How do you assess a pregnant patient?

doi: 10.1016/j.anclin.2015.10.016.

Affiliations

• 1 Department of Anesthesiology, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA.
• 2 Department of Anesthesiology, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA. Electronic address: [email protected].

Always begin with Rapid assessment and management (RAM) B3-B7. If the woman has no emergency or priority signs and has come for antenatal care, use this section for further care.

Next use the Pregnancy status and birth plan chart C2 to ask the woman about her present pregnancy status, history of previous pregancies, and check her for general danger signs. Decide on an appropriate place of birth for the woman using this chart and prepare the birth and emergency plan. The birth plan should be reviewed during every follow-up visit.

Check all women for pre-eclampsia, anaemia, syphilis and HIV status according to the charts C3-C6.

In cases where an abnormal sign is identified (volunteered or observed), use the charts Respond to observed signs or volunteered problems C7-C11 to classify the condition and identify appropriate treatment(s).

Give preventive measures due C12.

Develop a birth and emergency plan C14-C15.

Advise and counsel on nutrition C13, family planning C16, labour signs, danger signs C15, routine and follow-up visits C17 using Information and Counselling sheets M1-M19.

Record all positive findings, birth plan, treatments given and the next scheduled visit in the home-based maternal card/clinic recording form.

Assess eligibility of ART for HIV-infected woman C19.

If the woman is HIV infected, adolescent or has special needs, see G1-G11 H1-H4.

C2. ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS, BIRTH AND EMERGENCY PLAN

Use this chart to assess the pregnant woman at each of the four antenatal care visits. During first antenatal visit, prepare a birth and emergency plan using this chart and review them during following visits. Modify the birth plan if any complications arise.

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ASK, CHECK RECORDLOOK, LISTEN, FEELINDICATIONSPLACE OF DELIVERYADVISEALL VISITS

• Check duration of pregnancy.

• Where do you plan to deliver?

• Any vaginal bleeding since last visit?

• Is the baby moving? (after 4 months)

• Check record for previous complications and treatments received during this pregnancy.

• Do you have any concerns?

• Feel for trimester of pregnancy.

• Do you use tobacco, alcohol, or any drugs?

• Are you exposed to other people's tobacco smoke at home?

• Prior delivery by caesarean.

• Transverse lie or other obvious malpresentation within one month of expected delivery.

• Obvious multiple pregnancy.

• Tubal ligation or IUD desired immediately after delivery.

• Documented third degree tear.

• History of or current vaginal bleeding or other complication during this pregnancy.

REFERRAL LEVEL

• Explain why delivery needs to be at referral level C14.

• Develop the birth and emergency plan C14.

FIRST VISIT

• How many months pregnant are you?

• When was your last period?

• When do you expect to deliver?

• Have you had a baby before? If yes:

• Check record for prior pregnancies or if there is no record ask about:

  →

  Number of prior pregnancies/deliveries

  →

  Pre-eclampsia or eclampsia in previous pregnancies

  →

  Prior caesarean section, forceps, or vacuum

  →

  Prior third degree tear

  →

  Heavy bleeding during or after delivery

  →

  Convulsions

  →

  Stillbirth or death within first 24 hours of life.

  →

  Other diseases such as diabetes, chronic hypertension, kidney, autoimmune disease

  →

  Do you use tobacco, alcohol, or any drugs?

→

Are you exposed to other people's tobacco smoke at home?

→

HIV status and ARV treatment.

• Last baby born dead or died in first day.

• More than six previous births.

• Prior delivery with heavy bleeding.

• Prior delivery with convulsions.

• Prior delivery by forceps or vacuum.

PRIMARY
HEALTH CARE LEVEL

• Explain why delivery needs to be at primary health care level C14.

• Develop the birth and emergency plan C14.

• If yes to alcohol/tobacco/substance use; advise cessation of substance use. C10 - C13

ACCORDING TO WOMAN'S PREFERENCE

• Explain why delivery needs to be with a skilled birth attendant, preferably at a facility.

• Develop the birth and emergency plan C14.

THIRD TRIMESTER

• Has she been counselled on family

• planning? If yes, does she want

• tubal ligation or IUD A15.

• Feel for obvious multiple pregnancy.

Next: Check for pre-eclampsia

C3. CHECK FOR PRE-ECLAMPSIA

Screen all pregnant women at every visit.

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE

• Blood pressure at the last visit?

• Eclampsia or pre-eclampsia in previous pregnancies?

• Other diseases (chronic hypertension, kidney disease or autoimmune disease)?

• Measure blood pressure in sitting position.

• If diastolic blood pressure is ≥90 mmHg, repeat after 1 hour rest.

• If diastolic blood pressure is still ≥90 mmHg, ask the woman if she has:

  →

  severe headache

  →

  blurred vision

  →

  epigastric pain and

  →

  check protein in urine.

• Diastolic blood pressure ≥110 mmHg and 3+ proteinuria, or

• Diastolic blood pressure ≥90 mmHg on two readings and 2+ proteinuria, and any of:

  →

  severe headache

  →

  blurred vision

  →

  epigastric pain.

SEVERE PRE-ECLAMPSIA

• Give magnesium sulphate B13.

• Give appropriate anti-hypertensives B14.

• Refer urgently to hospital B17.

• Diastolic blood pressure 90-110 mmHg on two readings and 2+ proteinuria.

PRE-ECLAMPSIA

• Diastolic blood pressure ≥90 mmHg on 2 readings.

HYPERTENSION

• Advise to reduce workload and to rest.

• Advise on danger signs C15.

• Reassess at the next antenatal visit or in 1 week if >8 months pregnant.

• If hypertension persists after 1 week or at next visit, refer to hospital or discuss case with the doctor or midwife, if available.

• Eclampsia or pre-eclampsia in previous pregnancies

RISK OF PRE-ECLAMPSIA

• Give calcium if low dietary intake area F2.

NO HYPERTENSION

Next: Check for anaemia

C4. CHECK FOR ANAEMIA

Screen all pregnant women at every visit.

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE

• Are you breathless (short of breath) during routine household work?

On first visit: On subsequent visits:

• Look for conjunctival pallor.

• Look for palmar pallor. If pallor:

  →

  Is it severe pallor?

  →

  Some pallor?

  →

  Count number of breaths in 1 minute.

AND/OR

• Severe palmar and conjunctival pallor or

• →

  >30 breaths per minute

  →

  tires easily

  →

  breathlessness at rest

SEVERE ANAEMIA

• Revise birth plan so as to deliver in a facility with blood transfusion services C2.

• Give double dose of iron (1 tablet twice daily) for 3 months F3.

• Counsel on compliance with treatment F3.

• Give appropriate oral antimalarial F4.

• Follow up in 2 weeks to check clinical progress, test results, and compliance with treatment.

• Refer urgently to hospital B17.

• Palmar or conjunctival pallor.

MODERATE ANAEMIA

• Give double dose of iron (1 tablet twice daily) for 3 months F3.

• Counsel on compliance with treatment F3.

• Give appropriate oral antimalarial if not given in the past month F4.

• Reassess at next antenatal visit (4-6 weeks). If anaemia persists, refer to hospital.

NO CLINICAL ANAEMIA

• Give iron 1 tablet once daily for 3 months F3.

• Counsel on compliance with treatment F4.

Next: Check for syphilis

C5. CHECK FOR SYPHILIS

Test all pregnant women at first visit. Check status at every visit.

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE

• Have you been tested for syphilis during this pregnancy?

  →

  If not, perform the rapid plasma reagin (RPR) test L5.

• If test was positive, have you and your partner been treated for syphilis?

  →

  If not, and test is positive, ask “Are you allergic to penicillin?”

POSSIBLE SYPHILIS

• Give benzathine benzylpenicillin IM. If allergy, give erythromycin F6.

• Plan to treat the newborn K12.

• Encourage woman to bring her sexual partner for treatment.

• Counsel on safer sex including use of condoms to prevent new infection G2.

NO SYPHILIS

• Counsel on safer sex including use of condoms to prevent infection G2.

Next: Check for HIV status

C6. CHECK FOR HIV STATUS

Test and counsel all pregnant women for HIV at the first antenatal visit. Check status at every visit.

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEProvide key information on HIV G2.

• What is HIV and how is HIV transmitted G2?

• Advantage of knowing the HIV status in pregnancy G2.

• Explain about HIV testing and counselling including confidentiality of the result G3.

• Tell her that HIV testing will be done routinely, as other blood tests, and that she may refuse the HIV test.

Ask the woman:

• Have you been tested for HIV?

  →

  If not: tell her that she will be tested for HIV, unless she refuses.

  →

  If yes: Check result. (Explain to her that she has a right not to disclose the result.)

  →

  Are you taking any ARV?

  →

  Check ARV treatment plan.

• Has the partner been tested?

Check the record

• When was she tested in this pregnancy?

  →

  Early (in the first trimester)?

  →

  Later?

• Perform the Rapid HIV test if HIV-negative and not performed in this pregnancy L6.

HIV-INFECTED

• Give her appropriate ART G6, G9.

• Support adherence to ART G6.

• Counsel on implications of a positive test G3.

• Refer her to HIV services for further assessment and the eligibility for lifelong ART.

• Provide additional care for HIV-infected woman G4.

• Provide support to the HIV-infected woman G5.

• Counsel on benefits of disclosure (involving) and testing her partner G3.

• Counsel on safer sex including use of condoms G2.

• Counsel on family planning G4.

• Counsel on infant feeding options G7.

• Ask her to return to the next scheduled antenatal care visit.

HIV-NEGATIVE

• Counsel on implications of a negative test G3.

• Counsel on the importance of staying negative by practising safer sex, including use of condoms G2.

• Counsel on benefits of involving and testing the partner G3.

• Repeat HIV testing in the 3rd trimester L6.

• She refuses the test or is not willing to disclose the result of previous test or no test results available

UNKNOWN HIV STATUS

• Assess for signs suggesting severe or advanced HIV infection C10.

• Counsel on safer sex including use of condoms G2.

• Counsel on benefits of involving and testing the partner G3.

Next: Respond to observed signs or volunteered problems

If no problem, go to page C12.

C7-C11. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF NO FETAL MOVEMENT

• When did the baby last move?

• If no movement felt, ask woman to move around for some time, reassess fetal movement.

• Feel for fetal movements.

• Listen for fetal heart after 6 months of pregnancy D2.

• If no heart beat, repeat after 1 hour.

PROBABLY DEAD BABY

• Inform the woman and partner about the possibility of dead baby.

• No fetal movement but fetal heart beat present.

WELL BABY

• Inform the woman that baby is fine and likely to be well but to return if problem persists.

IF RUPTURED MEMBRANES AND NO LABOUR

• When did the membranes rupture?

• Look at pad or underwear for evidence of:

  →

  amniotic fluid

  →

  foul-smelling vaginal discharge

• If no evidence, ask her to wear a pad. Check again in 1 hour.

• Foul-smelling vaginal discharge.

UTERINE AND FETAL INFECTION

• Give appropriate IM/IV antibiotics B15.

• Refer urgently to hospital B17.

• Rupture of membranes at <8 months of pregnancy.

RISK OF UTERINE AND FETAL INFECTION

• Give corticosteroid therapy: either IM Dexamethasone or IM Betamethasone (total 24 mg in divided doses), when the following conditions are met:

  →

  gestational age is accurate: from 24 weeks and 34 weeks of gestation;

  →

  Preterm birth is considered imminent;

  →

  There is no clinical evidence of maternal infection;

  →

  Adequate childbirth care is available;

  →

  The preterm newborn can receive adequate care if needed.

• Give Erythromycine as the antibiotic of choice B15.

• Refer urgently to hospital B17.

• Rupture of membranes at >8 months of pregnancy.

RUPTURE OF MEMBRANES

• Manage as Woman in childbirth D1-D28.

Next: If fever or burning on urination

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF FEVER OR BURNING ON URINATION

• Do you have burning on urination?

• If history of fever or feels hot:

  →

  Measure axillary temperature.

  →

  Look or feel for stiff neck.

  →

  Look for lethargy.

• Percuss flanks for tenderness.

• →

  very fast breathing or

  →

  stiff neck

  →

  lethargy

  →

  very weak/not able to stand.

VERY SEVERE FEBRILE DISEASE

• Insert IV line and give fluids slowly B9.

• Give appropriate IM/IV antibiotics B15.

• Give artemether/quinine IM B16.

• Refer urgently to hospital B17.

• →

  Flank pain

  →

  Burning on urination.

UPPER URINARY TRACT INFECTION

• Give appropriate IM/IV antibiotics B15.

• Give appropriate oral antimalarial F4.

• Refer urgently to hospital B17.

• Fever >38°C or history of fever (in last 48 hours).

MALARIA

• Confirm malaria with parasitological diagnosis

• Give appropriate oral antimalarial F4.

• If no improvement in 2 days or condition is worse, refer to hospital.

LOWER URINARY TRACT INFECTION

• Give appropriate oral antibiotics F5.

• Encourage her to drink more fluids.

• If no improvement in 2 days or condition is worse, refer to hospital.

Next: If vaginal discharge

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF VAGINAL DISCHARGE

• Have you noticed changes in your vaginal discharge?

• Do you have itching at the vulva?

• Has your partner had a urinary problem?

If partner is present in the clinic, ask the woman if she feels comfortable if you ask him similar questions.

• If yes, ask him if he has:

• urethral discharge or pus.

• burning on passing urine.

If partner could not be approached, explain importance of partner assessment and treatment to avoid reinfection.
Schedule follow-up appointment for woman and partner (if possible).

• Separate the labia and look for abnormal vaginal discharge:

  →

  amount

  →

  colour

  →

  odour/smell.

• If no discharge is seen, examine with a gloved finger and look at the discharge on the glove.

• Abnormal vaginal discharge.

• Partner has urethral discharge or burning on passing urine.

POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION

• Give appropriate oral antibiotics to woman F5.

• Tre at partner with appropriate oral antibiotics F5.

• Counsel on safer sex including use of condoms G2.

• Curd like vaginal discharge.

POSSIBLE CANDIDA INFECTION

• Counsel on safer sex including use of condoms G2.

• Abnormal vaginal discharge

POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION

• Give metronidazole to woman F5.

• Counsel on safer sex including use of condoms G2.

Next: If signs suggesting HIV infection

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF SIGNS SUGGESTING SEVERE OR ADVANCED HIV INFECTION(HIV status unknown and refused HIV testing)

• Have you got diarrhoea (continuous or intermittent)?

• Have you any difficulty in breathing?

  How long (more than >1 month)?

• Have you noticed any change in vaginal discharge?

• Look for visible wasting.

• →

  Is there a rash?

  →

  Are there blisters along the ribs on one side of the body?

• Feel the head, neck and underarm for enlarged lymph nodes.

• Look for ulcers and white patches in the mouth (thrush).

• Look for any abnormal vaginal discharge C9.

• →

  weight loss or no weight gain visible wasting

  →

  diarrhoea >1 month

  →

  cough more than 1 month or difficulty breathing

  →

  itching rash

  →

  blisters along the ribs on one side of the body

  →

  enlarged lymph nodes

  →

  cracks/ulcers around lips/mouth

  →

  abnormal vaginal discharge.

OR

• One of the above signs and

  →

  one or more other signs or

  →

  from a risk group.

STRONG LIKELIHOOD OF SEVERE OR ADVANCED SYMPTOMATIC HIV INFECTION

• Refer to hospital for further assessment.

Assess if in high risk group:

• History of blood transfusion?

• Illness or death from AIDS in a sexual partners?

IF SMOKING USING TOBACCO, ALCOHOL OR DRUG ABUSE, OR HISTORY OF VIOLENCEAssess if dependent on:

• Counsel on stopping use of tobacco and avoiding exposure to second-hand smoke

• For alcohol/drug abuse, refer to specialized care providers.

• For counselling on violence, see H4.

Next: If cough or breathing difficulty

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ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF COUGH OR BREATHING DIFFICULTY

• How long have you been coughing?

• How long have you had difficulty in breathing?

• Do you have any blood in sputum?

• Are you exposed to other people's smoke at home?

At least 2 of the following signs:POSSIBLE PNEUMONIA

• Give first dose of appropriate IM/IV antibiotics B15.

• Refer urgently to hospital B17.

• At least 1 of the following signs:

• Cough or breathing difficulty for >3 weeks

POSSIBLE CHRONIC LUNG DISEASE

• Refer to hospital for assessment.

• If severe wheezing, refer urgently to hospital.

UPPER
RESPIRATORY TRACT INFECTION

• Advise safe, soothing remedy.

• If smoking, counsel to stop smoking

• Avoid exposure to second-hand smoke

IF TAKING ANTI-TUBERCULOSIS DRUGS

• Are you taking anti-tuberculosis (TB) drugs? If yes, since when?

• Does the treatment include injection (streptomycin)?

• Taking anti-tuberculosis drugs.

• Receiving injectable anti-tuberculosis drugs.

TUBERCULOSIS

• If anti-tubercular treatment includes streptomycin (injection), refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus.

• If treatment does not include streptomycin, assure the woman that the drugs are not harmful to her baby, and urge her to continue treatment for a successful outcome of pregnancy.

• If her sputum is TB positive within 2 months of delivery, plan to give INH prophylaxis to the newborn K13.

• Reinforce advice on HIV testing and counselling G2-G3.

• If smoking, counsel to stop smoking, and avoid exposure to second-hand smoke

• Advise to screen immediate family members and close contacts for tuberculosis.

Next: Give preventive measures

C12. GIVE PREVENTIVE MEASURES

Advise and counsel all pregnant women at every antenatal care visit.

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ASK, CHECK RECORDTREAT AND ADVISE

• Check tetanus toxoid (TT) immunization status.

• Give tetanus toxoid if due F2.

• If TT1, plan to give TT2 at next visit.

• Check woman's supply of the prescribed dose of iron/folate and aspirin, calcium and ART if prescribed.

• Give 3 month's supply of iron, aspirin, calcium and ART if prescribed and counsel on adherence and safety of each medicine F2, F3, G6, G9.

• Check when last dose of mebendazole given.

• Give mebendazole once in second or third trimester F3.

• Check when last dose of an antimalarial given.

• Ask if she (and children) are sleeping under insecticide treated bednets.

• Give intermittent preventive treatment in second and third trimesters F4.

• Encourage sleeping under insecticide treated bednets.

First visit

• Develop a birth and emergency plan C14.

• Counsel on importance of exclusive breastfeeding K2.

• Counsel on stopping use of tobacco and alcohol and drug abuse; and to avoid second-hand smoke exposure.

• Counsel on safer sex including use of condoms.

All visits

• Review and update the birth and emergency plan according to new findings C14-C15.

• Advise on when to seek care: C17

  →

  routine visits

  →

  follow-up visits

  →

  danger signs

  →

  HIV-related visits.

Third trimester

• Counsel on family planning C16.

• Ask and counsel on abstinence from use of tobacco, alcohol and drugs, and to avoid second-hand smoke exposure.

• Record all visits and treatments given.

Next: If cough or breathing difficulty

C13. ADVISE AND COUNSEL ON NUTRITION AND SELF-CARE AND SUBSTANCE ABUSE

Use the information and counselling sheet to support your interaction with the woman, her partner and family.

Counsel on nutrition

• Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat).

• Spend more time on nutrition counselling with very thin, adolescent and HIV-infected woman.

• Determine if there are important taboos about foods which are nutritionally important for good health. Advise the woman against these taboos.

• Talk to family members such as the partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.

Advise on self-care during pregnancy

Advise the woman to:

• Rest and avoid lifting heavy objects.

• Sleep under an insecticide impregnated bednet.

• Counsel on safer sex including use of condoms, if at risk for STI or HIV G2.

• Avoid alcohol and smoking during pregnancy.

• NOT to take medication unless prescribed at the health centre/hospital.

Counsel on Substance Abuse:

• Avoid tobacco use during pregnancy.

• Avoid exposure to second-hand smoke.

• Do not take any drugs or Nicotine Replacement Therapy for tobacco cessation.

Counsel on alcohol use:

• Avoid alcohol during pregnancy.

Counsel on drug use:

• Avoid use of drugs during pregnancy.

C14-C15. DEVELOP A BIRTH AND EMERGENCY PLAN

Use the information and counselling sheet to support your interaction with the woman, her partner and family.

Facility delivery

Explain why birth in a facility is recommended

• Any complication can develop during delivery - they are not always predictable.

• A facility has staff, equipment, supplies and drugs available to provide best care if needed, and a referral system.

• If HIV-infected she will need appropriate ARV treatment for herself and her baby during childbirth.

• Complications are more common in HIV-infected women and their newborns. HIV-infected women should deliver in a facility.

Advise how to prepare

Review the arrangements for delivery:

• How will she get there? Will she have to pay for transport?

• How much will it cost to deliver at the facility? How will she pay?

• Can she start saving straight away?

• Who will go with her for support during labour and delivery?

• Who will help while she is away to care for her home and other children?

Advise when to go

• If the woman lives near the facility, she should go at the first signs of labour.

• If living far from the facility, she should go 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility.

• Advise to ask for help from the community, if needed I2.

Advise what to bring

• Home-based maternal record.

• Clean cloths for washing, drying and wrapping the baby.

• Additional clean cloths to use as sanitary pads after birth.

• Clothes for mother and baby.

• Food and water for woman and support person.

Home delivery with a skilled attendant

Advise how to prepare

• Review the following with her:

• Who will be the companion during labour and delivery?

• Who will be close by for at least 24 hours after delivery?

• Who will help to care for her home and other children?

• Advise to call the skilled attendant at the first signs of labour.

• Advise to have her home-based maternal record ready.

• Advise to ask for help from the community, if needed I2.

Explain supplies needed for home delivery

• Warm spot for the birth with a clean surface or a clean cloth.

• Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for cleaning the baby's eyes, for the birth attendant to wash and dry her hands, for use as sanitary pads.

• Buckets of clean water and some way to heat this water.

• Bowls: 2 for washing and 1 for the placenta.

• Plastic for wrapping the placenta.

Advise on labour signs

Advise to go to the facility or contact the skilled birth attendant if any of the following signs:

• a bloody sticky discharge.

• painful contractions every 20 minutes or less.

Advise on danger signs

Advise to go to the hospital/health centre immediately, day or night, WITHOUT waiting if any of the following signs:

• severe headaches with blurred vision.

• fever and too weak to get out of bed.

• fast or difficult breathing.

• She should go to the health centre as soon as possible if any of the following signs:

• swelling of fingers, face, legs.

Discuss how to prepare for an emergency in pregnancy

• Discuss emergency issues with the woman and her partner/family:

  →

  where will she go?

  →

  how will they get there?

  →

  how much it will cost for services and transport?

  →

  can she start saving straight away?

  →

  who will go with her for support during labour and delivery?

  →

  who will care for her home and other children?

• Advise the woman to ask for help from the community, if needed I1–I3.

• Advise her to bring her home-based maternal record to the health centre, even for an emergency visit.

C16. ADVISE AND COUNSEL ON FAMILY PLANNING

Counsel on the importance of family planning

• If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session.

• Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as four weeks after delivery. Therefore it is important to start thinking early on about what family planning method they will use.

  →

  Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2 years before trying to become pregnant again is good for the mother and for the baby's health.

  →

  Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not.

  →

  Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process).

• Counsel on safer sex including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or HIV G4.

• For HIV-infected women, see G4 for family planning considerations

• Her partner can decide to have a vasectomy (male sterilization) at any time.

Method options for the non-breastfeeding woman

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Can be used immediately postpartumCondoms
Progestogen-only oral contraceptives
Progestogen-only injectables
Implant
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (immediately following expulsion of placenta or within 48 hours)Delay 3 weeksCombined oral contraceptives
Combined injectables
Diaphragm
Fertility awareness methods

Special considerations for family planning counselling during pregnancy

Counselling should be given during the third trimester of pregnancy.

• If the woman chooses female sterilization:

  →

  can be performed immediately postpartum if no sign of infection (ideally within 7 days, or delay for 6 weeks).

  →

  plan for delivery in hospital or health centre where they are trained to carry out the procedure.

  →

  ensure counselling and informed consent prior to labour and delivery.

• If the woman chooses an intrauterine device (IUD):

  →

  can be inserted immediately postpartum if no sign of infection (up to 48 hours, or delay 4 weeks)

  →

  plan for delivery in hospital or health centre where they are trained to insert the IUD.

Method options for the breastfeeding woman

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Can be used immediately postpartumLactational amenorrhoea method (LAM)
Condoms
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (within 48 hours or delay 4 weeks)Delay 6 weeksProgestogen-only oral contraceptives
Progestogen-only injectables
Implants
DiaphragmDelay 6 monthsCombined oral contraceptives
Combined injectables
Fertility awareness methods

C17. ADVISE ON ROUTINE AND FOLLOW-UP VISITS

Encourage the woman to bring her partner or family member to at least 1 visit.

Routine antenatal care visits

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1st visitBefore 4 monthsBefore 16 weeks2nd visit6 months24-28 weeks3rd visit8 months30-32 weeks4th visit9 months36-38 weeks

• All pregnant women should have 4 routine antenatal visits.

• First antenatal contact should be as early in pregnancy as possible.

• During the last visit, inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery.

• More frequent visits or different schedules may be required according to national malaria or HIV policies.

• If women is HIV-infected ensure a visit between 26-28 weeks.

Follow-up visits

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If the problem was:Return in:Hypertension1 week if >8 months pregnantSevere anaemia2 weeksHIV-infection2 weeks after HIV testing

C18. HOME DELIVERY WITHOUT A SKILLED ATTENDANT

Reinforce the importance of delivery with a skilled birth attendant

Instruct mother and family on clean and safer delivery at home

If the woman has chosen to deliver at home without a skilled attendant, review these simple instructions with the woman and family members.

• Give them a disposable delivery kit and explain how to use it.

Tell her/them:

• To ensure a clean delivery surface for the birth.

• To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. She should also keep her nails clean.

• To, after birth, dry and place the baby on the mother's chest with skin-to-skin contact and wipe the baby's eyes using a clean cloth for each eye.

• To cover the mother and the baby.

• To use the ties and razor blade from the disposable delivery kit to tie and cut the cord.The cord is cut when it stops pulsating.

• To wipe baby clean but not bathe the baby until after 6 hours.

• To wait for the placenta to deliver on its own.

• To start breastfeeding when the baby shows signs of readiness, within the first hour after birth.

• To NOT leave the mother alone for the first 24 hours.

• To keep the mother and baby warm.To dress or wrap the baby, including the baby's head.

• To dispose of the placenta in a correct, safe and culturally appropriate manner (burn or bury).

• Advise her/them on danger signs for the mother and the baby and where to go.

Advise to avoid harmful practices

For example:

not to use local medications to hasten labour.

not to wait for waters to stop before going to health facility.

NOT to insert any substances into the vagina during labour or after delivery.

NOT to push on the abdomen during labour or delivery.

NOT to pull on the cord to deliver the placenta.

NOT to put ashes, cow dung or other substance on umbilical cord/stump.

Encourage helpful traditional practices:

Advise on danger signs

If the mother or baby has any of these signs, she/they must go to the health centre immediately, day or night, WITHOUT waiting

What should be assessed for a pregnant woman?

What should you as a nurse assess during a pregnant woman's first prenatal visit?

Which examination can be performed on a pregnant patient?

What are the important steps in assessing a pregnant woman in her second trimester?