Safe Motherhood

Shahida Abbasi
Nursing Instructor
PGCN
11th September 2019
 Objectives

At the completion of this unit learners will be able to:

1. Discuss the objectives of MCH Services
2. Explain pre- conception factors contribute to
healthy/unhealthy pregnancy
3. Discuss the objectives of antenatal care
– History taking
– Physical examination
– Investigations
– Follow up
4. Describe the guidelines for antenatal assessment, care
and teaching.
 MCH Services

Maternal and Child Health Services (MCH) refers to

promoting, preventing, therapeutic or rehabilitation
facility or care for fetus, mother and child.
Objectives of MCH are:
• Reduce maternal, perinatal, infant and childhood
mortality and morbidity.
• Promotion of Reproductive Health/safe motherhood.
 Conti…

• Ensure birth of healthy child

• Prevent malnutrition and its related problems
• Early diagnosis and treatment
• Promote health of mother, infant and family
 Preconception Assessment /Counseling

Age
Nutrition status (anemia)
Immunization status (TT)
Medication (Folic acid)
Medical problems (HTN, DM…)
Genetics screening (thalassemia)
Habits (tobacco and alcohol…) need to stop
Hazards at work/home (prick injury, radiation…)
Psychological/emotional status (stress and coping)
 Antenatal Care

Antenatal Care (ANC): It is the preventive branch

of obstetric and consist of systemic supervision of
women during pregnancy.

Care of the mother and baby during pregnancy from

conception till labor

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 Importance of Antenatal Care

• Support and encourage psychological adjustment to

pregnancy, childbirth, breastfeeding and parenthood
• Monitor pregnancy progress to ensure the health and
wellbeing of mother and fetus.
• Monitor all women for signs of obstetric difficulties;
early identification of problem and management
• Recognize deviations from the normal, and treat or
refer as required.
• build a trusting relationship between the woman and
her care givers;
 Conti…

• Provide the woman with information with which she

can make informed decisions.
• Actively involve woman’s family or friends in the
experience of pregnancy.
• To prevent maternal and neonatal mortality, injury,
& ill health

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 Trimesters of Pregnancy

• First trimester---1st week till13th week

• Second trimester-- 14th week till 26th week
• Third trimester-----27th week till 38/40 weeks
 Calculation of the Expected Date of Delivery

• The duration of pregnancy is usually taken to be 40

weeks, with normal labour occurring between 38 and
42 completed weeks of gestation.
• (Nägele’s Rule - 1st day of LMP; subtract 3 months;
add 7 days = Expected date of birth (EDB, EDD)
• Nine months, and seven days are added to the first
date of the last menstrual period.
 Schedule of Antenatal Visits

Prenatal visits
• Every 4 weeks until 28 week (7 visits)
• q 2 weeks until 36 week (4 visits)
• q week until delivery
• At least 4 visits are required
• First trimester 1 visit
• 2nd trimester 1 visit
• 3rd trimester 2 visits

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 History Taking

• Personal profile / social history

• Menstrual history
• Obstetric history
• Previous pregnancies (length & problems), labor
(place, type & postnatal , birth weight &
complications)
• (term, preterm, abortions , still born)

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 Gravida and Para

Para: # of deliveries (born alive + still born)

Gravida: # of pregnancies (+ present pregnancy)
 Expected Date of Delivery

• Expected Date of Delivery (EDD)

• A women comes to an antenatal clinic. Her
history reveals that she is fourth time pregnant
her all babies are alive. Her LMP is 13-11-18.
• What will be her EDD/EDB
• Gravida=
• Para=
 Conti…

• Medical and surgical history

• (complicating pregnancy/ recent abdominal
surgery/blood transfusion in past)
• Family history; inherited diseases/ twins
• Partner history, smoking, blood type if
mother negative
• Pregnancy history ---any concern in this
pregnancy
• Medications /allergies
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 General Examination
BP: each visit to identify signs of hypertension.
a rise in the diastolic reading to above 90 mmHg or
of more than 10 mmHg from the baseline reading
taken before the twentieth week of pregnancy may
require evaluation
• Weight : 1st 20 weeks weight gain—2kg
remaining 20 weeks wt gain—9kg
• Height < than 5 feet concern
• Examine legs for varicose Vein

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 Conti…

Per Vaginal (P/V) examination

Before 16 weeks
• At first visit to confirm pregnancy, cervical
cytology
Last trimester
• Labor progress
Note Ask women to void before vaginal
examination

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 Abdominal Examination

Height of fundus (compare with LMP, fetal growth)

Two methods
• McDonald’s Rule - between 16 and 36 weeks,
height of fundus in cm = weeks gestation
• Manual method
• Lie (longitudinal , transverse, oblique)
• presentation (breech , shoulder, cephalic)
• Fetal heart sound
• Fetal movement
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 Urinalysis

• To check for the presence of bacteria to

screen for asymptotic bacteriuria.
• If a high level of bacteria is found (greater
than 100 000 colonies per ml), a suitable
antibiotic is required.
• Urine test for Albumin and sugar
 Rhesus

Rhesus factor and antibodies should be checked and

preparations made to provide anti-D for Rh negative to
non-sensitized women following any procedure/event that
could result in feto-maternal transfusion, also on 28th
week of gestation and after delivery.
 Investigations

Pregnancy test After fertilization hCG released in

blood & some passed in urine. In first few weeks of
pregnancy, the amount of hCG in the urine rises
rapidly, doubling every 2 to 3 days.
• Blood test Hb, hematocrits
If anaemia present one tablet of 60 mg elemental iron
with folic acid 0.5 mg twice a day for at least 90
consecutive days.
• Screening: Hep B &C, HIV, Rubella antibody

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 Conti…

• Ultrasound can be done as early as 6 weeks

• normally done at 16 weeks to detect any
abnormities and after 32 weeks to see the CPD
• Alpha fetoprotein ( 16 -18 weeks)
• Fetal proteins detected in mothers’ blood they
detect some congenital or genetic disorders
• Amniocentesis ( 11 -18 weeks) amniotic fluid test
(insertion of needle in Abdominal wall to detect
chromosomal abnormalities
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 Records
• All findings should be recorded on the
antenatal records.
• The records should be accurate and contain the
signature of the person making the record.
 Antenatal assessment, care and teaching

• Better self care improves maternal and neonatal

outcome
• Teach expected changes
• Reassurance of normal discomforts
• Warning signs of complications
• Avoidance of teratogens (warfarin, Isotretinoin)
• Others (x-rays, Radiation, chemotherapy)

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 Nutritional Requirements
Calories Increase of 250 kcal per day.
• Additional requirement is less important in the first &
most important in last trimester.
Calcium - 1200 mg/day. ↓intake of calcium ↑risk of
pre- eclampsia. up to 2,000 mg of calcium
supplement / day in pregnancy.
Protein - 60 grams/day essential for fetal & placental
growth.
Carbohydrates – 100 grams/day (fibers)
Fat - 20-30% of caloric intake
Iron - 30-60 mg supplement/day
Folic acid - 0.8-1 mg/day. Deficiency linked to LBW &
neural tube defects.
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 Teratogens

• Any substance that alters cell differenciation or

growth of fetus
Alcohol: first ten weeks cause malformations
Drugs: Cocaine and heroine cause blood vessels to
constrict----, IUGR higher risks of miscarriage,
premature labor, abruptio placentae (the partial
separation of the placenta from the uterus wall,
causing bleeding) respiratory difficulties and
intracranial hemorrhage

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 Medication

• Anticonvulsants
• Anti-migraine
• Anticoagulant
• Non-steroidal anti-inflammatory drugs (NSAIDs)
(Aspirin, ibuprofen)
– interfere with blood clotting
– hinder production of the hormones that stimulate
labor,
– facial malformations and mental retardation

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 Smoking

risk of miscarriage or premature labor, IUGR

• Nicotine depresses the appetite and reduces the
ability of the lungs to absorb oxygen. The fetus,
deprived of sufficient nourishment and oxygen, may
not grow as required
Other are :
• Chemicals (household, work)
• Radiation exposures
• Infectious diseases

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 Travel
• Avoid long traveling
• Avoid travel during last month of gestation
• Avoid travel if medical care is unavailable in that area
• Use seat belts
• Work
• Avoid excess lifting (>60 lbs)
• Avoid fatigue, don’t work > 8 hour days
• Avoid exposures, x-rays, or toxins

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 Exercise
• May continue with accustomed exercise but do not initiate
overly vigorous program
• Avoid excessive fatigue; keep pulse 120 bpm
• Wear supportive shoes and appropriate clothing
• Discontinue if short of breath
• If vaginal bleeding or abdominal pain, see doctor
immediately

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 Personal Hygiene
• May need to bathe more frequently
• Safety precautions when bathing
• Tub baths contraindicated in ROM
• Dental Care
• Continue regular dental exams & cleanings
• Local anesthetics without added epinephrine is
recommended

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 Immunizations

• Live attenuated virus vaccines contraindicated (i.e. measles,

mums, rubella)
• Inactivated bacterial vaccines, immune globulins and DNA-
based vaccines safe when indicated
• (e.g., Hepatitis B vaccine, TT)

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 Childbirth Preparation
Studies show women have easier, faster labors if
attend childbirth classes
Teach mother
• danger signs
• Medications
• stages of labor
• breathing & relaxation methods
• neoborn care
• breast feeding
 Danger Signs

Ensure that woman and family know danger

signs, which indicate need to consult doctor
• Vaginal bleeding
• Breathing difficulty
• Fever
• Severe abdominal pain
• Severe headache /blurred vision
• Convulsions / loss of consciousness
 Conti…
• Foul smelling discharge / discharge from vagina
• Decreased / absent fetal movements
• Leaking of greenish /brownish (meconium stained)
fluid from vagina
Primary Health care level
• Registration, if high risk put red mark
• TT vaccine
• Iron, folic acid / iodine supplements/ calcium
• Identification of high risk factors
• Identification of STI
• Strategies to address malaria, HIV where prevalent
• Follow up
• Referral level Management of complication

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 Nice to know weight gain in pregnancy
• Fetus 3.2 Kg
• Placenta 0.5 Kg
• Amniotic fluid 0.9 Kg
• Uterus 0.9 Kg
• Breasts 0.4 Kg
• Blood volume 1.3 Kg
• ECF 1.1 Kg
• Fat 2.7 Kg

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 References
Bennett, R & Brown K (2009) Myles' Textbook for Midwives
(15th ed.) Churchill Livingstone: London