Antenatal care

1. Antenata Care (ANC)
Session Objectives:
Discuss minor disorder of pregnancy
Define antenatal care
Describe focused antenatal care (FANC)
Describe basic elements of FANC assessment and care.
 Calculate EDD and G/A
Describe the elements of Birth Preparedness and
Complication Readiness plan
Demonstrate the provision of focused antenatal care

2. Minor Disorders Of Pregnancy
Minor disorders are only disorders that occur during
pregnancy and are not life threatening.
1.Nausea and vomiting:
This presents between 4 and 12 weeks gestation.
Hormonal influences are listed as the most likely causes.
It is usually occurs in the morning but can occur any time
during the day, aggravated by smelling of food.
Management: - Reassure the mother
- Small, frequent meals, dry meals
- Reduce fatty and fried containing foods.
- Rest
If severe, follow the management of hyperemesis gravidarum
( in hospital set up)
2

3. 2. Heart burn: - is a burning sensation in the mid chest
region.
Progesterone relaxes the cardiac sphincter of the
stomach and allows reflex of gastric contents into
esophagus.
 Heart burn is most troublesome at 30-40 weeks
gestation because at this stage is under pressure from
the growing uterus.
Management:
- Small and frequent meal,
-sleeping with more pillows than usual.
-eat less fat more protein
- For persistence/sever case/ prescribe antacids 3

4. 3. Pica:
• This is the term used when mother craves certain foods of
unnatural substances such as coal, soil...etc.
• The cause is unknown but hormones and changes in
metabolism are blamed.
• Reduce level of serum iron and zinc also suspected reason.
Management:
 help the women , to avoid eating of harmful substances
if the food harmless, give for the women
 Seek medical advice if the substance craved is potentially
harmful to the unborn baby.
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5. 4. Constipation: - Progesterone causes relaxation and decreased
peristaltic activity of the gut, which is also displaced by the
growing uterus.
Management:
 Increase the intake of water, fresh fruit, vegetables and
roughages in the diet.
 Exercise is helpful, especially walking
5. Backache:
 Progesterone relax joints and ligaments
 The enlarged uterus altered the posture, curved backward
Management:
Advice the mother to sleep on firm bed.
Advice support mechanisms of the back, support by straight wall.
5

6. 6. Fainting: In early pregnancy fainting may be due to
the vasodilatation occurring under the influence of
progesterone before there has been a compensatory
increase in blood volume.
In late pregnancy the pressure of uterus on the inferior
vena cava, slows the return of blood to the heart.
Management:
o Avoid long period of standing
o Sit or lie down when she feels slight dizziness
o She would be wise not to lie on her back except
during abdominal examination
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7. 7. Varicosities
Progesterone relaxes the smooth muscles of the veins and
result in sluggish circulation.
Cause swelling and clot on veins
It occurs in legs, vulva and anus (hemorrhoids)
Management:
• Exercising the calf muscles by rising on the toes
• Elevate the leg and rest on the table
• Support thighs and legs
• Avoid constipation and advise adequate fluid intake.
• Sanitary pad give support for vulva varicosities
Most minor disorders can be advanced into a more serious
complication of pregnancy (Danger signals of pregnancy)
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8. Antenatal Care(ANC)
Definition:
Antenatal care is a comprehensive primary health
care provided for a pregnant women to improve
maternal and perinatal outcomes.
Objectives of ANC: To
1.Screening, diagnosis and management of pre-existing
maternal disorders (DM, CVD, infections. etc).
2.Diagnosis and management of Obstetric and other
maternal complications during pregnancy including
minor disorders of pregnancy.

9. 3. Detection and management or preferable prevention of fetal
complications including structural anomalies, infections and
growth retardations.
4. Planning for labor and delivery, care of the newborn and
future reproductive performance.
5. Ensure the welfare of the mother and the fetus during
pregnancy and labour.
6. Ensure that the baby is born with its optimal intellectual and
physical abilities

10. Sites of ANC:
- Home
- Private sectors
- Public Health facilities
Personnel:
-Midwives
-Nurses
-Health officers
-Physician
-Obstetrician/Gynecologists

11. ANC Service should be:
- Available - Affordable(cost)
- Accessible(any time) - Acceptable(standard)
Insufficient antenatal care may be due to:
-Ignorance
-Poor skill
-Poor Incentive for personnel
-Ill-trained and supervised staff
-Lack of supply
-Cost of treatment

12. 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:
Get information about her health
Discuss her concerns, thoughts, and worries
Know in advance about any planned procedure to be
performed
Privacy
Confidentiality
Express her views about the services she receives
 Select the health institutions

13. Approaches on the number of visits:
1.Traditional Methods
2. Focused ANC Care
1.Traditional approach:
 Non comprehensive, old, time consuming
Follow – up Visits Ideally:
-every 4wks up to 28 wks
-every 2wks up to 36wks
-every 1wk till delivery
Alternatively patients can be grouped into low, medium and
high risk!!

14. The traditional visit is:- not used currently
Risk approach
Time consuming
Tedious for the mother & professionals
Quality of care is poor
Not woman friendly
Poor communication

15. 2. Focused ANC:
It is comprehensive, coordinated, short and with few
number of visits.
FANC emphasizes:-
Individualized care
Client centered
Fewer but comprehensive visits
Disease detection not risk classification
Care by a skilled provider

16. In focused ANC system:-
Privacy/Confidentiality is assured
Continuous care provided by same provider
Promotes partner/ support person involvement
Adheres to national protocols
Referral Facilitated: catchment, ambulance, phone.no
ANC, Labour & delivery, PNC And Family Planning
Services are linked and housed within the same location if
possible.

17. Objectives of Focused ANC
1. Health Promotion and Disease Prevention:
Counsel the woman and provide the services as
necessary:
• Immunization against tetanus(TT1-TT5)
• Iron and folate supplementation.
• How to recognize danger signs, what to do, and
where to get help (health education)
• Voluntary counseling and testing for HIV
• The benefit of skilled attendance at birth
• Breastfeeding
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18. • Establish access to family planning
• Protection against malaria with insecticide-treated bed
nets.
• Good nutrition and the importance of rest
• Protection against iodine deficiency
• Risks of using tobacco, alcohol, local stimulants, and
traditional remedies
• Hygiene and infection prevention practices
• Avoid use of any drug-b/c of Teratogenicity effect.
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19. 2. Early detection and treatment of complications and
existing Diseases:
 Detect pre-existing diseases as early as possible
Skilled treatment of complications
Do intensive level of monitoring and follow-up care
over the course of pregnancy.
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20. 3. Birth Preparedness and Complication Readiness Plan:
Approximately 15% of women will develop a life-threatening
complication. So, every woman and her family should have a
plan for the following:
 A skilled attendant at birth
 How to get the place of birth and
 How to access emergency transportation if needed
 Items needed for the birth
 Money saved to pay for transportation, the skilled provider
and for any needed mediations and supplies that may not
been provided for free
 Support during and after the birth (e.g., family, friends)
 Potential blood donors in case of emergency.
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21. In focused ANC WHO recommended 4visits in normal
condition:
First visit: before 16 wk( conception -16 wk)
Second visit: 24-28wk
Third visit: at 32 wk
Fourth visit: at 36 wk
ANC visit must started as early as possible .
Good clinical decisions must be made at each visit.
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22. Terminology
Gravidity: number of pregnancy
Primigravida -a woman pregnant for the first time
Multigravida -a woman who has had two or more
pregnancies
Parity- refers to delivery after point of viability(>28week)
Nullipara -a woman who has never produce a viable
offspring.
Multipara -a woman who has given birth to more than one
child.
Grandmultipara -woman who has given birth to six or
more children

23. Lie: is the relationship of the long axis (spine) of the fetus to
the long axis of the mother’s uterus. can be:
• longitudinal –normal lie
• Transverse- abnormal & horizontal
• Oblique- abnormal & inclined
Attitude: is the relationship of the fetal parts to one
another. It can be:
• flexion- normal attitude
• extension and deflection-are abnormal
-Presenting part: is the part of the fetus felt at the
lower pole of the uterus and felt on abdominal
examination and on vaginal examination.

24. Presentation: is the part of the fetus in the lower pole of the
uterus.
• the normal presentation is vertex and
• abnormal are: breech, face, brow and shoulder.
Position: is the relationship of the denominator to the six
areas of the mother’s pelvis.
• Normal position is anterior or lateral and
• abnormal position is Occipito-posterior position.
Crowned: When the Bi-parietals pass the ischial spines and
the head no longer recedes between contraction (the head
distends the vulva).
Viability= able to survive outside the womb (28+ weeks of
gestation.

25. Denominator: The part of the fetus which determines the
position.
 (Vertex- occipute, breach -sacrum.
 Face- mentum, & acromium processes -shoulder).
Engagement: when the Bi-parietal diameters of the fetal
head passes through the pelvic brim.
Stillbirth-birth of baby with no signs of life at or after 28
week of G.A.
Abortion-termination of pregnancy before 28 wk of GA.
IUFD-fetal death inside the utres after 28 wk of GA.
Initially un known by the mother & may not have labour.
Neonatal death-death of neonate (birth-28 day)

26. Examining a pregnant woman
Examination of pregnant woman starts when she enters to
the ward(room).e.g. gait, well/sick looking,
The examination begin by history taking
History taking
History taking: Is a means of assessing the health of the
woman to find out any condition which may affect child
bearing.
Social history: name, age ,address, occupation, marital
status…etc.
Family history: hereditary disease :DM, HPN, twins,
psychiatry, heart, allergies ..etc.

27. Medical Hx: Past &present: polio, TB, rickets, v. veins, HPN,
renal problem, allergy, epilepsy, psychiatry, infection
Surgical Hx: Any operation / blood transfusion
Past obs and Gyne Hx: History on previous pregnancies
and deliveries(complication, fetal condition, fetal Kg
-Problems during pregnancy, labour, PPH….
-Gravidity, parity, stillbirth, neonatal death, abortion.
-congenital anomaly, Reproductive tumor,
History of present pregnancy:
-Menstrual history
- LNMP, EDD, G/Age
-any problem during this pregnancy: malaria, infection,
vaginal bleeding, edema. Etc.

29. EDD & G/A Calculation:
EDD= Expected date of delivery
-EDD=LNMP+9month+1oday
LNMP=Last normal menstrual period
-first day of last menstruation period
G/A = Gestational age, age of fetus in intrauterine life
-time length from LNMP to the actual visit
-commonly express in week/month
NB: 5 or 6 day, the 13th month called pagume in
Ethiopian calader. So, pleas consider it in EDD & G/A
calculation.

30. Examples
1. Calculate EDD and G/A of a woman with LNMP of
10/01/2012 EC.
EDD=
G/A=
2. Calculate EDD and G/A if a woman with LNMP of
20/12/2011 comes for ANC visit by the date of
21/05/2012
EDD=
G/A=

31. Assignment for submission
1.
2.
3.
4.
5.

32. Physical examination
Objective:
 To diagnose pregnancy
 To identify high risk pregnancy
 To give advice for pregnant mother

33. General examination:
-weight, BP, fundal height, FHB, V/S
-appearance –sick looking, dehydrated, weak
-Abdomen – big ,small , pendulous, flat
- Measure height—less than 150 cms ???
- weight-total Wt increment in average is 12kg
-in 1st half 20wk- has 2kg increment
-In 2nd half 20 wk- has 10kg ’’ ”
- Blood pressure –to ascertain the baseline for follow up
through out pregnancy.
Ultrasound examination- if necessary
16-18wk and 36week is best time.

34. Investigations:
U/A – Protein, glucose, ketone at 1st visit & as necessary
Blood for: - Hemoglobin
- VDRL-for syphilis
-Blood group, Rh
-FBS
HIV-test: PMTCT
 Hgb at 1st visit and 36 weeks
 At 1st visit (booking visit )only: blood group & RH,
PMTCT, (VDRL-may indicate if).

35. Physical Examination:
Head – clean, scalp– oily, dry,
Face –clear, puffy, edema ,jaundice
Ear /nose –discharge
Neck –gland enlargement
Breast –mass , symmetry….
nipple– everted, erect, flat, depressed,
inverted, engorgement, colostrum.

36.  Abdominal Examination
AIMS
- To observe signs of pregnancy- if not early
- To assess fetal growth
- To detect any deviation from normal.
Steps for Abdominal Examination
1. Inspection
2. Palpation
3. Auscultation

37. Inspection
a. Shape:-Note contour -is it round, oval, irregular or
pendulous?
- Longitudinal, ovoid -in primigravida
- Round -in multiparaus.
- Broad- in transverse lie
b) Size:- Should correspond with the estimated GA.
c) Skin: - linea-nigra -the dark midline pigmentation
-Stare gravid arum –discoloration due to
abdominal distattntion
e) Scar - Any operation scar(c/s)

38. On Palpation:
1. Fundal height and fundal palpation (1st Leopold
Maneuver)
1.1 Fundal Height:
At 12 wk - the uterus is palpated at sympahysis pubis
At 20 week –uterus reaches at umbilicus
At 36 weeks -xyphoid process
At 40 weeks-returns to about 4 cm below the
xyphiod due to “lightening.”
Method: Measure distance of funds with points on
abdomen

39. Assessing the fundal height:
1.tape measurement:
 by centimeter from sympahysis pubis to xyphoid
process.
 1cm corresponds with 1 week
+/- 2week error
2.fundal palpation:
o finger method
o above umblicus-1 finger =2week
o below umblicus-1 finger =1week
Purpose- To know lie, presentation and fundal
height(GA).

40. Method: - Use palms of 2 hands palpate on with fingers held close
together, palpate the upper pole of the fundus. Soft, irregular,
bulky, non-ballotable mass(breech). Hard, round ,ballotable
mass(head).
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41. 2. Lateral Palpation: (2nd Leopold maneuver)
Purpose-To know lie & position
Always facing towards the mother and palpate gently by
supporting in opposite hands.
 Irregular, bulky- (Extremities-front side)
 Linear, rigide,and smooth -(back)
Check FHR : -rate and rhythm,
-count for one minute(100-180 beat/minute)
Use fethoscope:
- hand should not touch it while listening,
- ear must be in close from contact with fethoscope

42. Lateral palpation
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43. 3. Deep pelvic Palpation(3rd Leo poled Maneuver):
Always facing in opposite to the mother and palpate deeply.
Purpose -To Know Presentation ,Attitude & descent
Presentation: breech/cephalic
Attitude:
Flexed –cephalic prominence is in opposite side of back.
Extended-grove in neck
Descent: down warad movement of fetal head
-by using rule of 5th : 5/5th- floating, 2/5th -engaged

44. 3rd maneuver
44

45. Estimation of descent by rule of 5th
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46. 4.Pawlick's Grip: (4th Leopard Maneuver):The lower pole of
the uterus is grasped with the right thump &2/3 fingers.
Purpose: To know engagement & presentation
=fixed head - engaged and floating head is -not engaged
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47. Auscultation:
FHR is must auscultated at the back side of the fetus
 Fetal heart rate is first heard:
-at 16-18 week’s -in multipara and
-at 18-20 weeks -in primigravida.
In breech the fetal heart is heard above the
umbilicus.
In cephalic presentation it is heard below the
umbilicus
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48. Genito-Urinary System:
- Frequency of micturition
- Check for abnormal discharging
Circulatory System:
Varicosities: - Varicose veins may occur in the
legs, anus (hemorrhoids) and vulva.
-Vulval varicosities are rare and very painful.
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49.  The Vulva
- Vulval warts
-irritating discharge
 The Lower Limbs
-Examine for bones alignment and deformities.
-Check pitting edema in the lower limbs by
applying fingertip pressure for 10 seconds over the
tibial bone.
-Check DVT-by extension of lower legs.

50. Screening High – risk groups:
1. Previous IUFD
2. Previous neonatal death
3. IUGR
4. Polyhydramnios, oligohydramios
5. Unsatisfactory maternal weight gain or weight
loss
6. Hypertension
7. Sustained proteinuria of 2+ or >
8. APH
9. Multiple pregnancy

51. 10. Recurrent premature labour
11. Medical Conditions
12. Rh- isoimmunization
13. Post-maturity
Know decide for: -can we follow
-refer immediately or
-stay until term & referred

52. Health education:
 Nutrition: Diet – balanced (Protein, CHO, fat.
Vitamins) fruits , Iron; calcium, folic acid, increase
cal/day,
 Weight gain – favorable range of 10 – 12Kg
Recommended weight gain during pregnancy
1st half 20wk =2 kgs
2nd half 20wk=10—11kgs
NB: 0.5kg/week after 2nd half

53.  Bad habit: avoid use of any drug
Alcohol – is best avoided
-Fetal Alcohol Syndrome (80 gm/d)
-IUGR
-Mental retardation
Smoking:
-IUGR; abruption
- in prenatal mortality
 Exercise– not necessary to limit
-but not be vigorous and exhaustive

54.  Avoid use of raw meat & milk
 Have adequate rest
 Avoid any exposure to d/t chemical/radations
 Start TT vaccination starting from 1st visit.
 Hygiene : personal/enviromental
 Use of ITN/bed net-to prevent malaria
 HIV test & PMTCT
 Health education about minor disorders

55.  Clothing – Comfortable, non-constrictive
 Nipple stimulation -after 36 weeks of pregnancy
 The Birth plan & Complication Readiness(BP/CR)
-Skilled provider
-Transportation
-Funds(money)
-Support person
-Blood donor

56. `
 Provide Iron: take as soon as after gestation starts
 Every women must take Fe during pregnancy.
 Iron for 6 month/180 tablet & 1-3 month after birth. Take 1
tap/day in normal condition
 Iron Folate: 60 mg Ferrous sulphate(Fe) + 400mcg/0.4mg
Folic Acid/Vitamin B9
 Folic Acid: -formation of RBC & DNA
-prevent neural tube defect/spinal cord
-helps the body to produce & maintain new cells
-prevention & treatment of anemia
Source of FA: avocado, beans, peas, nuts, lentils, dark green
vegetables & citrus fruit and juice

57. Fe used for: -formation of hemoglobin; prevent anemia
-transport of oxygen
-formation of fetal & maternal RBC.
-Source: meat, liver, egg, poultry, brade, cereals, beans, peas,
lentils, fruits, & vegetables
SE: epigastric pain, constipation/diarrhea, dark feces.
Best time to take: empty stomach (1hr before/2hr after meal but
to reduce its SE usually taken with meal.
CI: milk, antiacid-Mts, oral contraceptive,& drugs like quinolone,
ciprofloxacine……
In history of recurrent abortion, spina bifida, hydrocephalus &
other conditions Fe folate may start before pregnancy.

58.  Advice on danger sign: must report???
Vaginal bleeding
Blurred vision
Reduced fetal movements
Sever headache
Sudden swelling
Rupture of the membrane
Premature onset of contractions
Maternal anxiety for whatever reason……..???

59. Ante partum Fetal Surveillance
 Definition: Ante partum Fetal Surveillance is
method used for assessment of fetal wellbeing
and used to identify the fetuses at risk of
intrauterine hypoxia or even death in uterus
 Aims :
 To identify fetuses at risk of intrauterine hypoxia
so that a permanent injury like death should be
prevented by timely intervention.
 To identify healthy fetuses among those suspected
to be in problem on clinical evaluation so that an
unnecessary intervention may be avoided.

60. INDICATATIONS
All pregnancies require fetal wellbeing assessment,
however it focuses to high risk groups like;
1. Primigravida aged 35 or more.
2. Multipara aged 40 or more.
3. Small for date fetus.
4. Bad obstetrics history.
5. Pre-existing medical conditions.
> Diabetes mellitus.
> Renal disease.
> Hypertension.

61. 6. Pregnancy related Diseases:
> PIH , rhesus incompatibility.
7. Post date pregnancy.
8. APH.Decreased fetal movements.
 Timing of prenatal Assessment :
-1st trimester – diagnosis of pregnancy and
gestational age.-2nd trimester – diagnosis of
congenial malformations
-3rd trimester – assessment of fetal wellbeing

62.  Ante partum Fetal Surveillance techniques:
1.Biophysical profile (BPP)
2.Nonstress test (NST)
3.Contraction Stress Test
4.Fetal movement assessment (“kick counts”)
=are common ,but many in number

63. 1.Biophysical profile (BPP):
 BPP is consists of 5 components:
-Amniotic fluid index (determination of the
amniotic fluid volume)
-Fetal breathing movements
-Fetal movement
-Fetal tone
-Non-stress test

64. Fetal Biophysical Scoring System
Parameters score 2 score 0
1.Breathing movements FBM for at least 30 i.Absent
secs in 30 mins ii.FBM>30 se
2.Gross body movements 3 movements of 2 or less fetal
limbs in30 min movements in
30 mins.
3.Fetal Tone 1 extention with flection i.no
ii.slow flextion
4.AFV > =2cm <2cm
5.NST Reactive Non reactivity

65. -Score of 8 to 10 - is normal
-Score of less 6- is abnormal
-Score of 6 &7- is borderline
 2.Non-Stress Test =FHB & fetal movement
 The NST is based on the premise that the heart rate of a
fetus that is not neurologically depressed will
temporarily accelerate with fetal movement. Heart rate
reactivity is thought to be a good indicator of normal
fetal autonomic function. Loss of reactivity is associated
most commonly with the fetal sleep cycle but may result
from any cause of central nervous system depression,
including fetal acidosis and some medications.

66.  To perform NST, the mother is asked to denote when the
fetus moves. The fetal heart rate tracing is then evaluated
for accelerations of the fetal heart rate corresponding with
fetal movement.
A reactive (normal)- >2 fetal heart rate accelerations
,15beat/m from base line lasting 15 seconds within a 20-
minute period.
 A nonreactive - lacks sufficient fetal heart rate
accelerations over a 40-minute period.
 The NST of the normal preterm fetus is frequently
nonreactive:

67. 3.Contraction Stress Test=FHB & Contruction
The CST measures the response of the fetal heart rate to
uterine contractions. It relies on the premise that fetal
oxygenation will be transiently worsened by uterine
contractions.
 To perform CST, the fetal heart rate and uterine
contractions are simultaneously recorded with in Doppler
US(FHB)&Toco-Daynamometr(contruction).
=Negative(normal)-no late deceleration in all contruction.
=Positive-has late FHB deceleration with in contruction.

68. Repetitive variable decelerations (at least 3 in 20
minutes), even if mild, are associated with an
increased risk of cesarean delivery.
Decelerations that persist for >1 minute (prolonged
decelerations) are associated with a markedly
increased risk of both cesarean delivery for a non
reassuring fetal heart rate pattern .

69. 4.Fetal movement assessment (“kick counts”)
 This observation provides the rationale for fetal
movement assessment by the mother ("kick
counts") as a means of ante partum fetal
surveillance.
 There should be minimum of 10 movement within
12hr .
- > 12hr for 10 movement is abnormal.
- >= 10 movement in 1hr is also abnormal.

70. HIV/AIDS
By the end of this session, students will be able
to discuss:
-The difference between HIV and AIDS.
-Body Fluids that Transmit HIV and prevention
- Stage of HIV/AIDS
-Counseling process and advantage of PMTCT
-Difference b/n PICT, VCT & PMTCT

71.  HIV - Human ImmunoVirus; is the virus that
attack our immunity and causes AIDS.
 Specific type of virus (a retrovirus)
 The CD4 cells are our soldiers and HIV attacks
them.
 Strong CD4 cells are able to fight off infection But,
HIV damages the CD4 cell, eventually killing it.
 So, HIV damages the system that usually protects
the body from infection.

73. • AIDS- stands for aquired Immuno deficiency Syndrome
• Disease limits the body’s ability to fight infection
• A person with AIDS has a very weak immune system
• No Cure. According to the Centers for Disease Control
and Prevention (CDC), a person with HIV infection has
AIDS when he or she:
has a CD4 cell count (a way to measure the strength
of the immune system) that falls below 200. A normal
CD4 cell count is 500 or higher. OR
develops any of the specific, serious conditions - also
called AIDS-defining illnesses - that are linked with
HIV infection(OI).

74. Potential Bodily Fluids contains HIV
 Blood products-mainly
 Semen
 Vaginal fluids
 Breast Milk
 What about tears, sweat, saliva, urine or feces?
Reading assignment :??????
-Transmition & Prevention?
-WHO 4-stage of HIV?

75. HIV and Pregnancy
 Pregnancy does not accelerate the progression of
HIV disease to AIDS. but
 Patients with AIDS are more likely to suffer from
pregnancy related complications.

76. Effect of Advanced HIV on pregnancy:
 Spontaneous abortion
 Infections (opportunistic, GU, postpartum, post-
surgical)
 Preterm labor
 Premature rupture of membranes
 Low birth weight babies
 Stillbirths

77. Current Status of Mother to Child Transmission:
During pregnancy: 5-10%
During labour &delivery: 1o-20%
During breast feeding: 5-10%
 Maternal factors increase the risk:
 Severe immune deficiency.
 Advanced clinical and immunological state
 Maternal malnutrition. ..etc

78.  Fetal factors increasing risk:
 Prematurity
 Low birth weight
 multiple pregnancy
 Viral factors-viral load
 Obstetric factors:
-mode of delivery
-PROM-
-Routine infant airway suctioning..etc

79. National Strategies for PMTCT
There are 4 strategies:
1st .Primary prevention of HIV in childbearing
women.
2nd .Prevention of unintended pregnancy in HIV
positive women.
3rd .Prevention of transmission from HIV + women
to their infants.
4th .Treatment, care and support of women infected
with HIV, their infants and their families.

80. All HIV+ pregnant woman must start ART
regardless of there cd4 number.
Preferred regiment is:(option B+)
=TDF+3TC+EVZ
TDF-Tenofovir- has risk of nephrotoxicity
3TC-lamivudine
EVZ-Efavirenz

81. Nevirapine suspension –to the neonate for 6wk.
Wt 2-2.5kg=10mg(1ml)daily
Wt >2.5kg=15mg(1.5ml)daily &W<2kg=2mg/kg
 Feeding option-exclusive breast feeding-best
- formula feeding-risk of infection
 Avoid blood contact b/n mother-baby
 Skill birth attendant
 Admit the mother as early as possible
 Immediately after birth initiate NVP-for neonate as
prophylaxis.

82. Definition of counseling:
Counseling: is a two-way communication process
that helps individual to :
 Examine personal issues
 Make decisions
 Make plans for taking action
 In HIV counseling and testing the focus of the
sessions is helping clients to make decision based
on their HIV status.

83. HIV counseling involves:
 Listening
 Respect for the client
 Confidentiality
 Asking questions
 Allowing clients to make their own decisions

84. Counseling is not:
-Telling clients what to do
-Criticizing clients
-Forcing ideas or values on clients
-Taking responsibility for clients’ actions or
decisions.

85. Patients Rights during counseling:
Confidentiality
Privacy
Refuse testing
Be treated with respect
Information
Ask questions

86. HIV counseling and testing (HCT) Approaches:
 Client – voluntary counseling and testing (VCT)
 Provider initiated testing and counseling (PICT)
 Mandatory and compulsory HIV testing
 Testing for medical research and surveillance

87.  Voluntary Counseling & Testing (VCT) is an
HIV-prevention intervention initiated by the client
at his or her free will.
 VCT provides the opportunity for the client to
confidentially explore and understand his/her HIV
risks and to learn his/her HIV infection status with
the support of a counselor.

88. Components of a VCT Program
 Type of counseling session
 Individual
 Couple
Pre-test counseling:
 Introduction and orientation
 Risk assessment
 Option for risk reduction
 Preparation for the test result

89. Post-test counseling:
 HIV negative test result:
 Negotiate risk reduction plan
 Support for risk reduction plan
 Negotiate disclosure & partner referral
 HIV positive test result:
 Identify source of support
 Negotiate disclosure and partner referral
 Risk reduction issues
 Referral

90.  PICTH-Routine testing of all patients who need an HIV test
in addition to other medical checkups.
 Test is usually offered by a health care worker as part of
regular medical care. Increase individuals’ access to HIV
testing, and therefore increase the number of people who
know their status.
 Increase uptake of ARVs .
 Many people prefer to be tested by a health care provider
during a regular visit to the clinic.
 PIHCT takes less time.

91. Take Aways
 Definition & objectives of ANC
 Approaches of ANC: Traditional Methods & Focused ANC
 Component of the 4 FANC-Visits:
-History taking
-EDD & G/A Calculation
-Physical examination
-4 abdominal Palpation(Leopold maneuver)
-Complete health education
-Health education about danger signs
-Iron folate supplying & TT vaccination
-The Birth plan & Complication Readiness
-National Strategies for PMTCT

92. Thank You