Standards of Care for Health Centers

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Volume III Reproductive Health September 2002 Ministry of Health Hashemite Kingdom of Jordan Standards of Care for Health Centers This publication, Standards of Care for Health Centers, was made possible through support
provided by the U.S. Agency for International Development, under the terms of Contract
No. 278-C-00-99-00059-00. The opinions expressed herein are those of the authors and do
not necessarily reflect the views of the U.S. Agency for International Development. Volume I Health Center Management Volume II Clinical Case Management Volume III Reproductive Health Volume IV Preventive Services Volume V Nursing Care Services Volume VI Performance Checklists ? September 2002 Ministry of Health Hashemite Kingdom of Jordan Volume III Reproductive Health Standards of Care for Health Centers Standards of Care for Health Centers Vol. III - ii Reproductive Health Standards of Care for Health Centers Vol. III - iii Reproductive Health Volume III – Table of Contents Acknowledgements...................................................................... iv Introduction ................................................................................. vi List of Acronyms .......................................................................... ix Antenatal Care ............................................................................. 1 Postnatal Care .............................................................................. 55 Family Planning ........................................................................... 91 HIV and AIDS Care....................................................................... 205 References ................................................................................... 215 Standards of Care for Health Centers Vol. III - iv Reproductive Health Acknowledgements These Standards of Care for Health Centers would not have been possible
without the leadership and commitment of his Excellency the Minister of Health
and Dr. Taher Abu El Samen, whose belief in standards as a cornerstone for
quality of care catalyzed the development process. Chairpersons and members
of the technical working groups brought their experience, expertise, and hard
work to bear in creating these Standards. Finally, the technical reviewers, all
recognized experts, were able to ? ne-tune the Standards, ensuring accuracy and
appropriateness for health center facilities. Members of the Clinical Standards and Protocols Committee Dr. Sa’ad Kharabsheh, PHC, General Director, Chairperson Dr. Safa’a Al Qsous, Internal Audit and PHCI/QA Counterpart Dr. Najeh Al Odat, Manager of Al Nasser Health Center/Capital Dr. Maysoon Al Kilani, Abu Nseir Health Center, Capital Dr. Mai Hadidi, Manager of Al Basheer Hospital Postpartum Center Dr. Raja’ Haddadin, MCH Supervisor, Capital Dr. Ziad Anasweh, Al Baqee’ Health Center, Balqa’ Dr. Lobov Al Zghoul, Ein Al-Basha Health Center, Balqa’ RN Rajwa Samara, Madaba RN Salma Masannat, Madaba Mr. Mahmoud Arslan, Clerk/ Internal Audit Directorate Members of the Management Standards Committee Dr. Azmi Hadidi, Chairperson, Director of Internal Audit Pharmacist Najwa Al Hweidi, Internal Audit and PHCI/QA Counterpart Dr. Mohammad Al Borini, Capital Health Directorate Dr. Mustafa Abu Drei’, Assistant Director/Capital Health Directorate Pharamacist Najat Abu Seir, Capital Health Directorate RN Mai Rahahleh, Internal Audit and PHCI/QA Counterpart Mr. Ali Al Abdullat, Directorate of Internal Audit Ms. Fayzeh Haroun, Directorate of Internal Audit Ms. Imtithal Idkeek, Directorate of Internal Audit Mrs. Majeda Karadsheh, Directorate of Internal Audit Standards of Care for Health Centers Vol. III - v Reproductive Health Technical Reviewers for Management Standards Dr. Ismail Sa’adi, Supply System Pharmacist Abeer Muwaswas, Family Planning Logistics System Procedures Dr. Salah Thiab, Mission Statement, Job Descriptions, Rights and Ethics Pharmacist Najwa Al Hweidi, Pharmaceutical System Management
Procedures Mr. Bassam Monier, Accounting Procedures Technical Reviewers for Clinical, Reproductive Health,
and Preventive Services Standards Dr. Ahmed Khair, Diabetes and Hypertension Dr. Mohammed Bataina, Antenatal Care, Postnatal Care, Family Planning Dr. Adel Bilbasi, Diarrheal Disease and Immunization Dr. Khalid Abu Roman, ARI and Asthma Dr. Sereen Mismar, Reproductive Health Mrs. Fatima Zoabi, Nursing Care and Infection Prevention Dr. In’aam Khalaf, Reproductive Health Special acknowledgements go to Dr. Jafar Abu-Taleb and Dr. Mary Segall,
PHCI/Initiatives advisors, who managed the Standards’ development process
with great care; identifying and involving Jordanian experts, building support
for the standards, and ensuring careful integration of PHCI expertise and
experience. We are grateful to Dr Salwa Bitar for her consistent support and
guidance, and to the United States Agency for International Development,
through contract #278-C-99-00059-00, for the vision and ? nancial support so
important to the success of this project. PHCI would also like to acknowledge
the work of consultants Betty Farrell and Pamela Putney, who made invaluable
contributions to the development of the Reproductive Health and Nursing Care
Standards. Finally, sincere thanks go to Hala Al Sharif of the PHCI Project and
to Jaime Jarvis of Initiatives Inc., who so capably coordinated the organization,
editing, and compilation of the documents. Standards of Care for Health Centers Vol. III - vi Reproductive Health Introduction Health for all is an achievable goal for the citizens of the Hashemite Kingdom
of Jordan where primary care focuses on providing high quality preventive,
promotive, and curative care in a cost-effective manner. The Jordanian Ministry
of Health and USAID-funded Primary Health Care Initiatives Project (PHCI) have
formed a partnership to reach this goal. The Standards of Care for Health Centers described here represent a milestone
in the road towards better health. They are tangible evidence of the considerable
thought and effort that has been devoted to promoting quality of care by the
Ministry of Health. The purpose of the “Standards” is to ensure that health center staff members
have the basic and essential guidance required for safe, effective, and humane
service delivery. The Standards are contained in ? ve volumes, each addressing
a distinct aspect of health center services. A sixth volume of performance
checklists is included with the Standards to facilitate self-assessment and
performance review. As a set, the Standards are intended to serve as a
convenient reference, a guide for service delivery, and a tool to support
performance improvement. When following the guidelines set forth in the
Standards, members of health center staff are assured that services meet the
accepted standard of care required by their communities. The volumes and
contents are described below. Volume 1: Health Center Management The Management Standards are organized in four sections. The ? rst section
contains job descriptions for staff providing direct and supportive care at
health centers. The descriptions are meant to serve as a job aid for those
who hold the positions and their supervisors rather than a model for staf? ng.
The second section conveys the expected values and norms for health center
services through a description of patient and provider rights and responsibilities.
The third section contains the MOH guidance for managing health center
accounting procedures and records. The fourth section contains instructions for
procurement of drugs, contraceptives, vaccines, and supplies for laboratory and
dental services. Standards of Care for Health Centers Vol. III - vii Reproductive Health Volume 2: Case Management The ? ve clinical problems addressed in the Case Management guidelines are:
diabetes mellitus type II, hypertension, acute respiratory infection, asthma, and
diarrhea. These conditions represent a signi? cant percentage of the common
medical problems encountered at health centers. Detailed guidance for diagnosis
and management of each clinical problem is given, including recommendations
for drug management, health education, referral, and follow-up care. Algorithms
accompanying each clinical problem inform critical diagnostic or management
decision-making. Together, these tools provide reference options for both quick
and comprehensive review. Performance checklists complete the package for
facilitating self-assessment and peer review. Volume 3: Reproductive Health This volume contains guidance for the reproductive health care services
typically performed by doctors, nurses, and midwives at primary health
centers. Antenatal care focuses on initial assessment and continuing support
for pregnant women. The postnatal care section guides follow-up care for new
mothers and their infants. Family planning includes guidance for counseling
and information on the full range of contraceptive methods available in Jordan.
A brief section on HIV/AIDS provides general information, basic education, and
prevention messages for the community. All procedures described in the volume
are accompanied by performance checklists, which reinforce and highlight the
essential skills required for high quality reproductive health services. Volume 4: Preventive Services This volume addresses two different but complementary aspects of prevention,
which are of great importance to the communities served by health centers.
The ? rst section covers prevention of childhood diseases through immunization;
the second addresses the prevention of infection transmission within the
health facility and among clients, staff, and the communities they serve.
Immunization guidelines describe management of the cold chain and vaccines,
immunization procedures and schedules, roles of staff, recordkeeping, and
supervision. Infection prevention includes guidelines for maintaining protective
barriers through handwashing, use of gloves and antiseptics, and procedures
for decontamination, cleaning, sterilization, and waste disposal. Performance
checklists are provided for all important procedures as a guide for self-
assessment and performance review. Standards of Care for Health Centers Vol. III - viii Reproductive Health Volume 5: Nursing Care Nursing procedures in? uence the care of most patients who visit the clinic by
supplying the medical information that forms the basis for higher-level medical
decisions about care and follow-up. This volume gives special attention to the
procedures that are commonly called nursing care, but which are frequently
performed by other members of the health center team. Guidance for home
visits, child growth and development, immunizations, general care, and ? rst aid is
presented. As in the other volumes, performance checklists are included. Volume 6: Performance Checklists The performance checklists presented in each of the ? ve volumes have been
compiled in this ? nal volume. These compiled checklists are a convenient tool
and job aid for refreshing knowledge, guiding self-assessment, and standardizing
performance assessment at the health centers. Standards of Care for Health Centers Vol. III - ix Reproductive Health List of Acronyms AIDS: Acquired Immunode? ciency Syndrome BCG: Bacilli-Calmette-Guerin vaccine BMI: Body Mass Index BP: Blood Pressure BSE: Breast Self-Examination C&S: Culture & Sensitivity CBC: Complete Blood Count CMM: Cervical Mucus Method COCs: Combined Oral Contraceptives DBP: Diastolic Blood Pressure EC: Emergency Contraception ECP: Emergency Contraceptive Pills EDD: Expected Date of Delivery EE: Ethinyl Estradiol EFM; Electronic Fetal Monitoring FAM: Fertility Awareness Method FP: Family Planning GATHER “Greet-Ask/Assess-Tell-Help-Explain-Return” GDM: Gestational Diabetes Mellitus GTT: Glucose Tolerance Test HLD: High-level Disinfection HIV: Human Immunode? ciency Virus HVS: High Vaginal Swab Standards of Care for Health Centers Vol. III - x Reproductive Health List of Acronyms continued IUD: Intrauterine Device IUGR: Intrauterine Growth Retardation LAM: Lactational Amenorrhea Method LMP: Last Menstrual Period MOH: Ministry of Health PCV: Packed Cell Volume PHC: Primary Health Care PID: Pelvic In? ammatory Disease POPs: Progestin-only Pills SBP: Systolic Blood Pressure SFH: Symphysis Fundal Height STI: Sexually Transmitted Infection U/S: Ultrasound UTI: Urinary Tract Infection VSC: Voluntary Surgical Contraception Standards of Care for Health Centers Vol. III - 1 Reproductive Health Antenatal Care Antenatal Care Table of Contents Introduction ................................................................................. 3 Objectives .................................................................................... 4 Schedule of Antenatal Care Visits ................................................. 4 Initial Evaluation .......................................................................... 6 History ............................................................................................ 6 Physical Examination ..................................................................... 7 Laboratory Tests............................................................................. 11 Health Education Topics............................................................... 12 Client Health Education Messages .................................................. 12 Speci? c Client Health Education Messages..................................... 12 Follow-up Visits ............................................................................ 24 History ............................................................................................ 24 Physical Examination ..................................................................... 24 Laboratory Investigations............................................................... 24 Referral: Sending a Client for Additional Services......................... 25 Referral Criteria.............................................................................. 25 Completion of Client Records....................................................... 25 For the Provider Accepting a Referral ............................................ 25 How can the pain of labor and delivery be reduced? ...................... 38 How will you tell your children about your new pregnancy?.......... 39 List of Tables Table 1. Timing and Content for the Minimum
Number of Antenatal Care Visits .................................................. 5 Table 2. Common Complaints of Pregnancy. ............................... 13 Table 3. BMI Assessment and Recommended Weight Gain.......... 16 Table 4. Tetanus Toxoid Immunization Schedule. ........................ 16 Table 5. Drug Classi? cation Scale ................................................ 18 Standards of Care for Health Centers Vol. III - 2 Reproductive Health Antenatal Care List of Attachments Attachment 1 Antenatal Risk Assessment Form (Coopland) ......... 26 Attachment 2 Fundal Height Measurement .................................. 27 Attachment 3 Lie & Presentation ................................................. 28 Attachment 4 Pelvic Examination ................................................ 29 Attachment 5 Indications for Ultrasound...................................... 32 Attachment 6 Rh Incompatibility ................................................. 33 Attachment 7 Gestational Diabetes Mellitus (GDM) Screening ...... 34 Attachment 8 Drug Classi? cation Table........................................ 35 Attachment 9 Preparing the Pregnant Woman
for Labor and Delivery ................................................................. 38 List of Performance Checklists Page Performance Checklist 1: Pelvic Examination Checklist ............... 47 Performance Checklist 2: First Antenatal Visit.............................. 49 Performance Checklist 3: Antenatal Return Visits ........................ 52 Standards of Care for Health Centers Vol. III - 3 Reproductive Health Antenatal Care Antenatal Care Introduction Pregnancy is a very important event from both social and medical points of
view. Therefore, pregnant women should receive special care and attention from
the community and from health care providers. Since effective communication
builds trust and fosters con? dence, providers should talk with women and
their husbands in a manner that encourages communication about potential
symptoms of complications or high-risk pregnancies. Keep in mind that
pregnant women who develop complications may have dif? culty explaining their
problems. Antenatal care includes the provision of counseling and health care, the
identi? cation of high-risk clients and appropriate fetal surveillance. The objective
of antenatal care is to assure that every pregnancy culminates in the delivery of
a healthy baby without impairing the health of the mother. It is essential for the
provider who assumes responsibility for the antenatal care to be very familiar
with the normal physiological changes as well as the pathological changes that
may develop during pregnancy. Rights of the Pregnant Woman Health care providers should be aware of the client’s rights when offering
antenatal care services. The pregnant woman has the right to: • Information about her health • Discuss her concerns, thoughts, and worries • Know in advance about any planned procedure to be performed • Privacy • Express her views about the services she receives Antenatal care should address both the psychosocial and the medical needs
of the client, within the context of the health care service delivery system and
the culture in which she lives. Periodic antenatal care check-ups provide the
opportunity to increase a woman’s con? dence in her provider and receive
counseling related to her pregnancy. In addition, antenatal care makes it
feasible to identify and manage maternal complications or risk factors. Standards of Care for Health Centers Vol. III - 4 Reproductive Health Antenatal Care Objectives The major objectives of antenatal care are to: 1. Promote, protect, and maintain health status of the mother and fetus. 2. Determine the gestational age of the fetus and monitor fetal growth
and development. 3. Identify the client at risk for complication and minimize that risk
wherever possible. 4. Anticipate and prevent problems before they occur to the pregnant
woman or fetus and decrease occurrence of problems when possible. 5. Educate clients concerning ways to remain healthy during pregnancy,
prepare for labor and delivery, including birth plan, and how to care
for a newborn infant. Schedule of Antenatal Care Visits The early initiation of antenatal care is important for screen and preventing
maternal complications. Early antenatal care also allows for the development
of interpersonal relationships between health care providers and clients so that
each pregnant woman’s particular needs and wants are known and expressed in
a plan for delivery. Normally, the schedule of antenatal visits should be as follows: Up to 28 weeks — Once every 4 weeks 28-36 weeks — Every 2 weeks After 36 weeks — Weekly Note: The WHO Technical Working Group 1 (1994) recommended a minimum of four antenatal
visits for a woman with a normal pregnancy
to set a basic, essential standard for quality.
In Jordan, the practice is for ? ve antenatal
visits, scheduled at speci? c times during the
pregnancy to provide essential antenatal
services. Additional visits may be necessary
depending on the woman’s condition and
needs. 1 Antenatal Care: Report of a Technical Working Group (1994, November), World Health Organization Family and Reproductive Health, Geneva. 4. Standards of Care for Health Centers Vol. III - 5 Reproductive Health Antenatal Care For antenatal care to be effective, it should be: EARLY: beginning as early as possible in the
? rst trimester PERIODIC: according to the follow-up visit schedule
and with a frequency that depends on client
needs and level of risk ACCESSIBLE: to reach the target population Table 1. Timing and Content for the Minimum Number of Antenatal Care Visits Timing Content First Visit Before end of 3rd month
(12 weeks) • Screen & treat anaemia • Screen & treat an reproductive tract infections • Screen for risk factors & medical conditions • Initiate prophylaxis where required (e.g., iron supplementation for anaemia) Second Visit 6th or 7th month (24-28 weeks) • Assist mother to develop a birth plan • Begin discussion about family planning options • Review risk factors Third Visit 8th month
(32 weeks) • Screen for pre-eclampsia, multiple gestation, anaemia • Further develop the individualized birth plan and prepare for labor and delivery • Counsel about family planning options Fourth Visit In 9th month (36 weeks) • Continue screening for risk factors: pre- eclampsia, multiple gestation, anaemia • Identify fetal lie/presentation • Continue review to prepare for labor and delivery • Refer to where client has decided to give birth • Counsel about importance of postpartum care and family planning Fifth Visit 38 weeks • Review signs of labor and when to go to hospital • Review process of labor & delivery • Counsel about importance of post- partum care Standards of Care for Health Centers Vol. III - 6 Reproductive Health Antenatal Care Initial Evaluation History An obstetric history should be taken by a trained midwife or trained physician.
The data requested should be accurate, complete and include the following. • Client pro? le (registration): name, age, address, highest level of education achieved, occupation, duration of marriage, consanguinity,
special habits like smoking, and emergency contact. • Husband’s pro? le: highest level of education achieved, occupation. • Risk factors: age of mother, number of children, and space between children. • LMP and Estimated Date of Delivery (EDD). If the pregnant woman does not know when her last menstrual period was, recommend using
ultrasound to determine the EDD. Note: EDD (Expected date of delivery) is calculated by
Naegele’s Rule: add seven days, subtract three
months from the ? rst day of the LMP, or use the
Birth Wheel. • Menstrual regularity, lactation, use of contraception in the past, gravidity, parity, abortions, pre-term deliveries, still births • Mode, place, and date of previous deliveries. • Client’s desire for pregnancy; social history and support; history of medical problems; any other complaints or problems. • Outcomes and complications of previous pregnancies (e.g., full term normal healthy baby, stillborn, cesarean section, bleeding/
spotting during pregnancy), postpartum hemorrhage; multiple
gestation; eclampsia, sepsis, or other complications; operative
delivery; neonatal death; small infant (premature or intra-
uterine growth retarded); • Current pregnancy: symptoms of pregnancy; time of initial quickening during current pregnancy (Normal: 16-18 weeks for
multiparas; 18-20 weeks for primiparas); • Any symptoms or complaints during current pregnancy. • Medications taken during pregnancy. • Smoking or non-smoking (cigarettes or other forms). Standards of Care for Health Centers Vol. III - 7 Reproductive Health Antenatal Care • Fetal movement. • Perform risk assessment at initial visit, and reassessed throughout pregnancy. Use Coopland Risk Assessment table (see “Attachment 1:
Antenatal Risk Assessment Form”). • Family history: Diabetes mellitus, hypertension, multiple pregnancy, congenital abnormality, thalassaemia. • Surgical history: previous operations, abortion, caesarian sections. Physical Examination Perform the physical examination according to the following guidelines: • In a private area to ensure and protect the client’s privacy, dignity, and health. • In a comfortable manner. • In a systematic way, informing the client of results. Con? rm diagnosis of pregnancy: • By missed menstruation in otherwise normal cycles. • Typical changes in breasts and evidence of pregnancy on pelvic exam. • Pregnancy test: Urine ß-HCG most accurate on ? rst morning specimen, and within 7-10 days after missed menstrual period. Height and Weight Height measurement can indicate the need for risk assessment. A woman
with a height of 145 cm or shorter should be referred. • Weight should be measured at each visit by a trained staff member. • Measure height and weight at ? rst visit in order to determine the body mass index (BMI) using the BMI calculator/wheel.
Continue to determine and document BMI at successive visits.
The Normal range for BMI is 18.5-24.9 BMI = Weight (kg) Height (m²) • Use an adult scale to weigh the client: - Adjust balance at zero on a ? at level. - Weigh client in light clothing without shoes. - Record weight in kilograms (kg). Standards of Care for Health Centers Vol. III - 8 Reproductive Health Antenatal Care • Document any sudden weight gain and underline in red. • Total weight gain during the entire pregnancy should be determined according to the client’s B MI at the initial visit. • Average total weight gain during pregnancy is 9-12 kg. Note There has not been any documented evidence
that weight gain is a signi? cant risk factor. Blood Pressure • Should be taken for every client at each visit. • Allow client ? ve minutes to rest. • Check sphygmomanometer and stethoscope for proper operation. • Measure blood pressure using the following protocol: - Patient is in sitting or supine position and BP is measured at the level of client’s heart. - Cuff of suitable size; stethoscope placed 2.5 cm above the antecubital fossa of arm. - Note appearance of ? rst sound (korotoff) as systolic blood pressure (SBP). - Note disappearance of sound as diastolic blood pressure (DBP). - Record results and underline in red if deviated from normal. Range of normal: 80/60-140/90. If BP is higher than 140/
90 and does not come down after rest, refer for medical
management. HEENT (Head, Eyes, Ears, Nose and Throat) • Inspect (look at): face for puf? ness; conjunctiva for paleness and lips for cyanosis, tongue for color; mouth for cavities. • Palpate (feel) thyroid for enlargement. Breast • Inspect the breasts for symmetry, condition of nipples (? at, inverted). Standards of Care for Health Centers Vol. III - 9 Reproductive Health Antenatal Care Chest • Auscultate (listen to) heart and lung sounds. Extremities • Inspect ? ngernails for color, hand for swelling (ability to remove rings), feet and legs for swelling (an impression or dent when
pressed by your ? ngers). • Check re? exes, tap knee with re? ex hammer. If woman’s leg jerks VERY briskly and quickly, refer in the presence of high
blood pressure. Back • Tap the back over the kidney for signs of tenderness. If pain, check for other signs of urinary tract infection. Abdominal Examination • Inspect: shape and symmetry of the abdomen; signs/scars of previous operations; and for fetal movement. Obstetrical Examination • Palpation: assess growth by fundal height measurement starting at 16 weeks. Measure symphysis fundal height
(SFH) in centimeters; determine approximate gestational
age in weeks when the bladder is empty starting from upper
edge of pubic bone up to the upper limit of the fundus; any
discrepancy between date and SFH should be marked in red
(see “Attachment 2: Fundal Height Measurement”). • Starting at 16-20 weeks, use a fetoscope to measure fetal heart sound (auscultating) listening for rate and regularity.
Doppler can pick-up fetal heart tones easier and earlier but
? rst detection with a fetoscope helps in dating pregnancy; fetal
heart can ? rst be heard with a fetoscope between 18 and 20
weeks. Abnormality in fetal heart rate should be underlined in
red and referred. Expected fetal heart rate is 120-160 beats per
minute • Use the technique described in “Attachment 3: Lie & Presentation” for abdominal palpation in each visit after 28 weeks. • Manage and document any abnormality. Standards of Care for Health Centers Vol. III - 10 Reproductive Health Antenatal Care Pelvic Examination when speci? c vaginal or pelvic complaints exist Note Pelvic examination is not routinely required
at the initial evaluation. See “Attachment 4:
Pelvic Examination” for steps of the pelvic
examination: Step 1: External genital inspection Step 2: Internal speculum inspection Step 3: External genital palpation Step 4: Internal bimanual palpation Step 5: Rectovaginal palpation Ultrasound (U/S) If not routinely available, women at risk should be referred. • Ultrasound scan for determination of fetal size or abnormalities when indicated. Note that ultrasound scanning is not routinely
recommended for normal, uncomplicated pregnancies without
any of the following indications (see also Attachment 5): - Assessment of bleeding or pain in early pregnancy. - Differential diagnosis of troublesome vomiting. - Estimation of gestational age if otherwise uncertain. - In mothers who have large or small newborns (for gestational age) in past pregnancies. - Monitor fetal growth in high-risk pregnancies. - Assessing placental site, or identifying the source of antenatal bleeding or hemorrhage. - Examination of the fetus when the risk of congenital anomaly is high. - Determination of fetal presentation if unclear from the abdominal examination. Standards of Care for Health Centers Vol. III - 11 Reproductive Health Antenatal Care Electronic Fetal Monitoring • Electronic Fetal Monitoring (EFM) should be done when indicated (e.g., postdate). Note: In the case of postdates or reduced fetal
movement, refer the client to the hospital for
management including EFM. Laboratory Tests • Urine for albumin, glucose, and acetone at each visit • Urine analysis: ? rst visit, second and third trimesters • Blood group and RH factor at ? rst visit (see Attachment 6 for Rh incompatibility and indications for Rh type testing) • Hb and PCV at ? rst visit, second trimester, and in last month: Hb value of <10.5 mg underlined in red and refer for treatment
PCV: value of <32% underlined in red. Alternatively, a CBC can be
ordered to more fully assess anemia • VDRL (if indicated by history); if positive, Dark Field Examination is recommended • Rubella antibody titre (recommended) • Hepatitis B screening (recommended) • Vaginal smear if necessary for abnormal discharge • Blood sugar*: 18 weeks • Gestational Diabetes Mellitus (GDM) screening: if no risk factors screen at 28 weeks gestation; if any symptoms described in
“Attachment 7: GDM Screening” are present, then screen in ? rst
trimester or at ? rst visit, at 28 weeks, and 34-36 weeks. * Random blood sugar for all clients at initial visit and not later than 18 weeks; screen for gestational diabetes for a woman with a high risk for GDM by
determining if blood sugar level is over (135mg-140mg). A three-hour GTT
should be performed and referred according to standards. Standards of Care for Health Centers Vol. III - 12 Reproductive Health Antenatal Care Health Education Topics Client Health Education Messages General Guidelines • Divide information over the course of antenatal visits giving information when it would be most relevant. • Information needs to be repeated or assessed throughout the course of the pregnancy. • Build on information previously given. • Avoid giving too much information at one time. • If you may see the woman only once, choose the most important information to give her. Speci? c Client Health Education Messages 1. Birth planning 2. Common complaints and symptoms of pregnancy 3. Nutritional advice 4. Immunizations during pregnancy 5. Bathing and personal hygiene 6. Clothing 7. Relaxation and sleep 8. Danger signs during pregnancy 9. Travel 10. Drug education and classi? cation of drugs 11. Work during pregnancy 12. Sexual relationships 13. Care of teeth and gums 14. Breast care 15. Breastfeeding (lactation) counseling 16. Bowel habits 17. Birth spacing counseling 18. Exercise 19. Fetal movement 20. Health hazards to pregnant women and infants: smoking and
alcohol 21. Childbirth education 22. Warning signs of preterm labor 23. Physiology of labor 24. Postnatal care 25. Psychosocial problems 1. Birth Planning Counsel the client and her family to think ahead and make plans for when
the client will need to come to the facility to give birth. Waiting until the last
minute will only add additional stress to a very exciting period. Guide clients
in discussion to consider the following and take appropriate actions: • How far from where you live is the facility where you will give birth? • How will you get there? Who will go with you? • If you have to leave home during the night, who will care for the children? Standards of Care for Health Centers Vol. III - 13 Reproductive Health Antenatal Care If you have to use public transportation: • How much will it cost (transportation costs)? How can you save the amount? • Will the transportation be available at night? How will you get in contact with transportation? Help the client make realistic plans and link her to resources in her area. 2. Common Complaints & Symptoms of Pregnancy Many discomforts are expected in pregnancy, which are related to
cardiovascular changes, hormonal effects, uterine growth, and the change in
body posture. After investigation to rule out a serious pathologic condition, treatment may
be directed to symptomatic relief. Table 2. Common Complaints of Pregnancy. Complaint What to Tell the Client Provider Management Constipation • Increase your water intake (8 glasses); eat high-? ber foods,
and take daily exercise. • Use mild laxatives as a last resort. • Counsel the client on diet. • Prescribe psyllium hydrophilic mucilloid
(Metamucil), Lactulose
(Duphalac) • Suggest mild laxatives only if the other measures have
failed. Headache • Take mild pain relievers; e.g., paracetamol. Avoid aspirin. • Inform provider if pain becomes severe. • Determine that the headache is not a Danger
Sign (see below). • Offer paracetamol (Panadol, Revanin) 300 mg every
3-4 hours. • For severe headache or migraine, offer codeine or
other related narcotic might
be used. Remember: headache can be
associated with hypertension. Standards of Care for Health Centers Vol. III - 14 Reproductive Health Antenatal Care Complaint What to Tell the Client Provider Management Backache • Avoid excessive bending, lifting, or walking without a
rest period. • Rock pelvic periodically during the day for relief. • Wear supportive, low-heeled shoes. • If severe, wear a maternity girdle for additional support. • Heat or ice to back for relief, whichever is more comforting. • Counsel regarding comfort measures. Remember: the symptoms of
UTI and onset of labor include
backache. Nausea and
vomiting • Eat small, meals frequently. Keep crackers at bedside and
eat before getting out of bed.
Eat fruit or drink fruit juice
before going to sleep. • Avoid oily, spicy foods. • Get out of bed slowly. • Symptoms should not extend beyond the ? rst three months;
if severe and persistent, see
your health care provider. • Counsel about comfort measures. • Provide Vitamin B6, 50 mg, twice daily. • If symptoms are severe, refer for possible hospitalization
and intravenous
? uids. Medications for
management may include: - Meclozine, promethazine
(Phenergan) - Diphenhydramine
(Benadryl) - Other antihistamines • Birth defects have not been associated with the use of
these drugs. Varicosities • Elevate legs periodically during the day. • Wear support hose (elevate legs before putting on hose for
maximum support). • Prescribe support hose, as necessary. • Refer if varicosities are severe and painful. Standards of Care for Health Centers Vol. III - 15 Reproductive Health Antenatal Care Complaint What to Tell the Client Provider Management Vaginal
discharge • Cleanse genitalia daily. Wear cotton underwear. • Use light sanitary pads if discharge is heavy. • Avoid vaginal douching. • If discharge develops with itching, irritation or foul odor,
see the provider as soon as
possible for treatment. • If not infection, counsel for genital hygiene. • With symptoms of infection, treat according to guidelines
or refer for treatment. Leg cramps • During cramping, straighten leg slowly with the heel
pointing and the toes upward
or push the heel of the foot
against the footboard of the
bed or ? oor, if standing. • Exercise daily to enhance circulation. • Elevate legs periodically throughout the day. • Take calcium tablets daily. Eat calcium rich foods such
as dairy and dark green leafy
vegetables. • Prescribe Calcium carbonate or calcium lactate tablets 3. Nutritional Advice Eat foods from each of the six major food groups: 1) Fat (sparingly) 4) Meat 2) Milk, yogurt, cheese 5) Fruit 3) Vegetables 6) Bread, cereals, and other carbohydrates Drink plenty of liquids (especially water—8 to 10 large glasses, or 2 liters),
increase ? ber, and increase calcium and iron intake. For women whose BMI
is normal before pregnancy, maintain a normal weight gain according to BMI.
This is usually achieved by a well-balanced diet containing 60-80 gm protein,
2400 or more calories, low sugar and fats, high ? ber, milk and other dairy
products; higher weight gain may be required. Excessive weight gain or high
pre-existing maternal weight is associated with increased risk factor for the
infant in terms of birth trauma and delivery by Caesarean section. Standards of Care for Health Centers Vol. III - 16 Reproductive Health Antenatal Care Table 3. BMI Assessment and Recommended Weight Gain. BMI Assessment of Weight Recommend Weight Gain Less than 18.5 Underweight 12.5-18 Kg 18.5-24.0 Normal weight 11.5-16 Kg 24.0 and above Overweight 7.0 - 11.5 Kg Prescribing prenatal vitamins in most cases may not be necessary where diets
supply adequate calories, protein, and minerals for appropriate weight gain.
However, there are two exceptions: Folic Acid Supplementation pre-conceptually and throughout the early
part of pregnancy has shown to decrease the incidence of fetal neural
tube defects. Thirty to sixty (30-60) mg/d calcium up to 1.5 mg/d in later
months of pregnancy and during lactation. Iron Supplementation after 12 weeks is recommended. Also, increased
iron requirements in the latter part of pregnancy are dif? cult to meet in
the routine diet. To enhance the absorption of iron, instruct mothers to
take iron when eating meat or vitamin-rich foods (fruits and vegetables).
Avoid tea, coffee, and milk at the same time when taking iron; it
interferes with the body’s absorption of iron. Iron can also be taken
between meals with orange juice. 4. Immunizations during pregnancy for previously non-immunized women: adjust for
immunized women. Tetanus toxoid should be administered during pregnancy, especially if
exposure to pathogens is likely. Table 4. Tetanus Toxoid Immunization Schedule. Dose Schedule TT1
TT2
TT3
TT4
TT5 At ? rst contact, or as early as possible during pregnancy
Four weeks after TT1
Six to 12 months after TT2, or during subsequent pregnancy
One to three years after TT3, or during subsequent pregnancy
One to ? ve years after TT4, or during subsequent pregnancy • Live virus vaccine should be avoided during pregnancy because of possible damaging effects on the fetus. • Hepatitis B vaccine series may be given in pregnancy to women at risk of exposure. • Immune globulin is recommended for pregnant women exposed to measles, Hepatitis A, Hepatitis B, tetanus, chickenpox, or rabies. Standards of Care for Health Centers Vol. III - 17 Reproductive Health Antenatal Care 5. Bathing and Personal Hygiene • There is no objection to bathing during pregnancy; it is encouraged. • Advise taking extra precautions not to slip or fall when bathing or showering near the end of the pregnancy. • Tub baths at the end of pregnancy may be not advisable, as the heavy uterus usually upsets the balance of the pregnant woman
and increases the likelihood of tripping and falling in the
bathtub. Advise using a shower or pouring water over the body. • Advise washing breasts daily with a soft cloth and wearing a supportive bra. Avoid massaging nipples during washing. • Advise cleansing external genital daily, wiping from front to back, especially if vaginal discharge is present. Change
underwear frequently, and if possible, use cotton underwear. 6. Clothing • The clothing worn during pregnancy should be practical and non-constricting. • Well ? tting supporting brassieres indicated. • Contracting garters should be avoided. • Low-heeled shoes are recommended. 7. Relaxation and Sleep Instruct the pregnant woman to continue all ordinary activities with one or
two hours bed rest during the day. Adequate sleep may be dif? cult to achieve
as sleeping patterns change. Therefore, it becomes more important to ensure
rest breaks during the day. 8. Danger Signs During Pregnancy Teach the pregnant woman and her family to report any of the following
conditions immediately: • Vaginal bleeding • Sudden gush of ? uid or leaking of ? uid from vagina • Severe headache not relieved by Paracetamol • Dizziness and blurring of vision • Sustained vomiting • Swelling (hands, face, etc.) • Loss of fetal movements • Convulsions • Premature onset of contractions (before 37 weeks) • Severe or unusual abdominal pain • Chills or fever Standards of Care for Health Centers Vol. III - 18 Reproductive Health Antenatal Care 9. Travel • Travel is not harmful for a healthy pregnant woman. Avoid long periods of sitting, and take a walk every two hours to promote
circulation. • Travel in pressurized aircraft presents no unusual risks. 10. Drug Education and Drug Classi? cation The following are guidelines for the clinician who prescribes medication
during pregnancy or lactation: • Try to avoid any medication during the ? rst trimester. • Use single, non-combination, short-acting agents. • Choose topical (if available) over-the-counter medications. • Use the lowest effective dosage of the safest known medication. • Instruct breastfeeding mothers to use a single dose or short acting medication so they can feed again, past the peak blood
level to minimize the risk to infants. • Encourage breastfeeding mothers to watch and see whether the infant seems to have any problems related to any medication
the mother may be taking. Table 5. Drug Classi? cation Scale (to be used with Attachment 8): Category Description A No fetal risks (multivitamins).
Proven Safe during pregnancy. B Fetal risks not demonstrated in animals but there
are no human studies. C No adequate studies, fetal risks unknown. D Some evidence of fetal risks. 11. Work During Pregnancy Most women can safely work until term without complications. A ? exible
approach must be taken. Pregnant women who work should take breaks every
two hours and walk around frequently to support circulation. Pregnant women my have less tolerance to heat, humidity, environmental
pollutants, prolonged standing, and heavy lifting. Standards of Care for Health Centers Vol. III - 19 Reproductive Health Antenatal Care Pregnant women who should probably not work include: • Those with history of two premature deliveries. • Incompetent cervix and fetal loss, secondary to uterine abnormalities. • Cardiac disease greater than Class II (tires after minimal activity). • Hemoglobinopathies. • Diabetes; greater risk with retinopathy or renal involvement. • Third trimester bleeding. • Premature rupture of the membranes • Multiple gestations after 28 weeks. 12. Sexual Relationships There are no restrictions of sexual relations for pregnant women without
complications. Whatever is comfortable and pleasurable may continue unless
or until a pregnancy complication occurs (e.g., vaginal bleeding, preterm labor,
known placenta previa). Support the woman to avoid sexual contact if she or
her partner has symptoms of STI; ask her to see the provider immediately.
Encourage couples to use condoms where the risk of STI exists. Instruct the
mother to avoid sexual intercourse if the waters break or labor begins. 13. Care of Teeth and Gums • Encourage the importance of daily care and brushing of the teeth after meals. • Encourage the daily drinking of milk and eating dark, leafy vegetables to prevent loss of calcium and loss of teeth. • Pregnancy does not prevent dental care; it is required during pregnancy to prevent serious infections. • Encourage dental visits when needed. 14. Breast Care • Avoid nipple stimulation (touching, rubbing) and massage since these can provoke contractions. 15. Breastfeeding (lactation) Counseling Counsel the client on infant feeding during the third trimester, using client
materials and videos covering the advantages and behaviors of successful
breastfeeding and care of the breasts. Review breastfeeding preparation
messages at the 36th week of gestation. Breastfeeding is vital for child
survival, maternal health, and birth spacing. Introduce or reinforce LAM
criteria and optimal breastfeeding practices. Standards of Care for Health Centers Vol. III - 20 Reproductive Health Antenatal Care LAM Criteria A woman can use LAM if she answers “No” to ALL of these questions: • Is your baby 6 months old or older? • Has your menstrual period returned? (Bleeding in the ? rst 8 weeks postnatally does not count.) • Is your baby taking other foods or drink or allowing long periods of time (4 or more hours) without breastfeeding, either day or night? If the woman answers “Yes” to any one of these questions, she cannot rely on LAM
for prevention of pregnancy, but she can continue to breastfeed her baby while
using a method of contraception that will not interfere with lactation. 16. Bowel Habits During pregnancy, bowel changes may occur due to sluggishness of the
intestinal tract caused by the effect of progesterone and pressure from the
growing uterus. The following changes may be observed: • Constipation (common), due to generalized relaxation of smooth muscle and compression of lower bowel by the uterus.
It is characterized by discomfort caused by passage of hard
fecal material. • Bleeding and painful small tears may develop in the swollen and vascular rectal mucous. • Development of hemorrhoids. Tell the client that, to avoid these problems, she should: • Increase water intake (eight glasses per day); drink prune juice; take warm water or hot ? uids upon waking. • Pay close attention to bowel habits; go to the toilet when you feel the urge. Take suf? cient quantities of ? uid, vegetables, and
fruits with their skins, to increase dietary ? ber. • Engage in reasonable amount of daily exercise (e.g., brisk walking). • Take stool softener prescribed by provider with plenty of water. 17. Birth Spacing Counseling Introduce client to family planning and its purposes during the second
trimester, using health education talks, pamphlets and posters, and videos.
During the third trimester, counsel the client regarding all available methods.
This will be particularly important for women wanting immediate postnatal
IUD insertion or immediate postnatal voluntary surgical contraception.
Counseling should continue after delivery until the mother is discharged and
provide her chosen method, if appropriate. Standards of Care for Health Centers Vol. III - 21 Reproductive Health Antenatal Care Emphasize to the client that the recommended interval for spacing of children
is a minimum interval of at least two years. • Birth spacing is vital for maternal health and child survival. Bene? ts of birth spacing are: - Gives the mother time to renew nutrient stores. - Reduces the risk of death and illness of the mother and infant. - Promotes the health of the entire family by ensuring a healthy mother. - Saves lives. 18. Exercise Continue to be active but avoid fatigue. The trained athlete can continue
rigorous training during pregnancy but should avoid raising her core
temperature or becoming dehydrated. Exercise should be varied during the
third trimester to avoid too much stress on knee and ankle joints. Walking can
be accepted to the needs of most women. Exercise should include women’s
posture, muscular relaxation, and breathing exercise. 19. Fetal Movements Fetal activity is usually of cyclic frequency or pattern and may vary throughout
pregnancy. Lack of fetal movement or marked decrease in frequency may be
warning signal of fetal distress; inform provider immediately. 20. Health Hazards to Pregnant Women and Infants: Smoking and Alcohol Smoking should be discontinued during pregnancy. It is important to counsel
patients about this and record their compliance. The potentially harmful
effects of cigarette smoking during pregnancy include low birth weight,
premature labor, miscarriage, stillbirth, (cot) death, birth defects, and
increased respiratory problems in neonates. More than 10 cigarettes a day can
have a pronounced effect on birth weight. Many women do not realize the
severity of the risk. Patient education is important, with counseling or referral
to appropriate community groups. Alcohol use should be discontinued in pregnancy. Chronic alcoholism has been
shown to cause fetal mal-development that is commonly referred to as fetal
alcohol syndrome. The more alcohol the mother drinks, the more the fetus is
at risk of damage. Encourage mother to avoid social drinking. Avoid Exposure to X-rays and contact with persons
with infectious diseases (e.g., German measles,
chicken pox). Standards of Care for Health Centers Vol. III - 22 Reproductive Health Antenatal Care 21. Childbirth Education During the second half of pregnancy, provide information about preparation
for labor and birth, the proper place and who will attend the delivery,
preparation of baby’s and mother’s clothes, care of newborn, breastfeeding,
care of other family member, in order to: • Help the mother and family take a decision about the appropriate place of delivery. • Promote hospital delivery and delivery by trained health professional (doctor and midwife). • Promote breastfeeding. • Explain these processes to the mother and her family: - Process of labor. - Process of birth. - Labor relaxation techniques. - Comfort and support measures by those staying with the woman. - Postnatal care/infant care. See “Client Health Education Messages” (see #18 below) below for additional details
concerning physiology. See also “Attachment 9: Preparing the Pregnant Woman for Labor & Delivery.” 22. Warning Signs of Preterm Labor Infant outcomes are improved when preterm labor is diagnosed and treatment
is started early. Teach the mother signs of preterm labor. These signs include: • A feeling that the baby is “balling up” which lasts more than 30 seconds and occurs more than four times per hour. • Contractions or intermittent pains or sensations between nipples and knees, lasting more than 30 seconds, and recurring
four or more times per hour. • Menstrual-like sensations, occurring intermittently. • Change in vaginal discharge, including bleeding. • Indigestion or diarrhea. Standards of Care for Health Centers Vol. III - 23 Reproductive Health Antenatal Care 23. Physiology of Labor During the second half of pregnancy, teach the woman, her partner, and her
family, through discussions with health care staff, lectures, pamphlets, and
videos, about the normal physiology of labor, stages, preparation, anatomy of
birth canal, signs of labor progression, breathing, and nature of pain in order to: • Reduce the need for analgesia and anesthesia during labor. • Ensure cooperation of client with the attending staff during delivery. • Minimize fetal distress. • Reduction of some maternal complications (e.g., exhaustion) during delivery. • Minimize instrumental and operative interference. • Ensure smooth and shorter progression of labor. See also “Attachment 9: Preparing the Pregnant Woman for Labor & Delivery.” 24. Postnatal Care Instruct pregnant women when to return after delivery for postpartum visits.
The ? rst visit should be within the ? rst week after delivery, and the second
visit should be two to six weeks after delivery or sooner, if necessary. Explain
to the woman that if the following occur anytime during the postnatal period,
she should return to the health center or hospital immediately: • Heavy bleeding. • Fever or chills. • Abdominal pain or foul-smelling lochia (vaginal discharge). • Pain and/or tenderness, heat in the calf of the leg(s). • Feeling depressed or not happy. Explain the importance of postpartum care: • Monitors the mother’s full recovery from the effect of pregnancy and delivery. • Helps detect complications early for their effective management. • Facilitates family planning counseling and provision of method(s). 25. Psychosocial Problems The pregnant woman may have worries and fears about labor, or may doubt
her ability to care for the baby or for her other children. Health providers
need to be sympathetic, reduce anxiety, and provide problem solving with
counseling and/or education for the woman. Standards of Care for Health Centers Vol. III - 24 Reproductive Health Antenatal Care Follow-up Visits It is the responsibility of the provider to share the schedule of visits with the
client. The standard schedule of visits is as follows: Up to 28 weeks — every month 28-36 weeks — very two weeks After 36 weeks — every week • Frequency of visits: In normal pregnancy, minimum of 5 visits • High-risk patients should be seen more frequently; every 2 weeks till 28 weeks then weekly till delivery with the physician. • During each visit: History Talk with the client about the following: • Family and community support • Any complaints or problems • Follow-up on advice, health education messages, care, or referral provided at previous visits. Physical Examination Include the following during follow-up visits: • General appearance: weight, blood pressure, clinical signs of anemia • Fundal height in second and third trimester • Fetal well-being, using fetal movements or fetal heart sounds in the second and third trimester - (not less than 10 movements
in 12 hours) • Signs of physical abuse. • Lie and presentation in the third trimester • Physical examination for assessment of complaints. • Inquire if any problems since last visit (vaginal discharge, bleeding, edema, etc.) Laboratory Investigations • Urine for sugar, protein and acetone. Standards of Care for Health Centers Vol. III - 25 Reproductive Health Antenatal Care Referral: Sending a Client for Additional Services A referral form should be completed in full and signed. Referral Criteria • High-risk women: use “Antenatal Risk Assessment Form” (Attachment 1) to determine risk. Refer to a specialist if score is
3 or more (high or severe risk). • For U/S if indicated. • Last trimester before delivery: in a normal pregnancy, the pregnant woman should be advised to see the specialist
(obstetrician/gynecologist) at the 38th week. • Special conditions as required by the physician • Complete client management: document the course and recommended follow-up. Inform the provider who made the
referral. Completion of Client Records For the Provider Accepting a Referral A trained midwife or provider should complete and sign client records. • Keep client records complete with all relevant information. • Document ? ndings and management at each visit. Standards of Care for Health Centers Vol. III - 26 Reproductive Health Antenatal Care Attachment 1 Antenatal Risk Assessment Form (Coopland) Client Name:______________________ File Number:____________ Age:____________ Gravida:__________________________ Para:___________________ Abortions:_______ LMP: _______________ EDD:________________ EDD by Ultrasound _____________ A. Reproductive History Risk Score B. Medical or Surgical History Risk Score C. Present Pregnancy Risk Score Age <16 or >35 years 1 Previous gynecologic surgery 1 Bleeding > 20 weeks
< 20 weeks 1
3 1st visit > 20 weeks 1 Chronic renal disease 1 Anemia < 11% 1 Parity 0 >5 1
2 Diabetes Class B or Greater 3 Postmaturity 1 Abortion > 2 1 Gestational diabetes (Class A) 1 Premature rupture of membrane (ROM) or Polyhydramnious 2 History of infertility 1 Epilepsy 1 IUGR 3 Antepartum or postpartum bleeding 1 Psychiatric problem 1 Multiple pregnancy 3 Infant > 4 Kg 1 Other signi? cant medical disorders (e.g. cardiac disease). Score 1-3 according to severity. Abnormal fetal position (breech or malpresentation) 3 Infant < 2 Kg 1 Rh isoimmunization 3 Toxemia or hypertension 2 Preeclampsia or hypertension 2 Previous C/S 2 Abnormal or dif? cult labor 2 Column Total Total Score* = Total of three columns (A + B + C) Low Risk: 0 – 2 High Risk: 3 – 6 Severe Risk: 7 or more If pregnancy is assessed as a high or severe risk status, refer the pregnant woman to an OB specialist. Standards of Care for Health Centers Vol. III - 27 Reproductive Health Antenatal Care Attachment 2 Fundal Height Measurement 2 Measuring the Baby’s Growth The uterus moves up in the mother’s abdomen as the baby grows. The uterus
grows about two ? ngerbreadths in a month. At 12 weeks, the top of the uterus
is usually just above the pubic bone. When the baby is about 20 weeks old, the
top of the uterus is usually at the mother’s umbilicus. Use a centimeter tape
to measure the distance from the top of the pubic symphysis over the curve
of the abdomen to the top of the uterine fundus. Fundal height in centimeters
correlates well with weeks of gestation until the 34th week of pregnancy. The ? gure illustrates fundal height at different stages of pregnancy: 2 Beck, D., Buf? ngton, S., McDermott, J, and Berney, K. Healthy Mother, Healthy Newborn Care: A Reference for Caregivers. American College of Nurse-Midwives, MotherCare (JSI, Inc.), 1998 Standards of Care for Health Centers Vol. III - 28 Reproductive Health Antenatal Care Attachment 3 Lie & Presentation Feel for the baby’s head and body. By 30-32 weeks, the baby is usually lying with
the head down towards the mother’s pelvis. (Vertex presentation). Most babies
lie more on one side of the mother than the other. Look and feel for movement of the baby as shown in the diagrams below: Step 1: Feel what part of the baby is in the upper uterus. Step 2: Feel for the baby’s back. Step 3: Feel what part of the baby is in the lower uterus. Step 4: Feel for descent of baby’s presenting part. Standards of Care for Health Centers Vol. III - 29 Reproductive Health Antenatal Care Attachment 4 Pelvic Examination In preparing to perform the pelvic examination: • Con? rm that the client has recently emptied her bladder. • Explain to the client what you are going to do and answer questions. • Layout all instruments and equipment that you will need. • Ensure that the examination space is private, that the examining table does not face the door; that curtains or a
barrier protects the client from exposure. • Position woman appropriately on examination table with feet in stirrups. • Drape the client’s abdomen and pelvis with a cloth, towel or her own clothing. In all cases, respect her modesty and treat
her with dignity. • Position light for good illumination of the cervix. • Open instruments or examination pack with instruments. • Wash your hands, dry them with a clean towel or air-dry, and put on high-level disinfected gloves. Step 1: Inspection of External Genitalia: Purpose: to check for any in? ammation, discharge, growth or lesions. Ask the client to separate her legs and look at the external genital structures: • Mons pubis – presence and distribution of hair; presence of lice or nits. • Labia majora and minora – presence, intact; color; presence of discharge, mass (growth), or discoloration. • Bartholin glands opening – normally not visible; abnormal ? nding include, presence of redness or discharge. • Perineum – smooth and unbroken, presence of mediolateral episiotomy scar; presence of ? stula or abnormal mass. Gently separate the labia major and labia minora and look at the deeper external
structures (tell the client you will be touching her before your touch her): • Clitoris – presence, size; abnormal masses. •