COMMUNITY MIDWIFERY

Jameela Haruna A.
Rn, Rm, Bnsc, Pgde, Pgdns

INTRODUCTION:
Antenatal care is a form of health service provided to a woman throughout pregnancy to ensure
a safe gestation and childbirth, and prevent complications to the mother and the baby. This type
of care offers a range of healthcare services including prevention, detection, and treatment of
anaemia, malaria, malnutrition, pre-eclampsia, sexually transmitted infections (STIs), and
prevention of mother to child transmission of human immunodeficiency virus (HIV).

Sufficient antenatal care (ANC) and skilled obstetric help during delivery are essential strategies
that considerably decreases maternal mortality and morbidity rate. The World Health
Organization endorses four antenatal visits, with different and tailored care during each visit.

The principles of ANC for women with uncomplicated pregnancies are to provide advice,
education, reassurance, and support; to address and treat the minor problems of pregnancy; and
to provide effective screening during the pregnancy.

Each of the ANC visits consists of a well-defined set of activities related to three equally
important general areas, namely screening for conditions likely to increase adverse outcomes,
providing therapeutic interventions known to be beneficial, and educating pregnant women about
planning for a safe birth, emergencies during pregnancy, and how to deal with them.

A single antenatal visit does not give information about the completeness and components of the
care provided. It is recommended by WHO that at least four visits are made during the
pregnancy and the timing (ideally, ANC should be initiated within the first 12 weeks of
pregnancy)
DEFINATION OF ANTENATAL CARE AT HOME:

This is the advice, supervision and attention given to a woman from the time conception is
confirmed until the beginning of labor at home.

OR

Antenatal care (ANC) is a careful, systematic assessment and follow-up of pregnant women, that
includes education, counseling, screening, and treatment to assure the best possible health of the
mother and her fetus at home.

AIMS OF ANTENATAL CARE

1. The primary aim of ANC is to promote and protect the health of women and their unborn
babies during pregnancy so as to achieve at the end of a pregnancy a HEALTHY
MOTHER and a HEALTHY BABY.
2. To promote and maintain good physical and mental health during pregnancy through
health education and nutrition, hygiene etc.
3. To promote an awareness of the sociological aspect of child bearing and the influence
this may have on the family
4. To build up a trusting relationship between the family and the care givers, which will
encourage client to participate and make informed choices about the care she receives.
5. To monitor the progress of pregnancy in order to ensure maternal health and normal
fetal development.
6. To reduce maternal and prenatal mortality
7. To recognize deviation from the normal and provide prompt management and
treatment as required or referring the woman to appropriate health team.
8. To ensure that a life, matured, healthy baby when the woman reaches the end of
pregnancy
9. To help and support the mother in her choice of infant feeding: to promote
breastfeeding and advise on preparation for lactation.
10. To offer the family advise on parenthood. Either within a plan program or on individual
basis.
 11. Providing a holistic approach to the woman’ s care that meet her individual needs.

GOALS OF ANC

 To reduce the mortality and morbidity of women and children

 To improve the physical, mental, and social well-being of women, children, and their
families.

OBJECTIVES OF ANC

 To ensure that the pregnant woman and her unborn child are in the best possible health
prior to delivery
 To ensure that all pregnant women understand
(i) The complications of pregnancies that may lead to death
(ii) The best approach to safe delivery, and
(iii) The best way of bringing up their babies.
PROCESS/ ACTIVITIES OF ANTENATAL CARE BOOKING

PHYSICAL ABDOMINAL
HISTORY EXAMINATION
HEALTH TALK INVESTIGATIONS EXAMINATION
TAKING
 HISTORY TAKING

FAMILY HISTORY SOCIAL HISTORY MEDICAL HISTORY

HISTORY OF TWINS,ANY MEDICAL
CONDITION E.G HYPERTENTION ,SICKLE BIODATA E.G NAME ,AGE E T C UNDERLINE MEDICAL CONDITION LIKE
CELL E.T.C FINANCIAL STATUS;INCOME AND IT CARDIAC
MENTAL DISORDERS SOURCE DISEASE,DIABETES,HYPERTENTION,RUBELL
AETC

SURGICAL HISTORY OBSTETRIC HISTORY

ANY PREVIOUS OPERATION ON MENSTURAL
ABDOMENT,UTERUS,INJURIES ACCIDENT HISTORY,PARITY ,ABORTIONS,
AND BLOOD TRANSFUSION APH,PROCESS OF LABOUR AND HISTORY
OF PEURPERIUM AND BABY'S HISTORY

GYNEACOLOGICAL HISTORY
HISTORY OF VENEREAL
DISEASE,GYNEACOLOGICAL OPERATIONS
AND TUMOURS

HEALTH TALK

HYGIENE EXERCISE AND SOCIAL HABIT

PERSONAL RECREATION SMOKING
ENVIRONMENTAL CYCLING ALCOHOL
FOOD WALKING DRUGS /SUBSTANCE
SWIMMING
AEROBIC EXERCISE
REST AND SLEEP
NUTRITION CARE OF CLOTHINGS
ADEQUATE DIET THE BREAST SHOE TYPE
CARE OF CLEANLINESS UNDERWEARS
BOWEL PREPARATION CLOTHING SIZE
FOR LACTATION
Antenatal advice is most important aspect of antenatal care. Care of the mother
continues at home. Mother should be educated about herself and her baby.

The midwife educates the mother about the following:

1. PERSONAL/ENVIRONMENTAL HYGIENE: Daily bath, wash cloth and

hair and cleaning of her environment.

2. NUTRITION: pregnant woman is expected to gain weight during pregnancy and

consume extra calories and nutrient. If she consumes less iron it will lead to less
storage; fetal may receive less iron stored, such baby may show normal hemoglobin
at birth but may become severely anaemic later due to lack of iron in the breast milk
3. REGULAR BOWEL MOVEMET: avoid constipation which might cause
pile. Regular bowel movement is encouraged by intake of green leafy vegetable and
fruits.
4. REGULAR EXERCISE: mother is advice to have regular walking exercise,
slight house work. Avoid hard typical labour and lifting of heavy weight which may
affect the fetal growth.
5. REST AND SLEEP: 6-8hours sleep at night and about 2hours rest and relaxation
during the day.
6. HEALTHY LIFE STYLE: Avoid cigarette smoking and alcohol intake. Heavy
smoking may lead to abnormality of fetal and placenta, spontaneous abortion, intra
uterine growth retardation (IUGR).
7. DRUGS: Aspirin, Tetracycline and most antibiotics affect the fetus
8. MEDICATION: mother must be given vitamin supplement; she is expected to
take her iron tablet during the pregnancy.
9. IMMUNIZATION: Example T.T injection.
INVESTIGATIONS

BLOOD
VDR L
GROUP/GENOTYPE

HEAMOGLOBIN
URINALYSIS
ESTIMATION/P C V

ULTRA
V C T FOR H I V INVESTIGATIONS SOUNDSCAN

PHYSICAL EXAMINATION
GENERAL EXAMINATION:
 BLOOD PRESSURE: is checked and recorded.
 WEIGHT AND HEIGTH: are measured and documented

HEAD TO TOE EXAMINATION: Observation is done by observing the patient from head to
toes=appearance, gait, posture, complexion
THE HEAD

Is examine to note personal cleanliness, presence of dandruff and lice untidy hair and
abnormal swellings.

THE EYES

Are observe for inflammation, discharge, pallor, abnormal growth, and infection.
THE EARS

They are examined for the location, the number, quality cleanliness abnormal discharge
and abnormal contour.

NOSE:

the nose is observed to note the size and shape and to detect ; discharge, disease and
abnormality.

THE MOUTH:
the lips are examine for pallor: dryness, crack and sore
The mouth is observed for bad breath and angula stomatitis. The teeth are examine for the
shape, dental hygiene or sores, the tongue is examine for pallor, dryness, coatedness and
sores.

THE FACE:
the countenance of the face is examined for puffiness which may be due to anaemia,
malnutrition, chronic Nephritis, Nephrotic syndrome, pre-eclampsia.

THE NECK:

This is observed for previous scar. It is palpated for any growth, distended jugular vein
and a large lymph glands.

THE UPPER LIMBS:

they are checked for equality and abnormality.

The hands are examine for:

Pallor and puffiness which can be elicited through a hand check with the patient

The fingers are examined for shape, size, pallor, abnormality and puffiness especially around the
ring finger if she wears one.

The nail bed are also examined for pallor.

The patient now assume a sitting up position for the examination of the breast.
THE BREAST

These are first inspected for shape, size, equality, cleanliness, abnormality, changes due to
pregnancy such as enlargement, pigmentation of primary areola, Montgomery tubercle,
appearance of secondary areola, visible engorge veins, the nipples are examine for the shape,
size. Then the ducts are tested for patency by expressing the breast fluid.

PALPATION:

The breast are each palpated, any feeling of undue lump or irregular mass should be reported to
the doctor.

Advice: the patient is advice on the care of the breast which focus on

a. Diet: the type of food she should take must be rich in protein such as eggs, beans, fish,
meat, and mellon. Minerals and vitamins such as green vegetables, carrots, egg fruits
with plenty of fluid. The quantity of breast milk produce will depend on the quality of
food intake.
b. BREAST HYGIENE: she is advice to pay particular attention to breast care during
birth time. The nipple should be washed with soft cloth or cotton wool and mild soap.

They are pulled out and later rolled between the thumb and index finger to get them
toughened, the nipples are then dried firmly with a soft towel and little oil such as kernel
oil or olive oil is rubbed on them to soften them and prevent crust formation
c. EXPRESSION OF COLOSTRUM: COLOSTRUM IS EXPRESSED FROM the breast
from the 31st week of pregnancy in order to maintain patency of the duct and thereby
preventing breast engorgement in peurperium.
d. BREAST SUPPORT: she is educated on the need to keep the breast well supported with
good , adjustable, firm, cotton material wide strapped brassier which is large enough to
accommodate the breast during the progressive enlargement of the breast.
ABDOMINAL EXAMINATION

AIMS:

- To observe signs of pregnancy

- To assess fetal size and growth

- To assess fetal health

- To diagnose the location of fetal parts.

- To detect any deviation from normal.

STEPS FOR ABDOMINAL EXAMINATION

AUSCULTATIO
INSPECTION PALPATION
N

INSPECTION (5s)
a) Shape:-
- Note contour -is it round, oval, irregular or pendulous?
- Longitudinal, ovoid in primigravida
- Round in multipara and- Broad in transverse lie.
b) Size:- Should correspond with the supposed period of
Gestation
c) Skin: - The dark line of pigmentation which is lineanigra is
Seen any rash?
d) Strae gravidarum
e) Scar - Any operation scar(c/s)

ON PALPATION:
1. Fundal height and fundal palpation (1st Leopoled
Maneuver)
1.1 Fundal Height
At about 12 to 14 weeks of pregnancy, the uterus is palpated
above the symphysis pubis as a firm globular sphere; it
reaches the umbilicus at 20 to 22 weeks, the xyphoid process
at 36 weeks, and then often returns to about 4 cm below the
xyphiod due to “lightening” at 40 weeks.
Method: Measure distance of fundus with points on abdomen
and assessing the fundal height in finger breadth below the
xiphisternum or measure by centimeter.
69
1.2 Fundal Palpation
Purpose- To know lie and presentation.
Method: - Use 2 hands using palms of hands palpate on
either side of the fundus. Fingers held close together, palpate
the upper pole of then uterus and feel that as it is hard or soft
or irregular.
Figure:12 Fundal palpation (Derex llewllyn-
Jones,vol.1,1990)
70

2.Lateral Palpation: (2nd Leopled maneuver)

Purpose-To know lie and position
Method: - always facing the mother, fix the hand on the
center of the abdomen, fix the right hand and palpate with left
hand and vise versa. Note the regularity; the regular side is
the back

.
Figure ; 13 Lateral palpation (Derex llewllyn Jone, vol.1,
1990)
71

3. Deep pelvic Palpation: (3rd Leopoled Maneuver)

Purpose -To Know Presentation & Attitude
Method: - Feel presenting part, is it hard or soft while
palpatingfor the presenting part feel for eminences on back
side.

Figure 14: Deep pelvic palpation (Derexllewllyn-Jone,

Vol.1,1990)
72

4. Pawlick's Grip: (4th Leopard Maneuver)

The lower pole of the uterus is grasped with the right hand the
midwife facing the women's head, feel the occiput and
sinciput, note which is lower.
Figure 15. Pwlick’s grip (Derexllewllyn-Jone,Vol.1,1990)
73

AUSCULTATION: Check Fetal heart, rate and rhythm, count for

one minute if regular.
Method: Use Pinards stethoscope
- hand should not touch it while listening,
- ear must be in close from contact with stethoscope,

Pelivic assessement
- By x-ray of the pelvis
- Clinical (assessing sign of contracted pelvis)
- Head fitting
Head fitting
The head is the best pelvimeter

METHOD 1: Head fitting, sitting patient, Method

Let her lie on a couch, place hand on the Symphysis pubes
and get the woman to sit up by her own effort. The effort
should force the head in to the pelvis.
METHOD 2 : Left hand grip method Grasp the fetal head with
left hand and push it down wards and backwards if a sense of
give is felt the head has entered and there is no over and no
cephalo pelvic disproportion.

At subsequent Visits:-
􀂃 Blood pressure, weight (edema)
􀂃 Abdominal examination (all steps of abdominal
examination)
􀂃 Hematocrit test should be repeated at 28 and 36 weeks of
􀂃 gestation Health Education
􀂃 Listening and managing any complaint
TYPES OF ANTENATAL CARE

FOCUSED A N
C

TYPES
W H O 2016
OF ANC
TRADIDIONAL
REVISED
ANC
MODEL

FOCUSED ANTENATAL CARE

Is an approach to ANC that emphasize

 Evidence-based, goal-directed actions

 Family- centered care
 Quality, rather than Quantity
 Care by skilled providers

GOALS OF FOCUSED A N C
To promote maternal and new born health and survival through:

 -Early detection and treatment of problems and complications

 -Prevention of complications and disease

 -Birth preparedness and complication readiness

 -Health promotion
 Number of Visit
 First visit (8-12wks): confirm pregnancy and EDD, classify women for basic ANC (4 visits) or
more specialized care, screen, treat and give preventive measures, develop a birth and emergency
plan, advice and counsel.

 Second visit(24-26wks):assess maternal and foetal well-being; exclude PIH and anaemia; give
preventive measures; review and modify birth and emergency plan; advise and counsel

 Third visit(32wks):assess maternal and foetal well-being, exclude PIH, anaemia, multiple
pregnancies, give preventive measures. review and modify birth and emergency plan; advise and
counsel

 Fourth visit(36-38wks):same as above, check malpresentation. review and modify birth and
emergency plan, advice and council

W H O 2016 REVISED MODEL OF ANTENATAL CARE

The new model increases maternal and fetal assessments to detect complications.
Improves communication between health providers and pregnant women
Increases the likelihood of positive pregnancy outcomes.
It recommends pregnant women to have their first contact in the first 12week

NUMBER OF VISITS

12WEEKS 36,38,40
20 ,26,30, WEEKS
34 WEEKS
CONCLUSION:

EVALUATION
1. Define antenatal care at home
 2. List the aims and objectives of antenatal care
3. Enumerate and explain the process of ANC booking
4. Discus on health education during antenatal care at home
5. Demonstrate abdominal examination during ANC at home

STUDENTS CONTENT
TOPIC: ANTE NATAL CARE AT HOME

LEARNERS OUTCOME:

At the end of the lesson the student should be able to:

1. Define antenatal care at home

2. List the aims and objectives of antenatal care
3. Enumerate and explain the process of ANC booking
4. Discus on health education during antenatal care at home
5. Demonstrate abdominal examination during ANC at home

TASK
 Brainstorm on the definition of antenatal care at home
 List the aims and objectives of antenatal care
 Using a role play demonstrate the activities of first visit in antenatal care
 Using cross over in a small group discus on health education during ANC
 Demonstrate abdominal examination during ANC at home