregnancy Extreme social disruption or
deprivation -Preterm labour in previous pregnancy Multiple gestation
- Abnormal lie/presentation Previous uterine scar
80. The second visit:
• Contents of the second visit
Review the history of the client & r/o any deviation from normal
Perform physical examination Measure blood pressure and pulse
Fundal height Oedema
Other signs of disease: shortness of breath, coughing, others.
Vaginal examination: do only if indicated.
If patient is bleeding or spotting, do not perform vaginal
examination but refer for further management.
81. Perform the following tests:
Urine: repeat multiple dipstick test to detect
urinary-tract infection, proteinuria, and sugar
Blood: repeat Hb if Hb at first visit was below
7.0 g/m1 or signs of anaemia are detected on
82. Implement the following interventions:
Iron: continue; if Hb is <7.0 g/ml,
consider further investigations If bacteriuria was treated at
first visit and test is still positive, consider culture, change
treatment and/or refer
Tetanus toxoid in line with national guidelines
In malaria endemic areas: administer
sufadoxine/pyrimethamine as per national guidelines
Administer mebendazole 500mg stat after 1st trimester
83. Re-assess for complications and possible referral
Reassess whether the woman has developed any new
complications since first visit, and refer/manage appropriately
Hb <7.0 g/ml at first and present (second) visit APH /
spotting high blood pressure (>140/90 mm Hg):
foetal growth, restriction gestation, diabetes ,reduced foetal
movement, polyhydramnios ,malnutrition, opportunistic
infections & any other alarming symptoms or signs
84. Advice, questions and answers, and scheduling
the next appointment
Repeat all the advice given at the first visit
Questions & answers: time for free
Schedule the next appointment
85. Maintain complete records
Complete clinic record. Give the ANC card
/mother child booklet to the patient and advise
her to bring it with her to all appointments she
may have with any health services.
Do the same in the next visits
87. The Mother and Child Health Booklet
On the new Ministry of Health MCH Health
Booklet, you will see a place to record:
Personal information Medical and surgical history;
information on previous pregnancies, gravida and
Findings of the general physical examination A
checklist to record additional data: urine, Hb, pallor,
maturity, fundal height, presentation, lie, foetal heart
rate and oedema
88. Intermittent Preventive Treatment for Malaria
Complications and/or referral information
Laboratory data Delivery Immunization and
maternal medication information.
Post natal information and a place to record
general "notes" Family Planning usage
89. National guidelines for IPT
Intermittent Preventive Treatment (IPT) is an effective
approach to preventing malaria in pregnant women by giving
antimalarial drugs in treatment doses at defined intervals
after quickening to clear a presumed burden of parasites
The Ministry of Health Guidelines on Malaria directs us to
give SP to pregnant women in endemic malaria areas, at
least twice during each pregnancy, even if she has no
physical signs and her haemoglobin is within normal range.
90. Administer IPT with each scheduled visit after
quickening (16 weeks) to ensure women receive
at least 2 doses at an interval of at least 4 weeks.
IPT should be given under Directly Observed
Therapy (DOT) in the ANC clinic and can be
given on an empty stomach
91. National guidelines for Tetanus Toxoid
DOSE OF TT WHEN TO GIVE
TT 1 At first contact or second
trimester in pregnancy
TT 2 At least 4 weeks after
TT 3 At least 6 months after TT2
or during subsequent
92. NUTRITION IN PREGNANCY
Pregnancy is a critical period in the life cycle due to the
many body changes in both the mother and the foetus.
Optimal maternal nutrition is critical for foetal growth and for
a successful delivery.
Dietary counselling and supporting interventions through
Focused Antenatal Care (FANC) are an essential package for
improving nutrition during pregnancy.
Poor nutritional status during pregnancy on the other hand
has been associated with IUGR, LBW, premature delivery,
birth defects and stillbirths.
93. Recommended weight gain during pregnancy
BMI Index (BMI pre-conception) Appropriate weight to gain
Underweight( BMI<18.5) 12.5-18 kg
Normal weight ( BMI 18.5-24.9) 12-15 kg
Overweight ( BMI 25-29.9) 7-11.5 kg
Obese (BMI >30) 6 kg
Twin pregnancy 16.0-20.5
Adolescent pregnancy Upper end of recommended values
94. GENERAL NUTRITION REQUIREMENTS IN PREGNANCY
Indicators of good nutritional status during
Weight gain: between 11.5–16 kg for the
duration of pregnancy
Haemoglobin level ≥ 11g/dl
Absence of clinical signs of micronutrient
95. ENERGY AND PROTEIN REQUIREMENTS
During pregnancy the needs for energy and protein
are increased in order to meet the demands for
adequate maternal gestational weight gain, as well as
the growth and development of the foetus.
Energy is needed to meet the increased basal
metabolism and there is normal accumulation of fat as
the energy reserves.
96. Maternal stores of nitrogen are increased in pregnancy hence
increased need for protein especially for women with low
BMI-<18.5. A 10% increase of protein equivalent to 60 gm
/day is required for:
Tissue growth; nitrogen balance; growth of foetus; enlarged
mammary glands, uterus and placenta; increased circulating
blood volume and plasma proteins; formation of amniotic
fluid; reserves for labour, delivery and lactation.
97. Rich dietary sources of proteins include milk, eggs,
soy beans, meat - which provide High Biological
Value (HBV) protein.
Vegetable proteins except soy bean provide low
biological value proteins.
A proper dietary balance is necessary to ensure
sufficient intake for adequate growth without drawing
from the mother’s own tissues to maintain her
98. Energy and protein requirements in pregnancy
In pregnancy total energy requirement is 36 to 40
kcal/kg/day where as protein requirement is 0.8 to 1 grm
In first trimester add 150 kcal/kg/day and in protein add
In second trimester add 300 kcak/day and in protein
Third trimester add 300 kcal/day and in protein 6grm/day
99. Frequency of meals in pregnancy
Pregnant women should increase their nutrient intake
by taking an extra meal in addition to the 3 regular
It is recommended that pregnant women have snacks
between meals to meet their daily energy requirement.
The table below shows a list of available snacks that
can be used by the pregnant women.
100. MICRONUTRIENT REQUIREMENTS FOR
PREGNANT AND LACTATING MOTHERS
During pregnancy there is an increased need for micronutrient
All major and trace minerals and vitamins have a role in
The pregnant and lactating mothers needs extra folic acid and
vitamin B12 due to the great increase in blood volume /cells and
the rapid growth of the foetus.
Iron demands increase as the body conserves more than usual
during pregnancy and the growing foetus draws on maternal iron
101. Minerals involved in building the skeleton- calcium,
magnesium and phosphorus are also in great demand.
A normal adult woman would require 800mg calcium,
280mg magnesium anMicronutrients are required by the body
for production of enzymes & hormones; formation of brain
cells; regulation of physical growth & development;
regulation of the immune system and reproductive system;
and for strengthening of the muscular and the nervous
system. d 800mg of phosphorus whereas in pregnancy the
needs are higher.
102. The following micronutrients play a critical role
Iron helps in the formation of blood. It is essential for many
enzymes that are required for metabolism of glucose and fatty
acids. It plays a vital role in body’s immune system as well as
in the synthesis of hormones and neurotransmitters.
Women of reproductive age and infants have the highest
need for iron. Extra iron is needed for haemoglobin synthesis
during pregnancy. The RDA doubles to 30mg/day, especially
in the 2nd and 3rd trimesters. Inadequate iron is the
commonest cause of anaemia.
Zinc is the essential trace mineral occurring in the body in
larger amounts than any other trace element because it is
present in all tissues. Zinc promotes normal growth and
It is a major component in body enzymes, hormones, genetic
material proteins. It promotes wound healing and maintains
an effective immune system. It is essential for sperm
production and the development of sex organs.
104. Zinc requirements are highest in the third trimester when the foetus
acquires two-thirds of its zinc stores. The RDA for zinc is 15gm/day
for pregnant women, 25% higher than for non pregnant women.
Inadequate zinc status in pregnancy increases the risk of delivering
low birth weight infants.
Diets that are very high in calcium, fibre or phytates may decrease
zinc absorption. Routine iron and folate supplementation may also
impair zinc absorption. Therefore, good dietary sources of zinc as well
as dietary habits should be reinforced.
• Iodine is essential for the functioning of the thyroid gland and
for normal mental and physical development.
• The body needs iodine to prevent goitre, cretinism and low
intelligence. Pregnant women and young children have
special needs for iodine. Iodine deficiency is the main cause
of preventable brain damage globally. Iodine deficiency also
causes cretinism, congenital anomalies, stillbirths and
abortions. It also contributes to increased prenatal mortality
and infant mortality.
106. The RDA for a pregnant woman is 175mg/day and
this covers for the extra demands of the foetus. Use of
iodized salt is highly recommended.
Health and economic impact of Iodine Deficiency
Disorders Increased risk of spontaneous abortions,
stillbirths and impaired foetal brain development
Goitre and cretinism Reduced mental capacity and
107. Vitamin A Vitamin A is an essential nutrient which is
required in small amounts for epithelial cell integrity,
effective immune system function and normal functioning of
the visual system.
It is also necessary for maintenance of cell function and for
growth and reproduction. Improving Vitamin A status among
pregnant women dramatically reduces maternal mortality,
foetal growth retardation and is necessary for embryo
development and spermatogenesis.
108. Food sources: Animal sources (liver, eggs) Plant source-
Dark green leafy vegetables (Amaranth, spinach, kales, Black
night shade, comfrey); yellow/orange fruits (Mango, passion,
Avocado; orange-fleshed vegetables (sweet potatoes,
pumpkin, carrot, tomatoes, and sweet pepper) Fortified foods
(fats and oils, margarines) Absorption of provitamin A may
be low in diets low in fat.
Calcium is needed during pregnancy to promote
adequate mineralization of the maternal skeleton
& teeth; for normal blood clotting mechanism;
normal muscle action and rapid foetal
mineralization of skeletal tissue especially in the
2nd and 3rd trimester.
110. To meet the recommended calcium requirements in
pregnancy, women should be counselled to:
Consume small amounts of milk with snacks. Drink
Dietary sources of calcium include: Milk, yogurt and
cheese and sardines (small fish eaten with bones).
Whole enriched cereal grains and green leafy
111. Folic Acid
The body needs folic acid for the production, repair, and
functioning of DNA - our genetic map and a basic building block
Folic acid is particularly important for the rapid cell growth that
occurs during pregnancy.
Its deficiency is associated with an increased risk of neural tube
birth defects. These birth defects occur early in gestation, before
pregnancy is apparent. Women of childbearing age should
consume a diet rich in folic acid daily.
112. Food sources:
Folate is present in a variety of foods such as
green leafy vegetables, liver, fruits and pulses.
The richest sources are spinach, kidney beans,
groundnuts, kidney and liver.
113. Some general nutrition recommendations for pregnant women
Weight gain: 12–16 kg throughout the course of pregnancy
Daily additional energy intake: 300kcal/day
Diversified diet, to ensure variety in the food choices using
the locally available foods(see Food pyramid below)
Iron and folic acid supplementation: 60mg of iron and 400
μg folic acid every day
Daily consumption of iodized salt Prevention and treatment
of malaria De-worming (Mebendazole given during 2nd
trimester) Adequate rest
114. The food guide Pyramid adapted from the A.D.A.M diabetes food pyramid below