health department

provision of maternal health and family planning services

Technical Instruction Series:

No. HD/FH/5/2020
January 2020
health department

provision of maternal health and family planning services

Technical Instruction Series:

No. HD/FH/5/2020
January 2020
© 2020 UNRWA
This document is a formal publication of the United Nations Relief and Works Agency for Palestine refugees in the
Near East (UNRWA) and all rights are reserved by the Organization. The document may, however, be freely reviewed,
abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial
purposes. The views expressed in documents by named authors are solely the responsibility of those authors. The
designations employed and the presentation of the material in this document, including tables and maps, do not
imply the expression of any opinion whatsoever on the part of the Agency concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of
specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by
UNRWA in preference to others of a similar nature that are not mentioned. Errors and omissions accepted, the names
of proprietary products are distinguished by initial capital letters.
Contents
Provision of Maternal Health and Family Planning Services...................................................................................3
I. Purpose.............................................................................................................................................................................................................3
II. Effective date................................................................................................................................................................................................3
III. Revision...........................................................................................................................................................................................................3
IV. Applicability.................................................................................................................................................................................................3
V. Introduction..................................................................................................................................................................................................3
VI. Goal and Objectives...............................................................................................................................................................................3

1. Standards of Care..........................................................................................................................................................................5
1.1 General procedures...............................................................................................................................................................................7
1.2 Obstetric history .....................................................................................................................................................................................7
1.3 Medical history.........................................................................................................................................................................................7
1.4 Medical history for preconception/antenatal/family planning.................................................................................7
1.5 Screening for domestic violence and postnatal depression.......................................................................................7
1.6 Specific procedures...............................................................................................................................................................................8

2. Preconception Care.....................................................................................................................................................................9
2.1 Objectives.......................................................................................................................................................................................................11
2.2 When preconception care can be provided.............................................................................................................................11
2.3 Components of preconception care.............................................................................................................................................11
2.3.1 Health promotion...................................................................................................................................................................12
2.3.2 Counselling................................................................................................................................................................................13
2.3.3 Screening activities...............................................................................................................................................................14
2.3.4 Periodic risk assessments..................................................................................................................................................15
2.3.5 Intervention and follow-up assessment..................................................................................................................16
2.3.6 Folic acid supplementation.............................................................................................................................................16

3. Antenatal Care.............................................................................................................................................................................17
3.1 Objectives.................................................................................................................................................................................................19
3.2 History........................................................................................................................................................................................................19
3.3 Screening for domestic violence...............................................................................................................................................19
3.4 Promotion of healthy lifestyle during pregnancy............................................................................................................19
3.4.1 Work during pregnancy.......................................................................................................................................................19
3.4.2 Diet and nutrition during pregnancy..........................................................................................................................19
3.4.3 Supplements and other health behaviors...............................................................................................................20
3.5 Common complaints during pregnancy..............................................................................................................................22
3.6 Medical examination.........................................................................................................................................................................23
3.6.1 General medical examination..........................................................................................................................................23
3.6.2 Obstetric examination..........................................................................................................................................................24
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3.7 Oral health screening......................................................................................................................................................................24
3.8 Laboratory investigations..............................................................................................................................................................24
3.9 Ultrasound imaging.........................................................................................................................................................................26
3.10 Risk assessment................................................................................................................................................................................26
3.11 Regular monitoring........................................................................................................................................................................27
3.12 Counselling on and preparation for labour, postnatal care and breastfeeding........................................29
3.13 Referral...................................................................................................................................................................................................29
3.14 MCH handbook/MCH Application........................................................................................................................................30

4. Postnatal Care..............................................................................................................................................................................31
4.1 Postnatal history.................................................................................................................................................................................33
4.2 Medical examination for the mother and newborn....................................................................................................33
4.3 Special considerations....................................................................................................................................................................34
4.4 Post-abortion care.............................................................................................................................................................................34

5. Family Planning Services......................................................................................................................................................35

5.1 Pre-requisites for service delivery..................................................................................................................................................37
5.2 Standards of care................................................................................................................................................................................37
5.3 Family planning methods.............................................................................................................................................................39
5.4 Follow-up................................................................................................................................................................................................40

6. Level of Responsibility and Authority...........................................................................................................................41

6.1 Obstetrician & Gynecologist......................................................................................................................................................43
6.2 Medical Officer....................................................................................................................................................................................43
6.3 Dental Surgeon..................................................................................................................................................................................44
6.4 Senior Staff Nurse.............................................................................................................................................................................44
6.5 Staff Nurse & Midwife....................................................................................................................................................................45

7. Recording and reporting.....................................................................................................................................................46

7.1 Recording..............................................................................................................................................................................................49
7.2 Reporting..............................................................................................................................................................................................49

8. Monitoring and evaluation.................................................................................................................................................51

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Provision of Maternal Health and Family Planning Services

I. Purpose: The purpose of this Technical Instruction is to define the policy and Establish uniform
procedures for the implementation of a comprehensive Maternal health and family
planning program, which is fully integrated within the Agency s primary health care
activities.

II. Effective date: January 2020.

III. Revision: This revision is an amendment to the Technical Instruction No. HD/FH/1/95,
revision No. 1/2001, revision No. 2/2003 and revision No. 3/2009.

IV. Applicability: Applicable in all Fields of UNRWA’s area of operations.

V. Introduction:
The burden of child and reproductive ill-health falls overwhelmingly on newborn infants and women in terms
of complications in pregnancy and child birth, infant and maternal morbidity and mortality, and congenital
malformations and disability. Maternal health care and family planning services are therefore central to health
in general and to socioeconomic development.

The various elements of reproductive health are strongly interrelated. An improvement in one element can
facilitate an improvement in others (vice versa, a deterioration in one element can cause a deterioration
in others). While all elements of reproductive health are individually important, given the current socio-
economic and environmental conditions, family planning is central to all other aspects of reproductive health.
For example, it has a bearing on the consequences of unintended pregnancy, safe motherhood, child survival,
sexual behavior, and the prevention of Sexually Transmitted and Reproductive Tract Infections (STIs and RTIs).

Based on UNRWA registration statistics, approximately two-thirds of the refugee populations are women of
reproductive age (15-49 years) and children below 18 years of age. Therefore, in order to be effective, future
investment in health should be focused on attaining the widest possible coverage and improvement of quality
maternal and child health care and family planning services. This could be best achieved by a reorganization
of services at the health center level to ensure continuity of preconception/inter-conception, antenatal,
postnatal, post-abortion and family planning services, rather than providing these services in fragmented
ways in line with the Family Health Team approach currently implemented in all UNRWA Health Centers.

VI. Goal and Objectives

The main goal of the program is to protect and promote the health of Palestine refugee women, children and
families by providing preconception, antenatal, postnatal, post-abortion and family planning services that
complement each other and are fully integrated within the Agency’s primary health care activities and the
Family Health Team Reform.

The specific objectives:

• To provide preconception health care to all women of reproductive age before pregnancy in order to manage
conditions and behaviors which could pose a risk to herself or her baby, and to ensure optimal health status
prior to conceiving;

• To provide optimal antenatal care to pregnant women as early as possible and until delivery in order to ensure
a healthy pregnancy, a safe delivery and healthy outcomes, and to prevent and early detect any deviation from
the normal pattern of pregnancy by maintaining a regular system of health care.

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To identify and pay special attention and care to pregnant women with risk of factors and/or diseases that are
universally recognized as major causes for increased probability of developing complications or result in adverse
outcomes of pregnancy;

• To ascertain the outcome of each registered pregnancy and follow-up on the survival of newborn infants;

• To reduce maternal deaths and perinatal mortality through early detection and management of risk factors/
complications that increase the probability of undesirable outcomes for the mother, the fetus or the newborn
infant;

• To ensure that optimal standards of care are provided to high-risk pregnant women during delivery, and that
neonatal care is provided to their newborn infants by providing assistance towards their hospitalization costs
(within the financial means available to the Agency);

• To prevent adverse developments that may arise after childbirth by providing postnatal care, either at home or
at the UNRWA clinics, as early as possible after delivery and within 42 days of child birth to all women who are
receiving antenatal care at UNRWA clinics;

• To provide post-abortion care for women attending UNRWA clinic, to prevent post-abortion complications by
providing care, management and referral of cases of abortion-related complications, in addition to counselling
and providing post-abortion, preconception care and family planning services;

• To promote birth spacing by avoiding too early, too late, too frequent and too close pregnancies through
the provision of comprehensive family planning services to women and men, including reproductive health
counselling and the provision of modern contraceptive supplies;

• To encourage women to take responsibility for their own health by avoiding health-damaging behaviors such
as smoking, and maintaining healthy lifestyles, such as appropriate weight, nutrition, physical exercise and oral
health; and

• To raise awareness in the communities about reproductive health issues through proper health education to
women of reproductive age.

• To provide psychosocial supports for pregnant women suffer from Gender Base Violence (GBV) or Domestic
Violence (DV).

• To treat women whom suffer from STIs / RTIs.

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Standards of Care

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1. Standards of Care
1.1 General procedures
A Maternal Health Record (MHR) on e-Health system should be opened, and an obstetric and general
medical history should be completed for each woman in the following categories:
• Women of reproductive age with preconception intentions attending a preconception care clinic,
in particular those categorized as at risk during the preconception risk assessment and in need of
specialized medical care before conception;
• Pregnant women during the antenatal period and the postnatal period; and
• Women who accept and use UNRWA s family planning services.

1.2 Obstetric history

A summary of the woman’s obstetric history should be taken, including the following:
• Details of previous pregnancies, including dates of previous deliveries by month and year, gestational
age at the time of delivery, type and place of deliveries, any complications (i.e. pre-eclampsia, gestational
diabetes mellitus, previous antepartum (APH) or postpartum (PPH) hemorrhage, etc.);
• The outcomes of each pregnancy, whether it ended in abortion, stillbirth or live birth, and whether it was
a single or multiple pregnancy; and
• For a live birth, the sex of the baby should be recorded and whether the birth weight was below normal,
normal or above normal, in addition to the gestational age at delivery (preterm, term or post-term).

1.3 Medical history

Under medical history, the woman should be asked about the following:
• Consanguinity: whether the husband / father of the baby is a close relative or not;
• Family Disease: any familial disease, especially diabetes mellitus and hypertension or other relevant
familial diseases such as thalassemia and sickle cell anemia etc.;
• Blood Transfusion: any history of blood transfusion, when and where, and the indication for transfusion;
• Major Surgery: any previous surgery under general anesthesia; and
• Major Morbidity Conditions: morbidities that she is suffering from at present or previously suffered
from (e.g. cardiovascular disease, thyroid disease, bronchial asthma, migraine, typhoid, epilepsy, severe
varicose veins and deep venous thrombosis (DVT)).

1.4 Medical history for preconception/antenatal/family planning

When a woman visits the health center seeking services for preconception, antenatal, or family planning,
either for the first time or if she is resuming family planning services, the following details should be
recorded:
• The type of service required: PC for preconception care, AN for antenatal care, and FP for family planning
services;
• Date of attendance;
• History of hypertension;
• History of diabetes mellitus;
• History of chronic or recurrent urinary tract infection;
• History of jaundice;
• History of epilepsy and convulsions;
• History of depression during previous pregnancies or postnatally; and/or
• History of any other diseases.

1.5 Screening for domestic violence

Domestic violence is defined by home abused despite it is verbal, physical, neglect, or sexual. Usually it is
associated with poor pregnancy outcomes, including an increased risk of antepartum hemorrhage, fetal
growth restriction and perinatal death.
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Women attending preconception, antenatal, postnatal and family planning services should be screened
and counselled on domestic violence. Although this is a sensitive issue, it should be made clear that
such violence is unacceptable, and women who are victims of abuse should be given the necessary
support and help.

Particular attention should be paid to signs and symptoms of abuse. Midwives should be familiar with
identification, counselling and the referral of victims of domestic violence and should have knowledge
of the availability of local help services. Our role is not to create more problems for the victim but rather
to provide counselling, adequate psychosocial support according to the technical instructions “Medical
Management Guidelines and Protocols for Gender Based Violence” and MPHSS TIs.

1.6 Specific procedures

The standards of care and procedures defined under each program component should be fully adhered
to. It should also be recognized that optimal care before, during, and after pregnancy can only be achieved
through an integrated approach based on family health team (Nurses, Midwives, Medical Officers), in
addition to Gynecologists/Obstetricians. The team should maintain the required standards of care and
provide regular feedback to each other on the health status of women who need special attention and
care. Supervision is of the utmost importance in order to provide support and technical assistance and
ensure that the proper standards of care are implemented.

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Preconception care

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2. Preconception care
Preconception health care comprises a set of prevention and management interventions that aim to identify
and modify risks to a woman’s health or pregnancy outcome by emphasizing the factors that must be acted
on before or early in pregnancy in order to have maximal impact.

2.1 Objectives
When poor pregnancy outcomes occur, they are frequently the result of events set in motion long before
the first antenatal visit. Therefore, many of the factors which contribute to poor birth outcomes can be
effectively managed and brought under control before pregnancy.

The specific objectives of the Agency’s preconception care are:

• To integrate preconception care as an essential component of maternal and child health care and other
relevant programs;
• To ensure that all women of reproductive age (15-49 years) enter pregnancy in optimal health;
• To encourage early registration for antenatal care;
• To achieve further reduction in infant, child and maternal morbidity and mortality by preventing or
minimizing health problems for the mother and her fetus;
• To provide psychosocial support for couples to be prepared for pregnancy and have a new baby;
• To identify pregnant women that suffer from domestic violence and apply related supports;
• To ensure immunization of Tetanus and Rubella for both the woman and her partner;
• To avoid unintended pregnancy by helping couples understand their reproductive health and adjust
their lifestyle accordingly, and provide family planning services
• To control the possibility of having hereditary diseases among newborns through identification of
parents with increased genetic risks, and to provide them with sufficient knowledge to make informed
decisions about their reproductive options;
• To prevent and treat infections, in particular genital tract infections;
• To identify and assist couples who may have infertility problems, according to available resources; and
• To improve the overall knowledge, attitudes and behaviors of men and women regarding reproductive
health in general, and preconception care in particular.
• To treat any STI / RTI if diagnose

2.2 When preconception care can be provided

Preconception care is a new concept that has been integrated within maternal health services in 2009 as
a part of UNRWA comprehensive primary health care services.

Preconception care can be provided as part of regular preventive care or during visits for other health
problems. Health center staffs should therefore take every opportunity to increase the availability of
preconception care, including:
• After the discontinuation of family planning (the last family planning visit should be regarded as the first
preconception visit);
• During outpatient medical consultations in general, and specialized clinics;
• During regular growth monitoring check-ups for infants and children;
• During consultations in the non-communicable diseases (NCDs) clinic; and
• During consultations in the dental clinic.

2.3 Components of preconception care

The main components of the Agency’s preconception care programs are:
1) Health promotion;
2) Counselling;
3) Screening activities;

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4) Periodic risk assessments;
5) Intervention and follow-up; and
6) Folic acid supplementation.

Procedures
The preconception period is not a well-defined period of time. Throughout their reproductive lives, most
women never really know when, or if, they will become pregnant. Therefore, women of childbearing
age attending the outpatient, non- communicable diseases (NCDs), specialist, dental, family planning
and growth monitoring clinics should be asked about their future reproductive intentions before health
services are provided.

The roles of family health team staffs are to ask, assess, assist, advice, and arrange for preconception
health care tailored to the needs of each woman, while conducting the following activities:

2.3.1 Health promotion

a) History taking
A detailed history should be recorded assessing past and current risks that may affect future
pregnancies, including:

Medical history
A detailed medical and surgical history should be taken to identify specific medical conditions
often associated with adverse pregnancy outcomes, and other conditions that are known to be
contraindications to pregnancy, such as:
• Hypertension (this should be brought under control before pregnancy);
• Diabetes mellitus (Glycaemia level should be controlled well before conception);
• Blood diseases, anemia, thromboembolism, among others;
• Epilepsy, seizure disorder and anticonvulsant therapy;
• Severe and poorly controlled asthma;
• Thyroid disorders, hypo/hyperthyroidism;
• Cardio-vascular diseases;
• Certain infectious diseases, such as sexually transmitted and reproductive tract infections
(STIs, RTIs) and HIV/AIDS;
• Autoimmune diseases;
• Tuberculosis;
• Kidney diseases;
• Cancer;
• Hepatic conditions such as active hepatitis (B or C);
• Mental health or psychiatric disorders; and
• Other relevant medical conditions.

Medications
Review any medication that affects the fetus or the mother, such as anticonvulsants,
immunosuppressant and teratogenic medicines frequently used to treat acne (Accutane).

Reproductive health history

A review of the reproductive health history should be conducted, including:
• Previous obstetric and gynecological history with pregnancy, abortion, fertility, birth, and
use of family planning methods;
• Immunization status, in particular immunization against rubella and tetanus; and
• Risk of exposure to hepatitis B, HIV, or other STIs, toxoplasmosis, congenital cytomegalovirus
(CMV), rubella, chickenpox or other infectious diseases.
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Behaviors and lifestyle history
Lifestyle and social behaviors should be reviewed to identify factors and conditions that might
affect future pregnancy, in particular:
• Smoking, second-hand smoking and substance use;
• Domestic violence;
• Psychological and mental health history;
• Dietary habits (vegetarian, weight reduction, diets);
• History of being underweight/overweight or obesity; and
• Physical activities (If the client sedentary, undertakes regular physical exercise, or participate
at severe activities).

b) Medical Examination
A comprehensive medical examination and risk assessment should be conducted during the
first preconception care visit;
• Inspection of the general appearance to assess if the woman looks ill, anemic, tired or
malnourished;
• Body weight measurement to the nearest 200 grams as a baseline for future weight gain;
• Blood pressure measurement;
• Examination of the eyes, ears, nose, mouth and throat for signs of abnormalities, infection or
anemia (The neck should be palpated for signs of thyroid enlargement);
• Auscultation of the heart and lungs;
• Assessment of mental health status (depression);
• Examination of the lower extremities for edema and/or varicose veins; and
• Ultrasonography should be carried out selectively by the Gynecologist/Obstetrician only.

c) Promotion of healthy lifestyle

The Ottawa Charter (WHO 1986) defines health promotion as a process of enabling people
(individuals and communities) to increase control over, and to improve their health. Promotion
of a healthy lifestyle is an essential component of preventive care and should form an integral
part of health care provision through health education sessions, counselling, and advocacy.
The following issues should be addressed during the provision of preconception care:
• Promotion of healthy behaviors such as appropriate weight, nutrition, physical exercise, oral
health and stress release;
• Family planning counselling to avoid unwanted and unplanned pregnancies;
• Cessation of smoking (cigarettes, e-cigarettes, shisha) and avoiding passive smoke; and
• Promoting a healthy environment at home and at the workplace by avoiding use of, and
exposure to, toxic substances, insecticide, pesticides smoke, alcohol and caffeine etc.

2.3.2 Counselling
Counselling should be provided by the Family Health Team (medical officer, staff nurse and
midwife). The aim of counselling is to enable the woman, and when possible her husband, to
make informed choices about pregnancy by providing them with information about their health
in relation to reproduction and the potential risks involved. The main elements of counselling
during preconception care should take into consideration the following:
• Impact of pregnancy on pre-existing medical conditions, and the impact of those conditions
on pregnancy;
• Healthy Lifestyle modification conducive to favorable pregnancy outcomes;
• Importance of appropriate preconception testing;
• Conditions associated with high-risk pregnancy, such as age, hypertension, diabetes, toxemia,
genetic disorders and previous fetal/newborn anomalies;
• Genetic assessment and genetic risks;

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• Environmental and occupational conditions and hazards, such as exposure to chemicals in work
settings, second-hand smoking, insecticides and extensive labor efforts; and
• Possible barriers to family planning provision and early prenatal care enrollment.

2.3.3 Screening activities

The following screening tests should be conducted during the first preconception visit (upon
registration):

a) Vital Signs
• Measuring weight to the nearest 200 grams and BMI; and
• Measuring blood pressure to the nearest 2mmHg.

b)Laboratory tests
Following assessments by the medical officer and the following laboratory tests should be
conducted (additional tests can be requested as required and upon the discretion of the
relevant physician):
o ABO Blood grouping:
The blood group and Rh factor of the woman should be identified if they are not already
known. If the Rh factor of the woman is negative, then the blood group and Rh factor of the
husband should also be tested. (If the husband is RH positive, the pregnant women needs
prophylactic Anti D at 32 weeks of gestation. And in case of any vaginal bleeding during
pregnancy, to be referred to hospital for anti D).
o Complete Blood Count (CBC) testing
CBC should be requested for all women upon registration.
• In setting where complete blood count testing is not available, hemoglobin testing is
recommended.
• In setting where the Hematology Cell Counter not integrated into eHealth system, the
following tests should be entered into e-health system manually:
Hb, RBCs, WBCs, Platelets count, MCV, RDW
• In case where iron deficiency anemia is suspected, further testing is necessary to rule out
thalassemia and sickle cell disease according to the relevant technical instructions. (HD/
FH/01/2000 revision 02/2001 and HD/PP/03/05).
o Urine analysis:
Should be conducted using urine test-strips (Combur 9). If an abnormal finding is detected a
complete urine analysis or other tests should be performed.
o Random plasma glucose:
Should be tested to identify undetected diabetes mellitus.
• If random plasma glucose (RBG) is ≥100mg/dl (5.6 mmol/L) the woman should be given
another appointment for fasting plasma glucose testing.
• Oral Glucose Tolerance Test (OGTT) should be performed if FPG ≥ 100mg/dl (5.6 mmol/L).
o HbA1c testing:
In order to minimize the risk of the developing baby on congenital malformations, women
with DM enrolled in the preconception care program and planning for pregnancy should
achieve a controlled blood glucose level.
• For women with diabetes who are planning to become pregnant, HbA1c test should be
performed during the first preconception care visit, and considered as baseline similar to
other NCD patients. The test can be repeated after 3 months if needed
• Women with diabetes should aim to achieve an HbA1c result of 6.1% or lower while if HbA1c
is above 10% of the acceptable results 6.1% (6.7 all above), it is strongly recommended to
avoid getting pregnant until good diabetes control is achieved and sustained; and
• Monitoring of glycaemia control should be made by measuring FPG monthly.

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c) Breast examination
A midwife/staff nurse should conduct a clinical breast examination (CBE) and train clients on
breast self-examination (BSE).

d) Genetic screening and counselling

This should be undertaken if there is history of pregnancy outcomes with autosomal trisomy
or other congenital anomalies. Identified cases with relevant congenital anomalies may
need to be referred to a specialized center for further investigations and specialized genetic
counselling.

e) Oral health screening

Oral care is an integral part of primary health care and should be adequately integrated into
maternal and child health care. Although most oral diseases are not life-threatening, they
nevertheless constitute an important public health problem. Their high prevalence, public
demand for treatment, and impact on the individual and society in terms of pain, discomfort,
functional limitation and handicap, have negative impacts on the quality of life. In addition,
the social and financial impacts of oral diseases on the individual and community can be
significant.

Newly registered women should be referred to the dental clinic for oral health screening and
counseling on oral hygiene, which should include:
• Dental screening by the dental nurse or dental surgeon;
• Oral health education and prevention during pre-conception, antenatal, postnatal care and
family planning and a part of the regular health education activities such as breastfeeding
and nutrition.
• Fluoride mouth-rinsing and the regular tooth brushing using fluoride toothpaste (twice-
daily) to improve anti-caries efficacy, in addition to having a positive impact on the condition
of periodontal tissues;
• Education and counselling of mothers on their children’s oral health needs;
• Advice on cariogenic food and unhealthy eating habits;
• The appropriate and rational use of antibiotics and analgesics for oral infections by dental
surgeons, in particular during pregnancy and lactation for possible teratogenicity and side
effects;
• Proper disinfection and sterilization procedures during screening to ensure the safety of
both patient and dental surgeon; and
• Dental treatment of the identified problem during the same session or at an agreed
appointment (the preconception period is ideal for dental interventions).

f) Screening for domestic violence / GBV

Women attending preconception care should be screened and counselled on domestic
violence / GBV. Women who are victims of abuse should be given the necessary support and
help.

2.3.4 Periodic risk assessments

The concept of risk assessment in preconception care focuses on identifying risk factors on
women’s health and pregnancy outcome and providing preventive and corrective measures to
improve outcomes. During the first visit, the medical officer should perform a comprehensive
examination and undertake a risk assessment and complete a management plan for the
patient. According to the presence or absence of risk factors, women are classified into the
following three categories:

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a) Normal Group (N)

This category includes women with no identified risk factors for pregnancy. Women in this
category should receive counselling and folic acid supplements.
b) Alert Group (A)
This category includes women with identified risk factors for pregnancy. However, the risks
are correctable or at least controllable before conception, such as diabetes, hypertension,
obesity, STDs, hypo/hyperthyroidism, medications (Isotretinoin’s, anti-epileptic drugs, oral
anticoagulant, ACE, ARBs and statins), immunization needs for rubella, tetanus and hepatitis
B, drug/alcohol/tobacco & e- cigarettes use, inadequate folic acid intake, poor dietary habits,
short inter-pregnancy intervals and psychosocial risks. Women in this category should receive
family planning methods and further consultations until optimal health for pregnancy.
c) High risk Group (H)
This category includes women with identified risk factors that could ultimately prove
life-threatening. Such risk factors may include cancer, renal failure, status asthmaticus,
uncontrolled severe hypertension, advanced cardiovascular diseases and hepatic conditions.
Women in this category should be advised to avoid pregnancy and should be provided with a
reliable family planning method in consultation with the gynecologist and obstetrician.

2.3.5 Intervention and follow-up assessment

The first questions asked to each woman of reproductive age attending UNRWA health facilities
should relate to her future fertility intentions and the current family planning method she is using.

It is expected that each woman should make at least two preconception visits: the first one
for assessment, counselling and treatment, and the second visit to discuss future plans for
pregnancy. Additional preconception visits can be arranged if deemed appropriate by the
attending physician. During each preconception visit, the Family Health Team should undertake
the following procedures:
• To determine if the woman suffers from any undiagnosed or uncontrolled medical problems
and provide treatment where necessary, and recommend the most appropriate time to attempt
pregnancy;
• To make sure that the woman is fully aware of any associations between the medical condition(s)
and medications(s) she is taking, and their impact on pregnancy outcomes;
• To determine the woman’s fertility intentions, discuss her current contraceptive method and
explain the risk of unplanned pregnancy;
• To ask the woman about lifestyle behaviors, social support and concerns that affect health,
such as smoking, alcohol, drugs, psychological problems, domestic violence, nutrition, health
conditions of the family, medications, and potential risks at home and at the workplace;
• To review the immunization statuses (tetanus and rubella) and update them if necessary;
• To assess the occurrence of STI /RTI using Sexually Transmitted Infection-Syndromic approach;
• To arrange for laboratory tests, including: urinalysis, CBC, ABO blood grouping, Rh factor,
random/fasting plasma glucose and other health conditions; and
• To perform comprehensive physical examinations and risk assessments.

2.3.6 Folic acid supplementation

• Women should take the recommended dose of 0.4 mg daily of folic acid at least three months
before and throughout pregnancy. This reduces the risk of having a child with neural tube
defects (NTDs).
• If the woman has previously had a child/children with NTDs, if she herself has NTDs, or if the
father of the child has NTDs, then it is recommended that she should take an extra dose of 4 mg
per day starting three months before and during and throughout pregnancy.
• Women on antiepileptic drugs should take a double supplementation dose (0.8 mg) of folic acid.
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Antenatal care

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3. Antenatal care
Antenatal care is defined as “A comprehensive antepartum care program that involves a coordinated approach
to medical care and psychosocial support that optimally begins before conception and extends throughout
the antepartum period.”1

Antenatal care significantly lowers fetal deaths, stillbirths and neonatal deaths associated with several high-risk
conditions, including placenta previa, fetal growth restriction, and post-term pregnancy. On the other hand,
failure to obtain antenatal care is associated with increased risk of preterm births and maternal morbidity and
mortality.

3.1 Objectives
Antenatal care aims to achieve the following:
• The maintenance and improvement of women’s health during pregnancy;
• Early identification of any deviation from normal and prompt treatment;
• Preparation for safe labor;
• Promotion of breastfeeding;
• Identification of depression and/or Domestic Violence;
• Optimize pregnancy outcome; and
• Provide counseling and health education on a wide range of relevant topics, including family planning.

Each time of antenatal care visits, a pregnant woman should have check-ups and proper health care
services. Her midwife and/or doctor should provide her clear explanations, information and opportunities
to discuss and ask questions about issues, concerns and a variety of related health topics. Whenever
possible, husbands should involve in providing support to pregnant women during this critical period.

3.2 History
Detailed information concerning past medical and obstetrical history is crucial because a lot of the
complications which experienced during previous pregnancies tend to recur in subsequent ones. In this
regard, the preconception record and the previous antenatal record should be revised with the relevant
findings recorded in the appropriate section of the new antenatal record.

3.3 Screening for domestic violence / GBV

Women attending antenatal care should be screened (asking the survivor about experiences of violence/
abuse, whether or not they have signs of symptoms indicating that they are being abused) and counselled
on domestic violence/GBV. Violence during pregnancy can cause serious harm to both mothers and
fetuses. Women who are victims of abuse should be given the necessary support and help.

3.4 Promotion of healthy lifestyle during pregnancy

During antenatal care provision, family health team members are requested to counsel and advise
pregnant women on the following topics:

3.4.1 Work during pregnancy

Pregnant women should be informed that for the majority of women it is safe to be active and to
continue work during pregnancy.

3.4.2 Diet and nutrition during pregnancy

In general, pregnant women should be advised to eat whatever they want. However, they should
try to maintain a balanced and varied diet that contains the following:

1. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists
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• Carbohydrates, such as whole bread, pasta, rice and potatoes;
• Products that are rich in protein and preferably in combination of meat, fish, eggs, beans and
lentils;
• Fibers, found in whole-grain bread, fruits and vegetables;
• An adequate portion of dairy products (milk, yoghurt and cheese), preferably low-fat products;
• Minimal amounts of products that contain sugar, such as soft drinks, juice and sweets;
• To avoid adding extra salt and eating salt products such as canned and preserved food.

3.4.3 Supplements and other health behaviors

o Folic acid
Pregnant women should take the recommended dose of 0.4 mg daily of folic acid from three
months before conception and throughout pregnancy. This reduces the risk of having a child
with NTDs and maternal anemia with related adverse outcomes. If the woman has previously
had a child with NTDs, if she herself has NTDs, or if the father of the child has NTDs, then it is
recommended to take extra folate in the dose 4 mg per day. Women on antiepileptic drugs
should take a double supplementation dose of folic acid.

o Iron
Very few women have sufficient iron stores to supply iron requirement during pregnancy, and
their diet seldom contains enough iron to meet this demand. Therefore, iron supplementation
should be given to pregnant women to provide sufficient iron to meet the requirements of
pregnancy, lactation, and to protect pre-existing iron stores to prevent maternal anemia,
puerperal sepsis, low birth weight and preterm birth. If daily supplementation is not available
because of side-effects or other reasons, intermittent scheme of weekly supplementation is
recommended. It is important to note that:

Non anaemic pregnant women should routinely receive iron supplementation one tablet
with 60 mg of elemental iron daily (if daily iron supplemantation is not acceptebale due the
side effects one tablet with 120 mg of elemntal ironshould be given once per week). Pregnant
women who are anemic should receive (one tablet with 120 mg of elemental iron per day) untill
her Hb concentration rises to normal (Hb 11.0 g/dl or higher). throughout pregnancy and for
three months postpartum (updated WHO nutritional anemias guideline in 2017).

• Supplementation should start as early as possible after detecting pregnancy.

• Women with iron deficiency anemia respond well to oral iron supplementation.
• Ingestion of iron at bedtime or on an empty stomach avoids interaction, facilitates absorption
and appears to minimize the possibility of an adverse gastrointestinal reaction.
• Multiple micronutrient supplementation is not recommended for pregnant women.
• Where the prevalence of anemia among pregnant women is more than 40%, daily
supplementation with 60 mg of elemental iron is recommended.

o Calcium:
Calcium supplementation is recommended for pregnant women with high risk of developing
hypertension and pre-eclampsia from 20 weeks of gestation to end of pregnancy. Suggested
supplementation dose is 1.5-2.0 g elemental calcium per day2.
• Pregnant women are regarded as being at high risks of developing hypertension and pre-
eclampsia if they have one or more of the following risk factors: obesity, previous pre-
eclampsia, diabetes, chronic hypertension, renal disease, autoimmune disease, nulliparity,
advanced maternal age, adolescent pregnancy and conditions leading to hyper placentation
and large placentas.
• The overall intake of calcium per day should not exceed the upper limit of calcium intake of 3 g/day.
• It is recommended to have 3 daily servings of milk and plain yogurt, for women who are
pregnant.
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• Interaction between iron supplements and calcium supplements may occur, therefore, the
two micronutrients should preferably be administered several hours apart. With intermittent
iron supplementation this should not be difficult to adhere on.
• For supplementation, calcium is present in the form of carbonate, citrate, lactate or gluconate,
and in general all these forms have good bioavailability. Calcium carbonate is the most
common with the highest content of elemental calcium (40%).

o Prevention of food-acquired infections

Pregnant women should be given information concerning primary preventive measures in order
to prevent infectious disease, such as:
• Washing hands after toilet use and before handling food and eating;
• Washing all fruit and vegetables thoroughly;
• Avoiding highly Listeria containing foods, including smoke salmon and natural cheeses
without heat sterilization;
• Cooking thoroughly all raw meat and fast food; and
• Boiling milk products if needed.

o Medicines during pregnancy

Few medicines have been deemed safe for use during pregnancy. Therefore, medicines should
only be prescribed when the advantages outweigh the risks for the foetus. Pregnant women
should avoid using over-the-counter medicines as much as possible. They should also be advised
not to use herbal medicines as there is a lack of clear evidence regarding the effects and safety of
most varieties of herbal medicines available for pregnant women.

o Physical activity
Moderate physical activity and fitness training is recommended during pregnancy. It improves
the pumping action of the heart and the ability of the muscles to take up and use oxygen. Physical
training to strengthen pelvic floor muscles is particularly important during pregnancy and after
the birth. Women who have previously not been physically active should try to be moderately
active during pregnancy and gradually increase the level of activity (up to 30 minutes per day).
Women who have undertaken regular physically activity before their pregnancy should continue
to do so at an appropriate level.

o Sexual activity
Pregnant women should be informed that sexual intercourse is normal during pregnancy and is
not known to carry any risks. It is also normal for sexual desire to vary during pregnancy.

o Tobacco
Pregnant women who smoke either cigarettes or shisha should be provided with information
concerning the increased risks to the foetus if they continue to smoke (i.e. low birth weight and
premature birth). To stop smoking should be stressed but beneficial at all stages of pregnancy.
Counselling on how to stop smoking has been shown to increase the number of pregnant
women who manage to give up the habit and should, therefore, form an integral part of
antenatal care. Such counselling should be offered on an individual basis. Pregnant women who
do not manage to stop smoking should be given advice about reducing the use of tobacco as
much as possible. They should also be counselled on the avoidance of passive smoking at home
and at the workplace. Pregnancy can be a particularly difficult time to stop smoking so rather
than stigmatizing these women, assistance, guidance and support should be provided.

o Breastfeeding
Women should be counselled on the importance of exclusive breastfeeding during the first six
months of pregnancy and also concerning complimentary food thereafter. Health staff should
discuss all the issues and possible difficulties facing the mother regarding exclusive breast
feeding.
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• During the last trimester health staff should encourage women to start breastfeeding as early
as possible after delivery and to continue breastfeeding day and night at least eight times in
24 hours or when the baby shows signs of hunger.
• Women should be advised not to give other fluids or food to the newborn.
• Staff should teach women the correct positioning and attachment for breastfeeding and signs
of good and effective suckling.

o Family planning counselling

Counselling on family planning should be conducted during the third trimester, in particular
during the last antenatal visit. The woman should be encouraged to take the decision with
her husband on the type of family planning they intended to use, to be able to prescribe it /
implementing it during postnatal or child vaccination visit.

3.5 Common complaints during pregnancy

o Nausea and vomiting in early pregnancy
Nausea (morning sickness) and vomiting are the most common symptoms experienced during the
first 3 months of pregnancy and often disappear thereafter. Pregnant women should be reassured that
nausea and vomiting usually resolve spontaneously between 16-20 weeks of pregnancy, and that they
are not usually associated with poor pregnancy outcomes. Many women find that small and frequent
meals reduce these symptoms, while others find that rest helps. In severe cases, such as hyperemesis
gravidarum, it can cause fluid and electrolyte imbalance and nutritional problems because vomiting
begins early in pregnancy. Women with this condition should be referred to a specialist for assessment,
treatment and follow-up.

o Heartburn
Pregnant women with symptoms of heartburn should be given information about lifestyle, habits and
nutrition. Antacids are safe and effectively relief the symptoms.

o Constipation
Women who suffer from constipation during pregnancy should be offered nutritional counselling,
with particular emphasis on increasing the amount of fiber-rich foods in the diet, such as whole bread,
vegetables and fruits. Some women find that physical activity and increased fluid intake help to reduce
the condition. If this does relieve the symptoms, bulk-forming preparations or fiber supplements are
recommended. Laxatives should be avoided.

o Hemorrhoids
Pregnant women who suffer from hemorrhoids should be given information about proper diet,
physical activity and fluid intake. If these measures do not relieve the symptoms, ointments that are
normally used for hemorrhoids can be recommended. In severe cases, referral for surgical treatment
may be considered.

o Varicose veins and oedema

Pregnant women who have varicose veins and oedema of the legs should be informed that they are
normal symptoms frequently associated with pregnancy and are not considered dangerous. Support
stockings may relieve the symptoms but will not prevent varicose veins. Some women find that the
following measures help to relieve the condition:
• Avoiding tight cloths and tight shoes;
• Sitting with the legs raised;
• Lying with a pillow under the buttocks (varicose veins of the vulva); and
• Lying down and resting at regular intervals.

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o Vaginal discharge
Women should be informed that increased vaginal discharge is a normal physiological change during
pregnancy. If it is accompanied by itching, soreness, unpleasant odour and pain during urination, the
woman may have an infection. In such cases, referral to the doctor is necessary. Women who have
candida infection (thrush) during pregnancy can be administered local treatment for a week (ointment
and vaginal pessaries). The safety of oral/systemic treatment of candida infection during pregnancy is
uncertain and is not recommended.

o Urine frequency
During pregnancy, the frequency of micturition usually increases and becomes more frequent as the
pregnancy progresses.

o Tiredness
Pregnant women should be informed that it is normal to feel tired during the first trimester of
pregnancy, and tiredness usually decreases during the second trimester. However, other possible
causes for fatigue, such as iron deficiency, should be excluded.

o Stretch marks (striae gravidarum)

Pregnant women should be informed that although there is little research on stretch marks, they
are known to be caused by the tearing of the dermis. Women should also be informed that there
is no evidence that anti-stretch mark creams are effective. Although stretch marks do not disappear
completely, they can naturally diminish over time.

o Leg cramps and backache

Pregnant women should be provided with information that leg cramps and backache usually are
associated with pregnancy and usually decrease over time. Some women find that walking, massage,
stretching and movement can help relieve cramps.

3.6 Medical Examination

Prenatal care should be initiated as early as possible when there is a reasonable likelihood of pregnancy.
The major aims of prenatal care are:
• To define the health status of the mother and fetus;
• To estimate the gestational age of the fetus; and
• To initiate a plan for continuing care.

During the first antenatal visit, midwives are responsible for weight measurement and the calculation
of gestational age by weeks. In addition, a complete medical and obstetric examination should be
performed by the Medical Officer as follows:

3.6.1 General medical examination

A thorough, general medical examination should be completed at the first antenatal care visit:
• Inspection of the general appearance to assess if the woman looks ill, anemic, tired and
malnourished;
• Body weight measurement to the nearest 200 grams as a baseline for future weight gain;
• Blood pressure measurement to the nearest 2mmHg;
• Examination of the eyes, ears, nose, mouth and throat for signs of abnormalities, infection and
anemia (The neck should be palpated for signs of thyroid enlargement);
• Auscultation of the heart and lungs;
• Examination of the lower extremities for oedema and/or varicose veins; and
• Selective ultrasonography by the Gynecologist/obstetrician only.

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3.6.2 Obstetric examination

o Gestational age in weeks:
It should be calculated according to the last menstrual period and compared to the uterine
fundal height.

o Breast:
Any changes in breasts that accompany pregnancy should be noted. Any abnormality that
might interfere with breastfeeding should also be detected. The nurse/midwife should take this
opportunity to train women on BSE techniques and inform her that changes during pregnancy
and lactation are mostly normal.

o Abdomen:
Shape and height of the uterus, fetal presentation and fetal movement should be assessed. The
size of the uterus should be determined by using a cloth measurement tape from symphysis
pubis to the top of the fundus of uterus. Assessment of fetal presentation is recommended
from week 36. The findings at this stage are relevant for further follow-up and planning of the
birth. If fetal mal-presentation is suspected, the woman should be referred for an ultrasound
examination from week 36 for diagnosis and follow-up. Pregnant women should be asked
about fetal movements and also be informed to visit the health center or the hospital if she
feels loss or decrease of fetal movements.

o Auscultation of the fetal heart:

The fetal heart can be checked using a fetal stethoscope or ultrasound Doppler apparatus.

3.7 Oral health screening

During the first antenatal care visit, all pregnant women should be referred to the dental clinic for
screening, advice and possible treatment. Women should be advised about measures for ensuring good
oral health during pregnancy, such as:
• Maintaining an adequate and varied diet and avoiding eating between meals;
• Using fluoride toothpaste twice a day and using additional fluoride preparations as needed during
daily tooth brushing;
• Rinsing the mouth with either water or fluoride mouth rinse if frequent vomiting or acid regurgitation;
• Educating and counselling mothers on their children’s oral health regularly;
• Providing women dental treatment either in the same session or at an agreed appointment;
• Emphasizing and monitoring appropriate and rational use of antibiotics and analgesics during
pregnancy for oral infections by the dental surgeons;
• Consulting by Medical Officer (MO) for possible teratogenicity and side effects of antibiotics and
analgesics; and
• Maintaining proper infection control measures (including cleaning, disinfection and sterilization
procedures) to ensure the safety of both patient and dental surgeon.

3.8 Laboratory investigations

An open-door policy should be adopted in performing laboratory tests for pregnant women and children.
Samples should be accepted at any time during duty hours up to 12:30 pm. Priority should be given to
pregnant women in completing and processing tests, which should take a maximum of 30-60 minutes,
according to the type of test.

o Pregnancy test
The standard pregnancy tests should be carried out at the laboratory for women of reproductive age
after two weeks of missing their period in order to provide antenatal care as early as possible after
confirmation of pregnancy.

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o Blood group
The blood group and Rh factor of the pregnant woman should be tested if they are not already known.
The blood group and Rh factor of the husband / father of the baby should also be established, especially
if the Rh factor of the mother is negative.

o Complete Blood Count (CBC) testing

• CBC testing should be carried out with respect to every pregnant woman during the first antenatal
care visit and at 24 weeks of gestation.
• In setting where complete blood count testing is not available, hemoglobin testing is recommended.
• In setting where the Hematology Cell Counter not integrated into eHealth system, the following
tests should be entered into e-health system manually:
Hb, RBCs, WBCs, Platelets count, MCV, RDW

o Fasting plasma glucose (FPG) test

Fasting plasma glucose (FPG) test should be performed with following criteria:
a) For all pregnant women with increased risk of gestational diabetes, such as (glycosuria, age >25
years, family history of diabetes; overweight (BMI > 27 kg/m2 at the beginning of the pregnancy);
and/or previously detected gestational diabetes).
b) If the woman is fasting, then tests should be performed in the same day and the results should
be processed without delay. However, if she is not fasting or if in doubt, she should be given an
appointment within one week. In all cases, medical officers are responsible for checking the results
of the FPG for further management/referral, if needed.
c) For all pregnant women, FPG should be performed/repeated between 24-28 weeks of gestation
regardless of the first result, age and health status.
d) The Oral Glucose Tolerance Test (OGTT) should be performed if the FPG is equal or more than 85
mg/dl (4.7 mmol/L).
e) Further FPG or other laboratory tests to diagnose diabetes mellitus can be performed/repeated for
pregnant women according to FHT medical officer management plan.

FPG test early in pregnancy (on the first visit if possible) should help to identify women who may
have undetected pre-existing diabetes, whereas the repeated test should help detect gestational
diabetes.

o HbA1c test during Pregnancy

Keeping blood sugar levels under control are hugely important for women who either has diabetes
before pregnancy or who develop diabetes during their pregnancy (gestational). Tight blood glucose
control helps increase the chances of a successful outcome of pregnancy by reducing the risk of
complications for the baby and the mother.
a) For all pregnant women with preexisting diabetes, HbA1c should be measured during the first
antenatal care visit to determine the level of risk for the pregnancy.
b) Pregnant women without diabetes will be screened for possible gestational diabetes as per the
standing technical Instructions.
c) For women who are newly diagnosed with diabetes (based on FPG as in NCD technical instructions),
HbA1c test should be performed and considered as baseline to assess blood glucose control.
Monitoring of glycemic control should be made by measuring FPG.
d) During the first trimester of pregnancy, the HbA1c target for women with diabetes is the same as for
planning a pregnancy and it is 6.1% or lower. During the second and third trimesters of pregnancy,
from week 13 onwards, HbA1c should not be used for assessing blood glucose control.
e) HbA1c is not used for diagnosing gestational diabetes.

o Urine analysis
• The urine should be tested for urinary tract infections (Nitrite) by urine test-strips (Combur 9) at
the first antenatal care visit and at 24 weeks gestation, and for glucose and albumin during every
antenatal visit.
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• If there is suspicion of urinary tract infections or in case of the presence of albuminuria, a complete
routine urine analysis should be performed. FPG test for those women is necessary to assess the
present of glucosuria regardless of whether they were previously diagnosed as a case of diabetes/
gestational diabetes or not.

3.9 Ultrasound imaging

Ultrasound imaging should be conducted selectively under the direction of the Gynecologist/Obstetrician
and not as a routine procedure or to determine the sex of the fetus. Ultrasound should be performed for
high-risk pregnancies and should not be used routinely to diagnose pregnancy.
• During the first and 10 weeks of pregnancy, its use should be mainly limited to establish the accurate
gestational age, multiple pregnancies, and to rule out abnormal pregnancy such as ectopic pregnancy,
molar pregnancy and blighted ovum.

• During 11-30 weeks, it may be used to estimate fetal maturity and assess any discrepancies between
the gestational age and the size/maturity of the foetus, intrauterine growth restriction (IUGR). In
addition, during this period, ultrasound should be performed to detect causes of questionable fundal
height and fetal death, if suspected clinically. Also, it is used to detect fetal malformation (if a previous
malformation is reported), polyhydramnios and oligohydramnios.

• For 31 weeks and after, ultrasound will help indicate if there is antepartum hemorrhage, mal-presentation,
hypertension, diabetes, severe renal disease and estimation of fetal growth. Gynecologist/Obstetrician
should record the assessment of fetal growth on the antenatal record as part of the ultrasound
examination. All scans should be carefully documented and archived, particularly if abnormalities are
detected, or when specific structures are seen that appear suspicious.

3.10 Risk assessment

Although pregnancy is a natural phenomenon, it must also be recognized that it entails certain risk
factors. The concept of risk in prenatal care focuses on providing preventive care to the majority of
pregnant women whose condition is normal, while giving special attention and care to those identified
risks. As such, the objective of risk assessment is to screen a predominantly healthy population and
detect factors or early signs of diseases that expose women to risk and provide effective interventions
to reduce the possibility of adverse pregnancy outcomes.

WHO has estimated that around 25 per cent of pregnant women have at least a condition or risk factor that
requires special care (in addition to normal care). Certain risk factors are specific to a particular outcome,
but more often than not, one risk factor including grand multiparity increases the frequency of additional
risk factors and the probability of various undesirable outcomes. Therefore, risk factors become links in a
causal chain of associations which can culminate in an undesirable pregnancy outcome.

Risk factors are categorized into the following two major groups:
a) Factors related to past history
These factors should be included in group A of the antenatal record. The frequency of these conditions
should also be recorded, for example, if there has been a history of cesarean sections, the number
should be recorded.

b) Factors related to/or might develop during the present pregnancy

These factors should be included in group B of the antenatal record. Since these factors may develop
at any time during the course of pregnancy, they should be screened at each and every antenatal care
visit. If at any time the pregnant woman develops any risk factors, this should be recorded by type
and date and should be followed-up during subsequent visits. The medical officer should examine all
pregnant women comprehensively on the first visit, and he/she should carry out the risk assessment
and record a complete plan of management.

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All pregnant women should be classified into one of the following three categories according to the
presence or absence of risk factors:

1. Normal pregnancy (N)

This category includes all pregnant women with no identified risk factors. All women in this
category will be examined by the medical officer in the first visit and by a staff nurse/midwife in
subsequent visits, unless risk factors have developed during the course of pregnancy. However, as
a matter of principle, all nulliparous women should receive special attention, counselling and care
during their first pregnancy as well as during delivery.

2. Alert pregnancy (A)

This category includes pregnant women with one risk factor either in group A or group B. Alert
pregnant women should be referred upon identification to the Gynecologist/Obstetrician who will
decide the course of management either to be followed-up by him/her or by the medical officer,
who will be responsible for the full management of all alert pregnant women. Except the cases that
require follow-up by the Gynecologist/Obstetrician.

3. High-risk pregnancy (H)

This category includes pregnant women with two risk factors or more regardless of whether they
fall in group A or group B, or both. All high-risk pregnant women should be managed completely
by the Gynecologist/Obstetrician in close coordination with the FHT medical officer, as the woman
may be admitted as an emergency case when the Gynecologist/Obstetrician is not present at the
health center.

Pregnant women with diabetes or hypertension with no other accompanying factors should be
categorized as alert risk. Nonetheless, they should be managed by the Gynecologist/Obstetrician
in close coordination with her FHT medical officer.

Although these criteria were established to help staff in the identification and classification of at-
risk pregnancies, a pregnant woman may still be classified as high-risk (without meeting the above
criteria) based on the clinical judgement of the medical officer or the Gynecologist/Obstetrician.
However, it should be recognized that in order to ensure effective maternal health care, risk scoring
should be a dynamic process. It is essential that the risk assessment is reviewed during subsequent
visits to detect any favorable or adverse developments during the course of pregnancy. All high-
risk and alert pregnancies should be referred to the hospital for delivery and must be advised to
forward the MCH handbook or downloaded the e-MCH Application together with the hospital
referral to the birth attendant before labor.

All pregnant women (with normal, alert and high risk) should be examined by her FHT medical
officer and/or Gynecologist/Obstetrician at 32 weeks of gestation to assess the course of pregnancy
and to complete the relevant section of the MCH handbook (where applicable) in addition to MHR
at e-health and to provide with the hospital referral for delivery. Women should be made aware
of the importance of the hospital feedback in the MCH handbook or the MCH Application on
the delivery and pregnancy outcomes with special emphasize on the accurate recording of birth
weight and other measurements.

3.11 Regular monitoring

To improve quality of antenatal care and reduce maternal and perinatal mortality and pregnancy
complications, WHO has issued in 2016 a new guideline on antenatal care. The guideline uses the term
‘contact’ as it implies an active connection between a pregnant woman and a health careprovider that is
not implicit with the word ‘visit’. The new guideline increases the number of contacts a pregnant woman
has with health providers throughout her pregnancy from four to eight.

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Eight or more contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when
compared to 4 visits. This is because of the increased opportunities to detect and manage potential
complications.2

Pregnant women should be encouraged to seek antenatal care as early as possible. All pregnant women
(with normal, alert, and high risk) must be counselled, and they should be encouraged to attend the
antenatal clinic 8 times (2016WHO ANC model) as follows2:

a) First trimester
- 1st ANC contact: before 12 weeks of gestation

b) Second trimester
- 2nd contact: at 20 weeks of gestation
- 3rd contact: at 26 weeks of gestation

c) Third trimester
- 4th contact: at 30 weeks of gestation
- 5th contact: at 34 weeks of gestation
- 6th contact: at 36 weeks of gestation
- 7th contact: at 38 weeks of gestation
- 8th contact: at 40 weeks of gestation

• Thereafter, women are advised to return to ANC at 41 weeks of gestation or sooner if they experience
danger signs.
• This schedule can be adjusted upon the recommendations of the attending physician, who will
define the management plan and necessary follow-up.
• If the woman is experiencing any problems, she must be encouraged to attend the clinic more
frequently or according to the recommendation of the medical officer or Gynecologist/Obstetrician.

Gestational age, weight, urinalysis, blood pressure, fundal height, fetal lie and presentation, fetal
heart, signs of edema, history of bleeding and risk assessment should be investigated/carried out
during every antenatal visit. If there is any deviation or suspicion of deviation from the normal course
of pregnancy, the woman must be referred to the medical officer or the Gynecologist/Obstetrician
for a second opinion. If there are changes in the risk score since the initial antenatal visit, the changes
should be recorded in the corresponding column and the risk tag changed accordingly.

o Post-term birth
Pregnancy is defined as post-term 14 days after the expected date of delivery which determined
by the ultrasound. Women who are identified as post-term should be referred to the Gynecologist/
Obstetrician or to the hospital.

o Pre-eclampsia
Following risk factors for developing pre-eclampsia should be assessed during each antenatal
visit:
• Age at younger than 15 years and older than 39 years;
• Nullipara;
• Long intervals between pregnancies;
• Previous history of pre-eclampsia;
• Multiple births;
• High BMI (27 or more) at the first antenatal check-up and change of weight thereafter;
• Diabetes mellitus and gestational diabetes;
• Pre-existing hypertension;

2. WHO recommendations on ANC 2016

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• Kidney diseases; and
• Symptoms of severe pre-eclampsia (following).
- Headache;
- Pain under the ribs;
- Sudden swelling of the face, hands or feet;
- Vomiting; and
- Sight disturbances.

Pregnant women should be informed about the above symptoms of severe pre-eclampsia
during the first antenatal care visit. When the woman is diagnosed with pre-eclampsia, he
should be referred to the Gynecologist/Obstetrician or to the hospital.

o Home visits
Wherever feasible, high-risk pregnant women should be visited at home if they have broken an
appointment(s) or before the expected date of delivery to ensure they have the necessary hospital
referral and that all the necessary information has been recorded on the MCH booklet and
e-Health.

3.12 Counselling on and preparation for labour, postnatal care and breastfeeding
Pregnant women should be offered individual or group counselling on labour, importance of postnatal
care and exclusive breastfeeding. Preparation for labour includes the provision of information on
warning signs of labour and hospital delivery for high-risk and alert pregnancies. The importance of
postnatal care and newborn examination and vaccination are critical to encourage the pregnant to
attend the clinic as soon as possible. Advice on breastfeeding should include a discussion of possible
barriers to exclusive breastfeeding, treatment for retracted nipple, practical and theoretical information
and teaching about breast milk, the best positioning of the child and attachment signs, and the value of
breastfeeding for pregnant women and their infants.

3.13 Referral
o The medical officer must examine and refer to the Gynecologist/Obstetrician all high-risk pregnancies
immediately. All high-risk pregnancies must be examined and managed by the Gynecologist/
Obstetrician who will define the management plan and the necessary follow-up required by him/
her and/or the hospital. The management plan should be discussed with the relevant medical officer
in order to ensure continuity of care in case the woman is admitted as an emergency case and the
Gynecologist/Obstetrician is not present at the health center.

o All alert pregnant women should be examined and receive follow-up by the medical officer and by a
Gynecologist/Obstetrician as early as possible after conception and until 36 weeks of gestation. The
stage at which the alert pregnancy would be referred and examined by the Gynecologist/Obstetrician
will be determined by the medical officer.

o The medical officer may refer any pregnant women to the Gynecologist/Obstetrician for a second
opinion regardless of their risk status. However, such referral should be supported by a brief medical
report describing the health condition of the woman and the reasons for seeking specialist advice.

o The nurse/midwife should refer any pregnant woman during the subsequent visits to the medical
officer if the pregnancy seems to deviate from the normal pattern, or the nurse has any concerns
regarding the pregnancy.

o In all the above cases, the Gynecologist/Obstetrician should provide feedback to the medical officer
with clear instructions on the management plan and necessary follow-up.

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3.14 MCH handbook/MCH Application

The MCH Handbook should be issued to all pregnant women upon registration, and they also are
encouraged to use MCH Application (e-MCH) on their smartphone for easy gathering of the registered
information within MHR at e-health. The handbook replaces all other currently used home-based
records and should be brought by the women on each visit to the health center. The relevant section
of the MCH handbook and MHR on e-Health (after 32 weeks of gestation) should be completed during
each antenatal visit.

The medical officer should carry out a full clinical and physical assessment of the health condition of
each pregnant woman at 32 weeks of gestation, including blood pressure measurement. The main
findings of the assessment should be fully recorded. The women should also be advised to present the
MCH handbook or MCH application to the other health care providers when feasible and to the birth
attendant/hospital before/during delivery. The women should themselves request that health service
providers complete the record in the handbook or e-MCH, particularly after delivery, in order to record
the accurate birth weight of the newborn, even in the case of stillbirth or premature death.

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Postnatal care

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4. Postnatal care
After the delivery of a pregnant woman who was receiving antenatal care at an UNRWA clinic, the
following postnatal standard elements of care should be provided for her and for the newborn infant,
and a postnatal record within e-Health should be completed. All mothers and babies need at least one
postnatal care visit and checkups in the first 6 weeks. The section on postnatal care in the MCH handbook
also should be completed.

4.1 Postnatal history

• A summary of the last pregnancy, including number of antenatal visits, date of the last visit, expected
date of delivery and actual date of delivery;
• A summary of the last delivery on the postnatal record, including the place of delivery, birth attendant
and type of delivery; and
• A summary of the outcomes of the last delivery, which should detail the condition of the newborn (live
birth, multiple live birth, stillbirth or neonatal death), gestational age, birth weight and the sex of the baby.

If the woman was not registered for antenatal care in one of UNRWA’s clinics and has any deviation from
the normal course during the postpartum period without completing a maternal health record and
postnatal record, she should receive required medical care. Any significant findings should be recorded
in the family file and e-Health.

All pregnant women who were classified as high-risk should receive special care and attention during
the postpartum period. If possible, these women should be home-visited and receive the appropriate
care/advice as they may be unable to report to UNRWA clinics soon after delivery, when such care is
most needed.

4.2 Medical examination for the mother and newborn

o The mother
The number of postpartum days should be recorded, and the mother should be examined on the
following elements:
• Blood pressure: to assess postpartum hypertension and should be repeated 42 days after delivery
for women who suffered from hypertension during pregnancy. If the blood pressure remains high,
managed though NCD program is necessary.
• Temperature: to monitor fever and signs of infection which may be contracted during labour
or in the post-natal period, particularly breast infections, endometritis, deep venous thrombosis,
urinary tract and chest infections, puerperal sepsis and a wound infection at the site of caesarean
section (CS) and episiotomy.
• Breast examination: to detect engorgement or any possible defects, such as cracked and retracted
nipples which may interfere with breastfeeding, and any signs of infection.

Hemoglobin concentration: to assess anemia status for women who have had any of the following risk
factors, including anemia during pregnancy, antepartum or postpartum hemorrhage, multiple births
and women who delivered by CS.

• Iron and folic acid supplementation should be continued until at least three months after delivery
to prevent anemia.
• Abdominal examination: to follow-up on the involution of the uterus and to look at the CS scar if
the delivery was by CS.
• Lochia: to check for possible signs of infection.
• Episiotomy: to examine the perineum for possible signs of infection or other complications if the
woman had an episiotomy or tear.
• Fasting plasma glucose (FPG) test: to assess the condition of blood sugar control at six weeks
postpartum for women who have had gestational diabetes and within the first two weeks for women
who gave birth to infants with birth weight ≥ 4,000 grams.
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- The result should be recorded in the space assigned to the test in the post-natal record, child health
record within e-health and in the MCH handbook. If the test is abnormal, then the women should
be managed though NCD program.
- For women with known DM before pregnancy, they can resume their previous course of treatment
soon after delivery.
• Other physical health assessment: to detect and monitor any other risk factors with taking into
consideration the examination and medical history.
• Mental health assessment: to detect postpartum depression and other mental disorders it is
recommended to conduct it at 10-14 days after birth.
• Domestic abuse /GBV: to observe for any risks, risks and signs.
• Breastfeeding: to monitor and train the methods and manage any related problems at each
postnatal contact.

• Vitamin A supplementation:
Vitamin A supplementation in pregnancy and postpartum as part of routine care is NOT recommended
for the prevention of maternal and infant morbidity and mortality.

Health care providers should take the opportunity to counsel the mother on family planning. The
response to this counselling should be recorded and an appointment for family planning services
should be made if the woman chooses to use contraceptives. Also, they need to be counselled on
common health issues after delivery, nutrition, physical activity and hygiene.

o The newborn
The child health record number should be recorded in the assigned space. The mother should be asked
about the condition of the umbilical cord, the method of infant feeding (with special emphasis on
exclusive breast feeding), the pattern of sleeping, and any other problem she is facing with respect to
infant-care.

The infant should be examined in accordance with the Technical Instructions on Provision of Child
Health Care Services with special emphasis on detection of congenital malformation, jaundice,
cyanosis or any other abnormalities.

4.3 Special considerations

The outcomes of each pregnancy should be recorded with respect to every woman who received
antenatal care. For this purpose, expected date of delivery for each registered pregnant women should
be established in each health center. Nurses/midwives should segregate the antenatal records of all
pregnant women who are expected to deliver during each month, and they should use all possible
means to contact the women and their family in order to ascertain whether the woman has delivered. If
it is found that the woman has delivered, the outcomes of the pregnancy should be recorded on e-Health
and MCH handbooks, and a first appointment date for a postpartum care should be decided.

In order to ensure that the newborn infant receives health care and monitoring as early as possible
after birth, a birth notification should be adequate for service provision without the need to wait for the
completion of the Civil/UNRWA registration formalities.

4.4 Post-abortion care

Complications from spontaneous and/or unsafe abortion are recognized as preventable causes of
maternal morbidity and mortality. In order to prevent post-abortion complications for women attending
UNRWA health centers, family health team staff are requested to provide comprehensive post-abortion
care, including the management and referral of cases of abortion with complications, in addition
to counselling and providing post-abortion family planning services. Findings as well as the plan of
management could be recorded either in the postnatal record on e-Health if the woman is registered
for antenatal care, otherwise, this can be recorded in the family file.
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Family planning
services

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5. Family planning services

Rapid population growth caused by sustained high fertility is associated with higher poverty levels, lower
levels of primary education and higher child and maternal mortality. Thus, high levels of population growth
in the least developed countries are a barrier to achieving the Sustainable Development Goals (SDGs).

Family planning services, including reproductive health counselling and provision of contraceptives should
be provided as an integral part of MCH services through preconception care, antenatal, postnatal and growth
monitoring of children 0-5 years of age.

The provision of family planning services through primary health care will allow for both achieving high coverage and
providing care for high-risk mothers and their children in order to increase effective and acceptable programmes.

5.1 Pre-requisites for service delivery

The pre-requisites for service delivery are:
• Well trained staff;
• Privacy and confidentiality; and
• Easy access of clients to supplies and to accurate information.

If the client is a new family planning acceptor, a family planning record should be completed and
included in the MHR on e-Health.

5.2 Standards of care

The followings are the specific minimum standard elements of care that should be provided for family
planning acceptors.

o History taking
In addition to the general medical and obstetric history, which already have been taken and recorded
on the MHR and e-Health, the following information should be obtained for every new family planning
acceptor:
• History of previous use of contraceptives, side effects, duration, source of supplies and reasons for
discontinuation, if applicable, as this might affect the choice of the contraceptive method;
• The preferred method of the woman’s choice should be established and provided unless there is a
contraindication for use of the method for that respective woman;
• Menstrual history (pain, amount and duration of bleeding), date of last menstrual period and any
other relevant menstrual disorders should be recorded; and
• History of breastfeeding (whether she is breastfeeding or not): If the client is breast feeding, the
frequency should be established, i.e. whether she is exclusively breastfeeding (breast milk only) or
partially breastfeeding (either bottle milk and/or weaning food).

This information should be recorded under either the findings section of the general medical
examination or under the comments/advice section under the follow-up section.

o Counselling
Appropriate counselling and education are crucial for correct and continued use, especially for
women newly enrolled in the programme. Family planning counselling is a process of discussion, and
whenever possible, her husbands should be provided with sufficient information that would enable
them to make a free and informed choice regarding their preferred contraceptive method. In addition,
clients should be informed about the effectiveness and probable risks of the selected method, if
any. The woman should be provided with her preferred method if available, as long as there are no
contraindications for using the particular method.

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• All preconception care clients should receive counselling on their reproductive health status, including
their plans for future pregnancy in order to provide them with the best family planning method.
• All clients attending antenatal care should receive counselling especially during the last trimester.
• All clients receiving postnatal care must be counselled on birth spacing. If they accept to use a modern
contraceptive, they should be given an appointment or provided with the service on the spot.
• All mothers who come with their children to the growth monitoring sessions should be counselled
and if they accept to use a modern contraceptive, they should be given an appointment or provided
with the service on the same day.
• All mothers should be informed that any contraceptive method other than modern methods, such
as safe period and withdrawal, are not reliable methods of contraception. Also, they should be
advised that lactation does not prevent pregnancy except in case of the presence of the following
three conditions of Lactation Amenorrhea method (LAM) together: exclusive breast feeding, the
infant’s age is less than six months, and the mother has amenorrhea.

o General medical examination

A general medical examination should be performed on the first visit for all women accepting oral
contraceptives, IUD or injectable. The examination should include:
• Blood pressure measurement to detect any deviation from the normal levels;
• Weight measurement to the nearest 200 grams;
• Auscultation of the chest and heart (listen carefully for murmurs) to exclude rheumatic heart disease,
endocarditis, cardiopulmonary shunt and artificial heart valve;
• Before inserting an IUD, hemoglobin test to detect anemia. For other family planning acceptors, a
hemoglobin test must be requested if indicated based on past history and/or medical examination;
• Counselling on breastfeeding to get along with modern contraceptive method use. There is no
interaction between breastfeeding and contraceptive use; and
• Advice about the importance of examining the breasts and demonstration on undertake a BSE by a
Nursing Staff.

o Abdominal examination
To check for:
• Hepatosplenomegaly;
• Masses or gross abnormalities, and
• Supra-pubic or pelvic tenderness.

o Pelvic and cervical examination

Pelvic and/or PV examinations will only be undertaken if the client has chosen the IUD as a contraceptive
method, on the advice of the medical officer, or if the client has an abnormal vaginal discharge. They
should be performed with the consent of the client by either:
• A Gynecologist/Obstetrician or trained medical officer in the presence of a nurse; or
• A staff nurse/midwife if she is trained up to competency level, provided that this is allowed by local
legislation.

The pelvic and cervical examination should include:

a) External genitalia and speculum examination:
• Inspect external genitalia for ulcers and enlarged groin lymph node;
• Check for vaginal discharge and other signs of lower genital tract infection;
• Check cervix for purulent cervicitis, erosions or narrowing of cervical canal (stenosis); and
• Take specimens of vaginal and cervical secretions for diagnostic purposes if indicated and facilities
are available. This presents the best opportunity for detecting and managing precancerous
cervical conditions through screening of women >35 years of age.

b) Bimanual examination:
• Determine size, shape and position of uterus;
• Check for pelvic and abdominal masses in particular enlargement or tenderness of the adnexa;
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• Check for pregnancy; and
• Check for uterine abnormalities.

5.3 Family planning methods

The family planning programme offers the following contraceptive methods:
a) Hormonal contraceptive methods;
• Combined oral contraceptive.
• Progesterone only pills.
• Injectable contraceptives.
b) Intra-uterine device (Copper T-380A);
c) Spermicide; and
d) Condoms with or without spermicide.

For more details regarding family planning methods, please refer to Annex 1 and the clinical guidelines
for the delivery of family planning services.

o Oral contraceptive pills

• When no pill-taking mistakes are made, less than 1 pregnancy per 100 women (3 per 1,000 women).
• The staff nurse must follow the prescription of the medical officer and only provide the prescribed
oral contraceptive if the client is not experiencing problems, the medical check-up is normal, and the
client wishes to continue the use of oral contraceptive.
• When oral contraceptives are first prescribed, appointments must be made for the client to return for
a follow-up visit one week before the next expected period. However, she can return to the health
center earlier for any client concern, side effects, any warning signs of complications (thrombosis/
thromboembolism), such as severe chest pain, shortness of breath, severe headache with visual
problems and sharp pain in leg and abdomen. The client should be given two cycles of pills so as
to keep one as a reserve in case she is unable to visit the clinic for any reason. If applicable and
possible, follow-up appointments should coincide with the appointments given to mothers for
growth monitoring of their babies in order to provide holistic services to the mother and newborn
infant simultaneously.
• If after the first appointment the client is experiencing no problems and wishes to continue on the
pills, two months’ supply may be provided. Thereafter, the client can return every three months for
the next two follow-up visits.
• On the fifth follow-up visit, the medical officer must undertake a medical review. If the client wishes
to continue using the pills, follow-up visits every 3 months are recommended.
• Once prescribed by the medical officer, oral contraceptives can be dispensed by the nurse for a
maximum of four follow-up visits. The nurse should ensure that the client knows when to take the
pills and what to do if she fails to take some of them.

o Injectable contraceptives
• Prescription should be provided by the medical officer only after thorough counselling;
• The client should be required to report back to the clinic one week before the end of the 3 months
after the first injection for check-ups, and earlier if the client has any concerns, side effects and
unexplained complaints.
• The likelihood of pregnancy might be higher for women who are late for the injection or who miss
the injection.

o Intra-uterine devices (IUDs)

The follow-up of inserted IUDs should be done by visualizing the cervix by a trained staff to check the
thread.
• If feasible, insertion of IUDs should be performed by Gynecologist/Obstetrician or by trained medical
officers up to competency level. Staff nurses/midwives who are trained up to competency level may
insert IUDs under the supervision of medical officers, provided that this is allowed by local legislation.
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• After insertion of the IUD, the client must receive follow-up after one month. However, she can return
to the health centre earlier for any client concern, side effects, any sign of complications such as low
abdominal pain, vaginal discharge, fever, missing strings and delayed menstrual period.
• If after the first month the client is not experiencing any problems, the client can then be followed up
after 3 months and then every six months up to a maximum of 10 years.
• After 10 years of post-insertion, the IUD should be replaced. Recent literature suggests that this period
may be extended to 12 years provided that periodic check-ups are made to rule out side effects.

o Spermicide and condoms

• Clients should be counselled on the correct use of the method including emergency contraception.
• Clients must be supplied according to their need. (The average number of condoms and pessaries
supplied monthly is 10 but individuals must be supplied according to need).
• Follow-up appointments should be by date/time, at monthly intervals.
• A client who attends the family planning service regularly can be given a three months’ supply.

o Emergency contraception
This constitutes a reliable contraceptive method after unprotected intercourse or when a condom
has been used incorrectly (slipped or broken). It may also be used in cases of incorrect use of fertility
awareness method, for example, abstinence and failure of coitus interruptus, inadequate use of
oral contraceptive pills (such as missing three or more pills and starting three or more days late on
a new pack), partial or complete expulsion of IUD and more than two weeks late for her injectable
contraception (Depo-Provera).

• Women should receive counselling on the option for emergency contraception, if indicated and
required, it should be provided in a timely manner.
• Emergency contraceptive pills (ECPs), also known as “morning-after pills,” are oral hormonal
contraceptives taken after sexual intercourse but before the implantation to prevent pregnancy. It
should be initiated as soon as possible after unprotected intercourse and within 120 hours (i.e., 5
days). The sooner they are taken, the better.
• Combined oral contraceptive pills (COC) can be used for emergency contraception using a dose of
four tablets which should be taken with small amount of water over half an hour. This should be
repeated after 12 hours. Client can take the first dose immediately and she should be advised to take
the next dose in 12 hours. The client should also be informed about the most common side-effects,
including nausea, abdominal pain, slight bleeding and change in timing of monthly bleeding.
However, these side-effects are not the signs of illness.
• IUD: Emergency insertion of a copper IUD is highly effective, reducing the risk of unwanted pregnancy
by as much as 99%.

Because of the short-term nature of their use, there is no medical contraindication on the provision of
ECPs and there are no medical conditions that make ECPs unsafe for any woman. All women can use ECPs
safely and effectively, including women who cannot use ongoing hormonal contraceptive methods.

5.4 Follow-up
The staff nurse responsible for supervising family planning services must record all follow-up
appointments in the diary, including the serial number, date and time of next appointment, and type of
contraceptive.

All clients must be encouraged to return to the health centre at any time, and if they experience any
problems and/or worries. Every effort should be made to ensure that defaulters are followed-up. The
procedure for follow-up depends on the method of contraceptive as outlined previously.

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Levels of
Responsibility
and Authority

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6. Levels of Responsibility and Authority

The Chief Health Protection and Promotion at HQ level and the Field Family Health Officer at Field level are
responsible for the planning, implementation, supervision and evaluation of the programme. The Field Family
Health Officer should coordinate programme activities closely with the Field Nursing Officer.

6.1 Gynecologist / Obstetrician

• Be responsible for examination, including blood pressure measurement, management and follow-
up of women classified as high-risk category in the preconception care clinic, high-risk pregnancies
and other women with special needs referred to him/her by family health team medical officers. The
Gynecologist/Obstetrician also provides feedback to the referring medical officers on management
plans;
• Manages and follows-up all women with gestational diabetes and/or hypertension in close coordination
with their FHT medical officer at the health center;
• Examines and treats all women with gynecological and/or obstetrical problems referred to him/her by
FHT medical officers according to a rotating work schedule prepared by the Field Family Health Officer
under the supervision of the Chief Field Health Programme, and provides feedback on outcomes of
care;
• Provides necessary counselling to high-risk pregnant women on safe delivery and possible adverse
pregnancy outcomes;
• Closely monitors the blood pressure and other necessary measurements of high-risk pregnant women;
• Wherever applicable, undertakes regular visits to UNRWA hospitals/contracted hospitals to ensure that
standards care, equipment, supplies and techniques should be maintained/performed;
• Participates in the in-service training of medical and nursing staffs on safe motherhood practices;
• Where health centre staff are not adequately trained to insert IUDs, performs this task for refereed
women;
• Participates in the organization and conducts health services research relevant to maternal health;
• Maintains close coordination with maternity hospitals in order to ensure feedback on high-risk
pregnancies referred for delivery or special care; and
• Supervises maternal health activities in the health centres assigned to him/her, including regular review
and assessment of all e-Health maternal health records in the health center.

6.2 Medical Officer

a) During the preconception
During the preconception care visit, the FHT medical officer is responsible for conducting the medical
and obstetric examination, providing counselling, and arranging for necessary referrals which should
be carried out as follows:
• Reviews the completed fields by the staff nurse/midwife in the e-Health record;
• Inspects the general appearance to assess if the woman looks ill, with skeletal deformities, short
stature, obese, pale, tired and malnourished;
• Conducts monitoring and assessments thorough medical and obstetric/gynecological history;
• Undertakes systematic clinical examinations of all systems and organs;
• Promotes referral for laboratory investigations;
• Determines the risk status of women and refers all cases under H category to the Gynecologist/
Obstetrician;
• Prompt referral for further specialized genetic or medical/gynecological consultation if needed;
• Records summary of the relevant findings and any deviation from the normal condition; records
action taken in the corresponding section under general medical examination;
• Provides counseling and draw up a management plan of identified conditions; and
• Provides folic acid supplementation.

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b) During antenatal care
• Reviews the completed summary of past obstetric history and completes the general medical
history;
• Reviews the completed parts of the MHR and undertakes comprehensive general medical and
obstetric examinations as mentioned earlier, including blood pressure measurement;
• Where applicable, completes the relevant section on the MCH handbook and e-Health;
• Undertakes risk assessment and determines the risk category under which the women should be
classified;
• Records under Conclusion/Management Plan on the First Visit Section of the antenatal record the
results of the risk assessment, his/her conclusions, and the plans of management;
• Refers all high-risk pregnancies to the Gynecologist/Obstetrician and reviews the management plan
recommended by the Gynecologist/Obstetrician;
• Manages all alert pregnancies and refers them to the Gynecologist/Obstetrician at least once during
the course of pregnancy. The time of referral should be decided by the medical officer based on the
risk status and condition of the woman;
• Examines all pregnant women at 32 weeks for general assessment and provision of the MCH
handbook;
• If a Gynecologist/Obstetrician is not available, takes a decision to classify an alert pregnancy in the
high-risk category when immediate hospital referral is justified (e.g. bleeding or change from mild
hypertension to signs of pre-eclampsia).

c) During postnatal care

• If any deviation from the normal progress is detected during the postnatal period, undertakes
an accurate history and full physical examination by the medical officer before deciding on the
appropriate management plan for the woman.

• Undertakes the examination of the infant.

d) During family planning activities

• Reviews the completed family planning record and undertakes a general medical examination for
all women accepting oral contraceptive pills, IUD, or injectable contraceptives;

• Provides family planning counselling;

• Certifies the woman as fitting to use oral contraceptives or for insertion of IUD;

• Inserts IUDs after he/she completes the necessary training and the Gynecologist/Obstetrician
certifies this by completing the evaluation standard checklist; examines and manages any referred
cases. If the management is beyond his/her training, he/she must refer the client to the Gynecologist/
Obstetrician.

6.3 Dental Surgeon

• Women during the first preconception visit or at the first antenatal visit should be referred to the dental
clinic for advice on oral hygiene, dental screening, and treatment if needed.

6.4 Senior Staff Nurse

• Acts as principal nursing officer at the health centre and supervises and directs staff nurses and other
nursing, midwifery staff, and assesses their performance;

• Conducts on-the-job training of supervised staff and participates in in-service courses as and when
required;

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• Directs and participates in all activities related to the nurse’s role in implementing the Agency’s maternal
health and family planning program in the assigned health centre;

• Controls and keeps records of equipment and medical supplies needed for nursing activities with regard
to maternal health, ensures their continued availability and supervises disposal of used items; and

• Supervises and controls the maintenance of high standards of cleanliness and infection control,
including sterilization of family planning equipment and instruments in the health centre.

6.5 Staff Nurse and Midwife

The responsibilities of the senior staff nurse are as follows:

a) During preconception care

• History taking and completing the relevant section on the preconception record (personal
information data, counselling, general appraisal on first examination and breast examination);

• Weight measurement to the nearest 200 grams, and to record the BMI;

• Blood pressure measurement to the nearest 2mmHg;

• Clinical breast examination; the nurse/midwife should take this opportunity to train women on BSE
techniques and

• Provide the necessary counselling, in particular family planning and healthy life style advice.

b) During antenatal care

• Completes the personal information section, present obstetric history, year of last tetanus toxoid
immunization and completes the laboratory section in the antenatal record;

• Reviews the risk assessment and the recommended management plan as established during the
first antenatal visit and performs the risk assessment during each follow-up visit, and refers the
woman to the medical officer in case there is any deviation from normal progress;

• Undertakes the obstetric examination during antenatal follow-up visits and the post-natal visit;

• Measures the blood pressure, and if there is deviation refers the client to the medical officer, using
first and fourth Korotkoff sounds;

• Measures the weight to the nearest 200 grams;

• Examines and teaches the client to perform BSE;

• Refers women with any deviation from the normal progress of pregnancy or with problems during
the postnatal period, to the medical officer for further assessment and appropriate intervention;

• Provides counselling on preconception care, birth spacing and contraception during the antenatal
and postnatal periods, as well as to all family planning acceptors; and

• Completes the relevant sections of the MCH booklet with respect to every pregnant woman and
advises her on the importance of maintaining this record for subsequent visits.

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c) Undertakes home visits to the following clients:
• High-risk pregnant women who live within reach of the health centre if they have not attended the
antenatal clinic for two weeks subsequent to their previous visits;

• High-risk women within reach during the first week of the expected delivery date, regardless of
whether the birth has been reported to the health centre;

• All pregnant women whose infants are expected to be low birth weight or premature;

• All pregnant women in need; and

• All eligible postnatal clients residing in camps in the first 14 days after delivery if they have not
attended the health centre for postnatal care;

d) During the family planning

• Completes the general information section;

• Records the previous use of modern family planning methods;

• Records the date of last menstrual period, menstrual disturbances, child feeding method
(breastfeeding or not), and other relevant problems which the woman suffering from.

• Performs a cervical or pelvic examination (if trained) with the consent of the client;

• Provides family planning services, including dispenses contraceptive supplies to clients and follows-
up family planning clients in subsequent visits; and

• Inserts/removes and follows-up inserted IUDs if she is well-trained and certified by the Gynecologist/
Obstetrician.

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Recording
and Reporting

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7. Recording and reporting

7.1 Recording
The following records should be maintained in e-Health and MCH handbook for women registered for
preconception, antenatal, postnatal and family planning services:

• Preconception care record.

• Maternal health record.

• Antenatal record.

• Postnatal record.

• Family planning record.

Instructions on the completion of these records are provided in the attached guidelines on completion
of preconception, maternal health, antenatal, postnatal and family planning records.

7.2 Reporting
The following reports should be completed:

• The monthly/quarterly reports on maternal and child health and family planning services should be
completed by all health centres/points and submitted to the field office on monthly basis for compilation
and subsequent transmittal to Headquarters on quarterly basis.

• The quarterly reports on Hypertension and Diabetes during Pregnancy (please refer to the Technical
Instruction on Prevention & Control of Non-Communicable Diseases) should be compiled from all health
centres and submitted to Headquarters.

• The report on the outcome of pregnancy should be compiled from all health centers and submitted
annually to Headquarters.

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Monitoring
and Evaluation

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8. Monitoring and Evaluation

Monitoring and evaluation should be based on the analysis of data collected through the regular reporting
system either by rapid assessments or by special health services research. Maternal health indicators that will
be used to assess the coverage and quality of care will comprise the following:

1) Coverage of preconception care;

2) Coverage of prenatal care;

3) Coverage of postnatal care;

4) Percentage of women in reproductive age who paid at least two preconception visits out of newly registered
pregnant women;

5) Percentage of women classified during preconception care as Normal, Alert and High risk categories;

6) Percentage of pregnant women who paid one antenatal visit;

7) Percentage of pregnant women who paid at least 4 antenatal contacts;

8) Percentage of pregnant women who paid at least 8 antenatal contacts;

9) Proportion of pregnant women below 18 or above 39 years of age;

10) Percentage of pregnant women immunized against tetanus;

11) Mean marital age;

12) Prevalence of anemia among pregnant women;

13) Percentage of deliveries attended by trained personnel;

14) Mean birth intervals;

15) Proportion of women with birth interval of 18 months;

16) Proportion of women with birth interval of 24 months;

17) Mother/Fetus outcomes of pregnancy by parity;

18) Mother/Fetus outcomes of pregnancy by risk status;

19) Mother/Fetus outcomes of pregnancy according to place of delivery;

20) C-section rate by risk status;

21) Maternal mortality ratio;

22) Contraceptive prevalence among women of reproductive age utilizing UNRWA services;

23) Contraceptive method mix;

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24) Overall contraceptive discontinuation rate;

25) Method-specific discontinuation rate; and

26) Percentage of women exclusively breastfeeding for at least 6 months.

This Technical Instruction “Provision Of Maternal Health And Family Planning Services” was updated by the
Health Department at UNRWA Headquarters, Amman, Jordan.

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Dr. AKIHRO SEITA
DIRECTOR OF HEALTH - UNRWA HEADQUARTERS, AMMAN Date: January 2020

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