Healthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.) Chapter Seven - ANTENATAL CARE (introduction...) The First Antenatal Visit Later Antenatal Visits Deciding on Where to Deliver High-Risk Pregnancies

Healthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.)

Chapter Seven - ANTENATAL CARE

Antenatal care is health care and education provided during pregnancy. The main goals of antenatal care are to ensure that the mother and baby are in good health, and that any problems during the pregnancy are recognised and treated promptly.

Pregnancy is not an illness, and the majority of women have normal pregnancies, safe deliveries, and healthy babies. Some women, however, do develop complications during the course of pregnancy. Some of these complications may be minor but others may be severe, even life-threatening to the mother, baby, or both. Regular visits to an antenatal clinic enable the midwife, nurse, or doctor to recognise the first signs of many pregnancy complications. Some traditional birth attendants (TBAs) have also been trained to recognise the signs of complications and to know when a woman must be taken to a hospital. The complication can then be treated before it becomes serious, or arrangements can be made to handle it safely.

The First Antenatal Visit

Ideally, a woman should make her first antenatal visit by the time she is four months pregnant, or even earlier. During this visit, a thorough history is taken and a physical examination is carried out. Certain laboratory tests will also be done if the facility has the resources and equipment. In most countries, some type of antenatal card is used to record the information gathered during the interview, laboratory tests, and physical examination. The findings are used to assess how healthy the woman is during her pregnancy, to identify potential problems she or her baby may have, and to record the effects of whatever treatment she is given.

PERSONAL HISTORY

During the first interview a thorough personal history should be taken, including questions about the following issues:

General characteristics:

· age

· number of living children

· number of dead children, if any

· last normal menstrual period

· regularity of periods before pregnancy

· use of contraception before pregnancy

History of current pregnancy:

· problems developed during this pregnancy

· antenatal care received elsewhere

· medications taken

Obstetric history:

· year of each pregnancy and outcome, including any problems before, during, or after birth (such as prolonged labour, retained placenta, fever after the delivery, fits, or convulsions)

· place of delivery

· type of delivery (normal, forceps, vacuum, or Caesarean section)

· whether delivery was pre-term or full-term

· weight of each baby delivered

· number of abortions, miscarriages, and ectopic pregnancies, if any

Medical/surgical history:

· current use of medications

· known allergies to medications

· medical problems, including sickle cell disease, heart disease, diabetes, asthma, tuberculosis, hypertension, or jaundice

· past operations or surgery, or past blood transfusions · sexually transmitted diseases and treatment

Family history:

· family members with medical problems such as high blood pressure, diabetes, cancer, or genetic problems

· whether any relatives have had twins

· whether any relatives had babies born with birth defects, including mental retardation

Social history:

· occupation

· current use of drugs

· use of cigarettes or alcohol

· living situation

· support from the father of the baby

· whether pregnancy is wanted

Some of the information may not be available, either because the woman does not know it or because she does not want to talk about it for some reason. Probably the most important information to get is whether the woman has had any problems with this pregnancy, or any serious complications with a previous pregnancy or delivery.

PHYSICAL EXAMINATION

After a personal history is obtained, the midwife, nurse, or doctor carries out a thorough, head-to-toe examination of the woman. He or she looks for signs of disorders, such as anaemia. Height and weight are measured and blood pressure is taken (see Figures 7.1 and 7.2). The size of the woman's womb is measured to check the baby's growth and, after 20 weeks of pregnancy, the baby's heart may be listened to with a special stethoscope called a foetoscope.

What Will Happen During the Antenatal Visits?

Figure 7.1: Measuring Weight

A pregnant woman's weight should be measured at every antenatal visit.

Figure 7.2: Measuring Blood Pressure

A pregnant woman's blood pressure should also be measured at every antenatal visit.

LABORATORY TESTS

Depending on the facilities available at the clinic or hospital, certain laboratory tests may be carried out before or after the physical examination. Urine may be tested at every antenatal visit. Tests on blood and vaginal fluids are usually done only once or twice during the pregnancy (see Figure 7.3). Laboratory tests usually include the following:

HAEMOGLOBIN: This indicates whether the iron levels in the blood are high enough, and whether a woman is anaemic.

SICKLING TEST: If a woman suffers from sickle cell disease, she will need very close and careful supervision during pregnancy and labour because this condition may become more severe unless it is expertly managed. Women who are only carriers of sickle cell disease as opposed to actually having it (see Chapter 5) are not at increased risk during pregnancy. However, the sickle cell status of the baby's father should be checked if possible, and counselling should be provided about risks, if any, to the baby.

BLOOD GROUPING: Tests to find out a woman's blood group are useful in case a blood transfusion is needed later. Sometimes tests are also carried out to determine if the woman has a blood type called rhesus negative, which is associated with a higher rate of complications for the mother and child. Women with this blood type need extra care during their pregnancies and deliveries.

SEXUALLY TRANSMITTED DISEASES (STDs): Most STDs can be treated effectively if they are diagnosed early. It is important that this be done, since some STDs such as syphilis and gonorrhoea can threaten the health of the mother and baby. Blood tests or tests done on fluid from the vagina (see Chapter 18) are used to diagnose these diseases, if the facilities are available. In some countries where STDs are common but laboratory facilities are not available, the Ministry of Health may recommend that any woman who has an unusual discharge or fluid from the vagina, or other symptoms, be treated for an STD. There are special charts that can be provided for health workers to use this system of diagnosis and treatment.

URINE TESTS: Urine is tested for two things: sugar, which suggests diabetes; and protein, which may indicate an infection or pregnancy-related hypertension (see Chapter 9).

MEDICATIONS (TABLETS AND INJECTIONS)

There are a few basic medicines that can help a woman have a healthy pregnancy. First, a woman should be immunised against tetanus, a disease that could kill the baby (see Figure 7.4). The first dose can be given at the first antenatal visit; the second dose should be given four weeks later. Second, in areas where malaria is common, Ministries of Health sometimes recommend that pregnant women should be given chloroquine or a related medicine; local guidelines should be checked. Third, iron tablets, folic acid, and vitamins are often given to prevent anaemia and make sure the mother and baby get the right nutrients.

What Will Happen During the Antenatal Visits?

Figure 7.3: Blood Test

Blood should be tested at least two times during the pregnancy to determine if the woman has anaemia or other complications.

Figure 7.4: Tetanus-Toxoid Immunisation

(first visit, and again four weeks later as a booster dose) Every pregnant woman should be given a tetanus-toxoid immunisation to protect herself and her baby.

What Will Happen During the Antenatal Visits?

Figure 7.5: Health Education and Counselling

The nurse or midwife should provide information and advice to the pregnant woman on how to take care of herself, and answer any questions that she may have.

Figure 7.6: Examination

An examination to make sure the baby is growing normally. Toward the end of pregnancy, the baby's position or "lie" can also be checked.

HEALTH EDUCATION

Information from the personal history, physical examination, and laboratory tests can be used as the basis for a discussion about what the woman can and should do to stay in good health (see Figure 7.5). She should be encouraged to ask questions or talk about any special problems she might have. Some women may be shy about asking questions; the health worker can help by using simple, understandable language to explain what was done and what the findings mean. It is especially important to explain any danger signs or complications the woman may have, and what should be done about them (see Chapters 9 and 11). In addition, basic information should be offered on nutrition, danger signs, personal hygiene, typical discomforts and what to do about them, and the baby's stage of development (see Chapters 4, 6, and 8).

Health education can be spread throughout the pregnancy; it is best not to go over too many topics at any one time. At the end of every antenatal visit, the next visit should be scheduled.

Later Antenatal Visits

Even women who are healthy and have no problems should have at least three or four antenatal visits to ensure that the pregnancy and delivery are free of problems. Women who have a problem, or are at risk of developing one, should go more often. Ideally, the first visit should be no later than the fourth month of pregnancy. All women should be sure to visit the antenatal clinic in the ninth month to check on the lie of the baby (see Chapter 11) and look for any other last-minute problems that can develop. Women should be encouraged to come to all antenatal visits even if they feel fine and do not seem to have any problems. Some of the serious complications of pregnancy do not show any signs until very advanced. To provide proper care, a clinic should be staffed with qualified medical personnel (a trained nurse, midwife, or doctor) and have the supplies and equipment to provide the services described above.

During later antenatal visits, the midwife, nurse, or doctor will be on the lockout for any complications that might develop. At each visit the woman is weighed, her blood pressure is checked, and usually her urine is tested. Half way through the pregnancy her blood is tested again to check for anaemia. At every visit her abdomen is measured and felt to make sure the baby is growing normally and, towards the end of pregnancy, that the baby is lying in the right position (see Figure 7.6). At times it is necessary to carry out some new tests or repeat old ones to rule out problems. Health education and counselling should be provided, based on the findings of the examination. In particular, the question of where the woman should deliver the baby needs to be discussed (see next section). Toward the end of the pregnancy, family planning methods can be discussed so that women know the options available to them after their babies are born (see Chapter 17).

Box 7.1: What Should Happen During an Antenatal Visit FIRST VISIT: This visit should occur as soon as the woman thinks she is pregnant, no later than the fourth month of pregnancy · A personal history is taken · A physical examination is done by a midwife, nurse, or doctor, who: Measures height and weight Measures blood pressure Examines the entire body · Certain tests are done using samples of: Blood Urine · Certain medicines may be given, including: Iron tablets (to prevent anaemia) Anti-malaria tablets An injection to prevent tetanus · Appropriate health education and counselling is provided, depending on the stage of pregnancy · Advice is given on where to deliver, based on the woman's health and history LATER VISITS: At least 3 or 4 additional visits should be made. One visit should be in the last month of pregnancy · A history of problems since the last visit is taken · A short physical examination is done that includes: Measuring the growth of the foetus and listening to the heart Checking weight gain Measuring blood pressure Testing urine and sometimes blood When the due date is near, checking on the lie of the baby · Appropriate health education and counselling is provided, depending on the stage of pregnancy · Advice is given on where to deliver, based on the woman's health and history (the advice may change during the pregnancy, based on whether problems are treated or new ones develop)

Deciding on Where to Deliver

Sometime during the pregnancy, the question of where the baby will be born needs to be discussed. The most important issues are whether there are any complications and whether the delivery is likely to be difficult. As discussed below, a woman who has a health problem or is at risk of developing a serious complication should deliver in a health centre or hospital. A woman who has had no problems with her current pregnancy or with any earlier pregnancies may be able to deliver safely at home, as long as she has a trained birth attendant with her. In fact, however, many women who should deliver in a health facility, or who would like to, end up delivering at home. Often this is because they do not know what the danger signs of pregnancy are, or they lack funds to pay for transportation, medicines, or fees. Or it may be that they simply cannot get transport when the time comes.

Health staff and others in the community can help by making sure that women and their families are aware of danger signs during pregnancy and delivery. Families should know what to do if a complication develops, and especially where to take women if help is needed. They can also help by mobilising funds, and by making arrangements for transport when necessary. Some hospitals have maternity waiting homes nearby. Women who are at risk of developing a complication, or who want to deliver in the hospital but live far away, can go to these waiting homes when labour is expected and stay there until after the delivery. That way if a complication does develop, they are right there at the hospital and can receive the care they need.

The following sections look at the choices for places to deliver.

HOME DELIVERY

The majority of deliveries in Africa take place at home, often attended by an untrained person such as a relative or neighbour. While most of the time both the mother and baby end up fine and healthy, home delivery can be dangerous. An untrained attendant may not know the proper procedures for a safe, normal delivery. Even more importantly, he or she may not know what to do if a serious problem arises. In most countries, many TBAs have been trained in the basic principles of safe delivery. Often, they have also been provided with TBA kits that include most of the basic supplies needed for a clean delivery. If the delivery is taking place at home, it is best if a trained birth attendant is there to spot trouble early and take the necessary action before the problem becomes serious or life threatening. The basic requirements for a safe delivery are listed in Chapter 10. Chapter 11 describes the signs of complications during delivery.

CLINIC OR MATERNITY CENTRE

Clinics and maternity centres are generally staffed by trained midwives. At a private facilities, the midwife may charge a fee for the delivery and for any medicines she may provide. If a woman has had one or two normal deliveries in the past and has had no complications with her current pregnancy, a clinic or maternity centre may be a safe place for her to deliver, provided it is clean and the midwife is well trained and experienced. She should know how to recognise emergencies, how to take appropriate first measures, and when to refer the patient to the nearest hospital.

HOSPITAL DELIVERY

Most women recognise that a hospital is the safest place to deliver, as long as it is staffed by trained medical personnel and has the supplies and equipment to deal with an emergency if one develops. Sometimes, however, hospitals are more expensive, and families do not think they can afford to pay for a hospital delivery. Other times, local hospitals do not have the proper supplies and equipment, which means the family may have to buy whatever is needed.

In addition, some women just do not like to deliver in hospitals. There are many reasons for this. Hospitals can be overcrowded, noisy, and impersonal. Their rules and routines can seem strange or frightening, and they may do things that are not always comfortable for women. Sometimes hospitals do not allow certain rituals, or they may require families to bring clothes for the baby, which some women consider bad luck. Some women are afraid of hospitals, because they believe women are brought there to die.

Medical personnel can help address these fears by explaining hospital procedures, and the reasons for them, in clear, simple terms. They can also help by being kind and sympathetic, and by allowing women and their families to carry out whatever rituals they are used to, as long as they do not harm the mother or baby. These steps can help make hospitals less frightening, and make women more willing to deliver there when necessary.

The following sections describe pregnancies that have a higher-than-average risk of developing complications. If a woman falls into any of these categories, arrangements should be made for her to deliver in a hospital. This is especially important if she has two or more of these conditions. While the chances are that the labour and delivery will be normal, it is better to take precautions; otherwise the life of the mother or baby may be lost.

High-Risk Pregnancies

Some women are more likely than others to suffer a complication, because of their age, the number of times they have been pregnant, because they have had problems with past pregnancies, or because their general health is not good. Even if a woman falls into one of these groups, which are described in more detail below, she is still likely to have a healthy pregnancy and delivery. She should, however, be treated with extra care; she should be encouraged to go for antenatal care early and often, and to follow the advice of a doctor, nurse, or midwife about what to do during pregnancy and where to deliver. If she is delivering outside a hospital, it is especially important to have a trained, experienced attendant present and to have transport ready in case a serious complication develops.

However, even women who are perfectly healthy can still develop complications during pregnancy or childbirth. All women, therefore, need to be familiar with danger signs, and be ready to go to a health facility if necessary. Danger signs during pregnancy are described in Chapter 9. Danger signs during labour and delivery are discussed in Chapter 11.

ADOLESCENTS: PREGNANCIES TOO EARLY

Adolescents, especially those less than 17 years old, are more likely to have problems, especially during labour. The physical demands of pregnancy and delivery are especially difficult for them to handle because their bodies are still growing and developing. This is especially true if they are having their first baby. During pregnancy, young teenagers are more likely than women aged 20-24 years old to develop the following complications, which are described in later chapters:

· High blood pressure (pre-eclampsia)
· Premature labour
· Prolonged and/or obstructed labour
· Low birth weight infants

Figure 7.7: Adolescent Pregnancy

Pregnancy can be more difficult for teenagers both physically and emotionally. They have a higher risk of developing complications because their bodies are still growing and developing. A pregnant teenager may have to leave school, and may not know how to care for her new baby.

They should therefore be advised to deliver in a hospital or with a trained midwife or doctor in attendance. Other issues related to adolescent health are discussed in Chapter 21.

OLDER WOMEN: PREGNANCIES TOO LATE

Women who are older (over 35 and especially over 40) are also more likely to have serious complications during pregnancy or labour, especially if they already have a large number of children. They may suffer from (see Chapters 9 and II):

· High blood pressure

· Problems with the placenta

· Problems with the baby, including a very large baby, deformities, mental retardation, miscarriage, and abnormal presentation (the baby is not lying head down)

While it is certainly possible for older women to have problem-free pregnancies and deliver healthy babies, they should be encouraged to seek more careful medical attention during pregnancy and delivery.

MULTI-PARITY: TOO MANY PREGNANCIES

After the fifth or sixth pregnancy, women are more likely to have complications, including high blood pressure, anaemia, and abnormal presentation of the baby. The main risks are problems caused by weakened muscles in the womb such as heavy bleeding, long labour, and rupture of the womb. Therefore, women who have had many children are advised to deliver in a hospital.

SPACING: PREGNANCIES TOO CLOSE TOGETHER

Pregnancy, delivery, and breastfeeding put a considerable strain on a woman's body; pregnancies less than two years apart increase this strain. Severe anaemia, for example, is common in women with frequent pregnancies. Older mothers who have had a large number of pregnancies close together face a much higher risk of dying during pregnancy and labour.

Figure 7.8: Pregnancy in Older Women

Women who are older (over 40 years of age) and have already had many pregnancies (more than five) have a higher risk of complications during pregnancy and delivery.

HEIGHT

If a woman is less than 5 feet tall (150 centimetres), she is more likely than taller women to experience obstructed (blocked) labour. This is why height is measured during antenatal care. Similarly, if a woman has some physical problem with her back, hips, or legs, she should deliver in a hospital because such conditions may make it difficult for the baby to pass through the birth canal.

POOR OBSTETRIC HISTORY

Many complications of pregnancy and labour tend to happen more than once. If a woman had problems with an earlier pregnancy, she should be strongly encouraged to deliver in a hospital under trained medical supervision. These problems include:

· If the last two or three pregnancies resulted in miscarriage, this may happen again. A woman should get careful medical attention during the pregnancy, and deliver with the help of a trained midwife or doctor.

· If labour started early (before 37 weeks) in a previous pregnancy, it is likely to happen again. She should be especially careful to rest and avoid hard work to try to prevent premature labour. The signs of early labour should be carefully explained to the woman. She should also be encouraged to go to a hospital where premature infants can be adequately cared for in case labour does start too soon.

· If severe bleeding occurred before or after a previous delivery, it is likely to recur. Blood transfusions are sometimes necessary, so the woman should deliver in a health facility where transfusions can be done.

· If a woman had obstructed labour during a previous delivery, and especially if she had a fistula (a hole between the vagina and the urinary tract that allows urine to drip into the vagina, she should deliver in a hospital (see Chapter 11).

· If a woman delivered by Caesarean section in the past, she may need to have the operation again. This depends on the kind of incision that was made in the womb; with some incisions the scar tissue is not as strong as the rest of the womb, and it could rupture (see Chapter 12). These women should avoid labour entirely, and arrangements should be made for them to have a repeat Caesarean section. While some women can have a normal delivery after a Caesarean section, all women who have had the operation should have a trained medical attendant with them and be ready to go to the hospital if necessary.

· Women who have had a Caesarean section in the past may be reluctant to go to hospital for the next delivery because they are afraid of having another operation. A health worker should explain the risks to them, and urge them to deliver in a hospital in order to prevent a tragedy. If possible, the medical records from the previous surgery should be obtained in order to plan what kind of delivery to have.

MEDICAL CONDITIONS OR PROBLEMS WITH CURRENT PREGNANCY

If a woman is pregnant with twins, or suffering from certain medical conditions before pregnancy, she will need careful supervision during pregnancy and labour. In most cases, this supervision can only be provided in a well-staffed and fully equipped hospital. These conditions include:

· High blood pressure (hypertension)
· Diabetes
· Heart disease
· Tuberculosis
· Kidney disease
· Obesity (overweight)
· Sickle cell disease
· Severe anaemia

These problems are discussed in Chapter 11.

Summary: Antenatal Care All women, regardless of how healthy they feel, should have at least three or four antenatal visits during their pregnancies. Women who have health problems should go more often, as recommended by a doctor, nurse, or midwife. The first antenatal visit should take place before the fourth month of pregnancy if possible. It involves: A personal history A physical examination Laboratory tests (if the facilities exist) Medications: tablets and injections Health education and counselling Later visits involve many of the same steps. These tests and examinations enable the midwife, nurse, or doctor to find out if there are any problems that need to be treated, or if the woman is likely to have complications with delivery. All women should be sure to make at least one visit in the ninth month of pregnancy. In this final visit, the health worker will look for any complications and make sure everything is ready for a safe delivery. Women who fall into the following groups should be treated with extra care during pregnancy, and should deliver in a health facility if possible: Adolescents (especially those under age 1 7) Older women (especially those over age 40) Women who have had many pregnancies (five or more previous births) Women whose pregnancies are too close together (less than two years apart) Shorter women (less than five feet or 150 centimetres) Women who had a problem with an earlier pregnancy or delivery (prolonged or obstructed labour, repeated miscarriages, premature labour, severe bleeding, or delivery by an operation) Women who have a medical problem with their current pregnancy (bleeding during pregnancy, high blood pressure, severe anaemia, sickle cell disease, diabetes, heart disease, tuberculosis, kidney disease)