Antenatal guidlines - For primary health care in crisis - ICRC Shop

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A N T E N ATA L G U I D E L I N E S F OR P R I M A RY H E A LT H C A R E I N C R I S I S CO N D I T I O N S Cristina Otero Garcia General nurse, paediatric nurse and midwife

To all the patients I have ever cared for, whether at the dawn or in the twilight of their lives, whose courage, strength, humility and nobleness of spirit – whose glances and smiles – have brought me and taught me so much. Cristina Otero Garcia

PHOTOS Cover: WINIGER Edouard / ICRC, Thailand, 1983 Back cover: AGUIRRE Nathalia /ICRC, South Sudan, 2004 International Committee of the Red Cross Health and Relief / Geneva 19 Avenue de la Paix 1202 Geneva, Switzerland T + 41 22 734 6001 F + 41 22 733 2057 E-mail: [email protected] or [email protected] www.icrc.org © ICRC, May, 2005

Acknowledgements Grateful acknowledgements are due to the following people for helping to make this book possible: Consultants Dr Michel BOULVAIN, obstetrician-gynaecologist, Hôpitaux Universitaires de Genève Dr Eric BURNIER, infectious diseases specialist, ICRC health services unit Dr Catherine DELAISSE, medical delegate, MPH (Master Public Health), ICRC Ana Gerlin HERNANDEZ BONILLA, nutritionist, ICRC economic security unit Dr Judith HERRERRA, primary health care programme manager, ICRC Dr François IRMAY, head surgeon, ICRC Dr Hervé LE GUILLOUZIC, head of the ICRC health services unit Marlène MICHEL, primary health care coordinator, ICRC health services unit Dr Pierre PERRIN, chief medical officer, ICRC Antje VAN ROEDEN, senior adviser, ICRC planning, monitoring and evaluation unit Dr Cordula WOLFISBERG, medical services for detainees, ICRC health services unit

Editorial and secretarial staff Hezia ABEL WALPOLE, Rowena BINZ, Sarah FLEMING and Christopher SNOW

Stéphanie ARSAC JANVIER, Ahmed BERZIG, Anne DEMIERRE, Marie-Thérèse ENGELBERTS LEONE, Chris GIANNOU, Jennifer HAYWARD KARLSSON and Mark STEINBECK deserve special thanks for their helpful comments and suggestions.

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CO N T E N T S Purpose of this document

P9

Introduction

P 10

Part I : Antenatal care programmes Aims of antenatal care

P 15

ICRC Assistance Policy

P 16

Setting up an antenatal care programme Initial assessment of needs

P 18-25

Planning the programme

P 26-27

Monitoring an antenatal care programme

P 28-37

Basic and emergency equipment

P 38-40

Health education

P 41-42

Training traditional birth attendants

P 42-44

Health education for pregnant women

P 45

Annexes I.A

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International Humanitarian Law

P 48

I.B.1-3 Planning for Results (PfR)

P 49-51

I.C.1-3 Sample ANC service indicators

P 52-54

I.D

P 55

Checklist for safe motherhood services

I.E.1-3 New WHO antenatal care model

P 56-58

I.F.1-5 Antenatal care quality service assessment

P 59-63

I.G.1-2 List of drugs with their ICRC order code

P 64-65

CO N T E N T S

Part II : Antenatal consultations Medical records

P 69-71

Diagnosis of pregnancy and Calculation of term

P 72-73

Physiological changes in pregnancy

P 74-85

Initial medical assessment

P 86

Standard antenatal consultation

P 87-95

Cases to be referred for delivery

P 96-99

Emergency obstetric care General information

P 100-101

Emotional and psychological support

P 102-104

Management of emergency cases:

P 105

- Convulsions or loss of consciousness

P 106-109

(schedules for magnesium sulfate and diazepam enclosed)

- Fever

P 110-113

- Respiratory distress

P 114-115

- Vaginal bleeding

P 116-121

- Abdominal pain

P 122-123

- Prolapsed cord

P 124-125

- Unsatisfactory progress in labour

P 125

- Trauma

P 126-127

Annexes II.A.1-5 Controlled cord traction with illustrations of placental delivery

P 130-134

II.B

P 135

Guidelines for rehydration

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CO N T E N T S

Part III: Antenatal problems

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Anaemia

P 139

Female genital mutilation (FGM)

P 140-142

Fever Malaria Urinary tract infection

P 143-146 P 147

Hypertensive disorders in pregnancy Management of mild or severe chronic hypertension Management of pregnancy - induced hypertension Mild pre-eclampsia Management of severe pre-eclampsia and eclampsia

P 148 P 149 P 149 P 150-151 P 151

Loss or diminution of foetal movements Foetal death Foetal growth retardation

P 152-153 P 154

Malpresentations Breech Transverse

P 155-156 P 157-158

Pregnancy after rape / Rape of pregnant woman

P 159-161

Pregnancy in detention

P 162-163

Pregnancy in teenagers

P 164-165

Prelabour rupture of membranes (PROM)

P 166-167

Sexually transmitted diseases Viral hepatitis HIV/AIDS Gonorrhoea Chlamydia trachomatis Syphilis

P 168-169 P 169-170 P 171-172 P 172-173 P 173-174

CO N T E N T S

Part III: Antenatal problems (contd.) Tetanus prophylaxis

P 175-177

Threat of premature delivery / Preterm labour

P 178

Twin pregnancy

P 179-181

Vaginal bleeding Abortion Ectopic pregnancy Molar pregnancy Placenta praevia Abruptio placentae

P 182 P 183 P 183-184 P 185 P 186-187 P 188-189

Vaginal discharge

P 190-191

Vitamin A deficiency

P 192

Annexes III.A.1-2 Vaccination and pregnancy

P 194-195

III.B

P 196

Vitamin A, Iron and Folic Acid food sources

BIBLIOGRAPHY

P 198-200

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PURPOSE OF THIS DOCUMENT These guidelines are designed for ICRC and other health professionals – nurses, midwifes, doctors – who either lack experience in antenatal care or are not used to working in countries where medical infrastructure is underdeveloped or non-existent. Their purpose is to: - provide staff involved in running antenatal care programmes with a concentrated source of information on the subject, with no claims to exhaustive coverage - direct readers to other works that deal with antenatal care in greater depth - ensure that a standard approach is taken to ICRC antenatal care programmes Each team will have to adapt the guidelines locally according to: - the type of community in which it is working - the available health facilities - the ICRC’s constraints in the country where the team is based These guidelines deal only with the first level of health care, that is to say the community health centre, and not with the second and third levels (reference and district hospitals). They cover the antenatal period, which begins when a woman suspects that she is pregnant and ends when she starts labour, but not the delivery or the postpartum period.

OBSTETRICS

Antenatal

Intrapartum

GYNAECOLOGY

Postnatal

LEVEL 1 Emergencies LEVEL 2 Emergencies LEVEL 3 Emergencies Treated in this document

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INTRODUCTION Throughout the years, the ICRC has been improving its ability to protect and assist conflict victims with a view to saving lives, alleviating suffering and restoring human dignity in an ever more complex world. In April 2004 it adopted a new assistance policy defining core activities in the areas of water and habitat, economic security and health care.With regard to health care, it decided to focus its efforts on emergency hospital care, hospital management, first aid, primary health care, support for victims of sexual violence, health in detention and physical rehabilitation. Taking the comprehensive meaning of primary health care into consideration, the health services unit defined a minimum package of activities that could be carried out in acute and chronic crisis conditions. The package includes treatment for most common diseases using essential drugs; mother and child care; vaccination campaigns; and water, sanitation and nutrition programmes. Within the area of mother and child care, antenatal care plays a key role in reducing death, disease and suffering among women, whose vulnerability is always exacerbated by armed conflict and poor security conditions. The death of a mother during pregnancy or delivery is a tragedy that affects not only families but society as a whole. The risk of dying during pregnancy or delivery is 175 times higher for African women than it is for women in developed countries. At the global level, 13 underdeveloped countries account for 70 per cent of maternal deaths. The highest figures are for Sierra Leone, Afghanistan, Malawi, Angola and Niger.1 Maternal mortality and morbidity are associated with preventable patterns: Late detection of complications - Late arrival in a medical centre - Delayed quality-care provision. Given the great variety of cultural settings in which we work, health staff must keep in mind the weight of local pregnancy-related beliefs that will have a direct impact on access to and use of antenatal care services.

1 Press Release WHO/77, 20 October 2003 (compilation of data from WHO, UNICEF and UNFPA).

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These Antenatal Guidelines for Primary Health Care in Crisis Conditions are the result of collaboration between ICRC staff at headquarters in Geneva and colleagues in the field. They serve two main purposes: To provide field staff with the basic practical information they need to run an antenatal clinic in situations that may vary greatly from one country to another. To highlight the specific nature of antenatal care within the framework of protection activities and international humanitarian law. With this aim in mind, particular attention has been paid to sexually transmitted infections, sexual violence, the health of mothers in places of detention and the access of mothers to care and home delivery services in situations where it might be dangerous for them to leave home. In view of the need to ensure the sustainability of assistance programmes, these guidelines must also be considered as a training tool for the national staff without whom we could hardly pursue our activities. We hope that these guidelines will be a useful contribution to discussions on how to further improve our mother-and-child care and protection activities.

Dr Hervé Le Guillouzic, Head of the ICRC health services unit

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Antenatal Care Programmes

1

" To all women who weave cloth and tales… To all women who influence time and shape the destiny of men …"

ANTENATAL CARE PROGRAMMES

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Part I : Antenatal care programmes Aims of antenatal care ICRC Assistance Policy Setting up an antenatal care programme Initial assessment of needs Planning the programme Monitoring an antenatal care programme Basic and emergency equipment Health education Training traditional birth attendants Health education for pregnant women Annexes I.A

International Humanitarian Law

I.B.1-3

Planning for Results (PfR)

I.C.1-3

Sample ANC service indicators

I.D

Checklist for safe motherhood services

I.E.1-3

New WHO antenatal care model

I.F.1-5

Antenatal care quality service assessment

I.G.1-2

List of drugs with their ICRC order code

AIMS OF ANTENATAL CARE Pregnancy and childbirth are not illnesses and as long as the mother is healthy there is usually no cause for alarm. Nevertheless, conditions may arise during pregnancy that are not necessarily obvious and may not always make the mother feel ill, but that if left untreated could be dangerous for the mother or baby. Such conditions may need to be monitored by a well-trained health professional and the baby may need to be delivered in a hospital. The purpose of antenatal care is to diagnose any dysfunction during pregnancy so as to anticipate problems and take the appropriate steps for a healthy delivery. This can be achieved by:

amonitoring the health of the mother amonitoring the health of the foetus adetecting risk factors aadvising the mother how to look after her health and that of her baby

The ICRC works in countries where mothers may not always be in good health or have access to appropriate medical care. The guidance provided in the following chapters is tailored to the specific situations that can be found in those countries. Even if from a physiological point of view pregnancy is the same for each woman on earth, it is always surrounded by specific cultural beliefs. Everyone should be aware that such beliefs exist, remain open to them and, in so far as there is no danger for the mother or her foetus, not oppose them.

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ICRC ASSISTANCE POLICY In April 2004 the ICRC adopted a new Assistance Policy (AP) defining core activities in the fields of water and habitation, economic security and health care. In order to clarify the framework in which the ICRC conducts its activities in the area of primary health care, and more specifically in that of mother and child care (including antenatal care), various points of this policy are summarized below. If assistance activities are to be effective, they must go hand in hand with protection work aimed at ensuring respect for the fundamental rights of conflict victims. For more information about the rights of expectant mothers under international humanitarian law, see annex I.A, page 48.

Implementation See AP 5.3 Implementation and 5.3.3 Health The ICRC adapts its response to the situation. In emerging or acute crises, the ICRC provides support for basic health services, prehospital and emergency hospital care. The basic services are selected from among the components of primary health care,2 which include mother and child care. In chronic crises and post-crisis situations, the ICRC may consider providing support for a broader range of primary health care activities. See AP Annex 4. 6 Minimum package of activities derived from primary health care Within this preventive, curative and participative framework, primary health care provides a vast range of services. Among these the ICRC has designated a minimum set of core activities including mother and child care, which encompasses antenatal care.

2 Primary health care is a process in which the community takes part. Carried out in consultation with civil society, it aims to assess health related needs and to implement health activities in the following fields: (1) ambulatory health care using essential drugs; (2) mother and child care, including family planning; (3) expanded immunization programmes; (4) programmes to fight communicable diseases; (5) health and hygiene promotion; (6) health education; (7) mental health; (8) water; and (9) nutrition.

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ICRC assistance policy

Modes of action See AP 4.3 Strategies: 4.3 Combining different modes of action The ICRC uses persuasion, mobilization and, where necessary, denunciation to induce the authorities to meet their obligation to provide essential services for the affected groups. Where the ICRC considers that its efforts are not going to bring about a satisfactory, timely response from the authorities, and that the problem is a serious one, it may simultaneously engage in appropriate support and/or substitution / direct provision activities. ICRC delegations must decide how best to combine and introduce different modes of action in order to optimize the impact of their activities.

Planning programmes and projects See AP 6 Operational directives: 6.3 to 6.5 aIn designing assistance programmes and projects, ICRC staff must respect the

methods laid down in the ICRC’s «Planning for Results» (PfR) process (see annexes I.B.1-3, pages 49-51).

aThe ICRC must have the skills and logistical capacity needed to carry out its core

activities rapidly and effectively.

aEntry and exit strategies must be provided for in the initial plans and, for exit

strategies in particular, must be drawn up together with the other entities concerned.

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SETTING UP AN ANTENATAL CARE PROGRAMME Before setting up an antenatal care programme, it is essential to carry out an initial assessment of needs and to plan the programme with great care.

FIRST STEP: INITIAL ASSESSMENT OF NEEDS Initial assessment as defined in ICRC Assistance Policy (AP) See AP 6. Operational directives: 6.2. Assessing the situation – integrated needs and background analysis The assessment of assistance needs must be based on an information network that is as broad as possible and must include a wide range of issues and areas of endeavour. These must encompass not only assistance related areas of activity, but also those relating to protection of the group concerned and security. 6.2.1 6.2.2 6.2.3 6.2.4

Initial assessment of needs Assessment methods Assessment partners Assessment reports

Assessing antenatal care needs The initial assessment of assistance needs must take into account the existence, quality and accessibility of all the services available to the population. Once the ICRC has decided to set up an antenatal care programme, it will be necessary to carry out a further assessment of needs specific to this type of activity. The general procedure for carrying out such an assessment is explained below, but it needs to be adapted to antenatal care and to local conditions. Whatever the particular constraints may be, antenatal care will achieve its basic aims if it ensures that advice and preventive treatment are given to pregnant women. At the very least, the ICRC considers that an antenatal care package must include the following: aPrevention of malaria and anaemia aTetanus immunization aPersonalized information for mothers At the very most, it could also include: aScreening aCare aReferral to secondary health care services aEmergency obstetric care at the primary health care level aTraining and coaching of traditional birth attendants in countries where they already exist aHealth education programme Each antenatal care package must be defined at the same time as the programme, in accordance with national policies and standards, if any exist, and taking the local situation into account. Different packages may be defined for different programmes.

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Setting up an antenatal care programme

Initial assessment as defined in «Boîte à outils pour l’analyse et la résolution des problèmes» (see bibliography)

Concept Essential services Needs

IMBALANCE BETWEEN NEEDS AND AVAILABLE SERVICES INCREASE IN NEEDS OWING TO :

aIncrease in the number of people

affected

aIncrease in morbidity

Appearance of new needs

DETERIORATION OF SERVICES OWING TO : aLack of means

aFlight of health personnel

aOrganizational disruptions

Destruction of medical facilities

The problems to be identified result from an imbalance between the needs of the population and the ability of local services to meet them. It is therefore essential to assess not only the population’s state of health, nutritional status and so forth, but also the state of agricultural, health and other services. The initial assesment must provide the information needed to: amake decisions when determining priorities for action, taking into account not only the consequences of a problem, but also its causes; aanticipate future developments with a view to reducing the risks which in any case must be taken in this type of situation as much as possible.

Problems Identifying problems The assessment team must measure the degree of imbalance between the physiological, social, security and other needs of the population and the capacity of local services to meet them. This imbalance is what humanitarian assistance seeks to correct.

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Setting up an antenatal care programme

Data gathering In order to identify problems, it is necessary to gather data on the population and its environment in the broadest sense, including physical, climatic, social (health services), economic (access to food) and other types of environment.

MEDICAL AND NON-MEDICAL FACTORS THAT INFLUENCE HEALTH Health factors

aState of medical and

nutritional knowledge a Possibility of applying knowledge

(personnel, equipment)

Socio-economic factors

Geographical factors

aTown and country planning

aClimate

aHabitat

aNatural resources

aWay of life

aCommunications

aEmployment situation

PROMOTION, PROTECTION AND RESTORATION OF HEALTH Cultural factors

Political Factors

aCustoms and beliefs

aEconomic and social plans

aAttitudes to health

aHealth programmes

problems

aPercentage of children

in school

Demographic factors

aDistribution of age groups aGovernment’s family

planning policy

aRatio of urban to

rural populations aMigration

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Setting up an antenatal care programme

Summarizing the data Large quantities of data may be difficult to analyse. Begin by selecting what is truly relevant, then summarize the main points, drawing them together in such a way as to provide a clear and simple picture of the situation. Analysing the data It is not enough to simply identify health problems. An assessment team is expected to analyse them as well, taking into consideration: aThe determining factors

It is essential to know what the previous living conditions of the population were so as to be able to weigh the analysis of current health problems.

aThe scale of the problems

It is not enough to simply perceive problems. It is important to try and quantify them (scale, number of people affected). Search for data collected before the disaster, gather new data according to precise criteria (morbidity, daily mortality, litres of water delivered each day at a specific pump, etc.).

aThe context

Problems occur in specific environmental, economic, socio-cultural and political contexts that must also be analysed during the initial assessment of needs. Most of the constraints that will later limit the possibilities of action will be encountered at this level.

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Setting up an antenatal care programme Setting priorities Every emergency situation is made up of a multitude of problems that cannot all be dealt with at once. It is therefore important to set priorities, doing so on the basis of precise criteria and not according to the whim of the moment. Criteria for setting priorities Two main factors must be taken into account when setting priorities: aThe scale of the problems aThe urgency of the problems These two factors can be measured using data on the number of people affected, the deterioration of local services, morbidity and mortality. However, a problem can only be a priority for action to the extent that it is truly possible to act. Consequently, it is essential to determine: athe feasibility of a technical solution athe weight of constraints athe impact that action will have on the problem. Examples of constraints 1. POLITICAL CONSTRAINTS Raison d’état State sovereignty Disinformation Insecurity 2. LOGISTICAL CONSTRAINTS Time needed to convey goods Customs formalities Storage problems Communication routes 3. ORGANIZATIONAL CONSTRAINTS Mobility of victims High number of victims Administrative disorganization Inexperience of health professionals 4. FINANCIAL CONSTRAINTS High cost of aid operations Funding policies that privilege certain types of operations over others. Depending on the technical feasibility of taking action, the specific constraints encountered on the spot and the expected impact of the operation, it may be necessary to confine oneself to certain types of problems, certain categories of victims or certain geographical areas. However, such restrictions must not be considered permanent. When action is impossible for security reasons, for example, negotiations must be started with the responsible authorities with a view to overcoming this difficulty. Initially, therefore, the priority will be to negotiate. In case of success, it will then be possible to act.

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Setting up an antenatal care programme

At the time of initial assessment it is important to ensure that: The programme is adapted to local conditions, to this end:

ameet with representatives from the Ministry of Health and with professionals who

can provide the required information and the advice and support needed to set up the programme

atake into consideration the views of the population and local staff since they know

the country, place or culture better than expatriates do and their direct involvement will help ensure that the programme is sustainable

acomply with the national health policy and with national health standards

aassess (with the help of any anthropological studies that may be available) the

cultural factors that bear on the management of pregnant women, such as:

- beliefs surrounding birth - customs surrounding birth - sexual behaviour - the place of women in society and their usual occupations - the place of men and children in society and their usual occupations - population movements - any other relevant cultural factors The necessary human resources are available It is essential to determine what kind of professionals are needed, national ones as well as expatriates with the right profile, and whether they are available or not. The sustainability of the programme will depend mainly on the capacity of national staff to provide high-quality antenatal care services on a long-term basis. If there is a lack of well-trained professionals on the spot, then look for them elsewhere in the country, if possible with the help of the authorities. Another possibility is to select people for training courses, which should be conducted in accordance with national standards so as to ensure that any certificates or diplomas delivered are recognized. Training local personnel is always an essential component of antenatal care programmes. If further training is considered, remember that it is often uncertain whether after obtaining a diploma trainees will return to their former workplaces or look for jobs elsewhere. One solution could be to have them make a commitment. The first step to take when starting an antenatal care programme is to find a welltrained local midwife to work with, or, if none can be found, to set up a team comprising an expatriate midwife and an untrained local midwife.

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Setting up an antenatal care programme

Final remarks In order to establish a solid base right from the start, it is essential to spend time on the spot gathering the necessary information before launching the programme. This will save time, energy and money later on. Remember that an adequate referral facility should be available in case of complications (for further information, see “Emergency obstetric care” pages 100-105). Owing to poor security conditions, long distances, lack of transport and other problems, this may not always be possible. However, every effort must be made to overcome whatever problems there are and to prepare for potential difficulties ahead. Before offering a new service to pregnant women, it is important to know exactly what can and cannot be done in order to avoid raising false hopes.

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Setting up an antenatal care programme

Once the ICRC has decided to set up an antenatal care programme after considering the initial assessment, the following steps should be taken before planning it.

CRITERIA FOR SETTING PRIORITIES Scale of health problems

Forseeable impact of action

aMorbidity

aWeight of constraints

aMortality

aTechnical efficiency

aNumber of victims

SCALE OF HEALTH PROBLEMS + FORSEEABLE IMPACT OF ACTION + LINK WITH PROTECTION ACTIVITIES

ANC PROGRAMME AND MODE OF ACTION

GENERAL OBJECTIVE

MEMORANDUM OF UNDERSTANDING WITH

MINISTRY OF HEALTH OR/AND HEALTH AUTHORITIES

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Setting up an antenatal care programme

SECOND STEP: PLANNING THE PROGRAMME Planning as defined in «Boîte à outils pour l’analyse et la résolution des problèmes» (see bibliography) Setting objectives Concept Setting objectives is the most difficult part of the planning process. It consists in translating often very general ideas into specific activities. Describing objectives Objectives should be defined according to the following rules with a view to moving from abstract to concrete: aAlways use an active verb to express an objective aDescribe and quantify the content of each objective

“An objective must mention: - What: the situation or condition to be reached - How much: the quantity or amount to be reached - How long: the expected time it will take to produce the desired effect - Who: the group of people or catchment area targeted by the programme - Where: the catchment area covered by the programme.”3 For further information on antenatal care objectives, see annexes I.C.1-3, pages 52-54. Breaking down activities into tasks Further along in the planning process activities must be broken down into specific tasks. This will make it easier to determine what resources are needed. Mobilizing resources Preliminary investigations will already have been made during the initial assessment. At the planning stage, the following questions are essential: - Do local resources exist? - Does the target population have access to local resources? Resources may be divided into four categories: - Human resources - Material resources - Means of transport - Financial resources Lack of resources may make it necessary to modify objectives.

3 W. Reinke, Health Planning: An overview of the planning process, 1972, p. 63

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Setting up an antenatal care programme

Final remarks When drawing up a plan of action it is important to ensure that it is realistic and adapted to existing constraints. Particular consideration must be given to what resources are needed and which are available. The referral system must also be taken into account in case of complications or emergencies (see «Emergency obstetric care», pages 100-105). Given the frequent turnover of expatriate staff, it is also vital to have a plan of action so as to guarantee the quality and sustainability of services. This will lead to greater professionalism and credibility.

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MONITORING AN ANTENATAL CARE PROGRAMME Monitoring as defined in ICRC Assistance Policy (6. Operational Directives) 6.6 Monitoring From the beginning, a system is put in place for situation monitoring and performance monitoring to ensure the systematic and continuous assessment of progress over time in using selected indicators. This monitoring system will promote timely and appropriate decision making. 6.7 Review and evaluation Monitoring must be supplemented by reviews and independent evaluations. These are intended to draw lessons that can be used to improve policies and practices, and help enhance the organization’s overall performance, transparency and accountability.

General information on monitoring Monitoring activities

aWhy (purpose of monitoring) aWhat:

- quality of care - progress towards desired results (output, outcome, impact) taking timing and input (human, financial and logistical resources, etc.) into consideration aHow (by collecting data and tracking indicators) aWho should be involved and at what stage If the purpose is to evaluate the programme as a whole, it is important to ask the following questions: aDoes the combination of materials, activities and administrative arrangements that

constitute the programme seem to lead to the achievement of its objectives?

aTo what extent were stated programme objectives attained? aWhat other results did the programme produce? aHow well did the participants do? aWas there support for what went on in the programme?

One of the aims of every antenatal care programme is to give national staff the training they need to provide quality care and be able to run the programme on their own. Once the specific objectives of the programme have been set, it will be necessary to ensure that expatriates have the tools they need to evaluate the quality of care provided by the programme. These tools include checklists and indicators, for which the necessary data will have to be collected (see below). When evaluating the quality of care, do not forget that it can also be useful to ask the referral hospital for its opinion about the relevance of the cases referred to it. Moreover, it is essential to ensure that staff members enjoy good personal relations and respect one another so that criticism can be taken in a positive and constructive way.

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Monitoring an antenatal care programme

Collecting and analysing data Before starting an antenatal care programme it is important to determine what data need to be collected and analysed. What should be measured? - Decide what to look for. Which features of the programme are most critical or valuable to describe? - Decide how much effort will be required. What data must be collected in order to ensure that each feature is accurately described? How to assess? - See how you can make good use of existing records. - If possible, set up a record-keeping system that will give you the needed information without burdening the staff.

Quantitative data are always necessary, both for monitoring progress and for comparing the programme with others.They should be of immediate practical use, understandable to those in charge, easy to analyse and collected according to the national data collection system, if one exists. Basic points to consider:

aWhat will the data be used for? aWhat is it necessary or useful to know? aFor whom are the data intended? aWho will collect and analyse the data? aHow should the data be reported? aIs any training required? aRemember that exact census figures are often lacking. aStatisticians and epidemiologists can provide useful advice.

Remember that is better to have a few reliable figures than a great many figures that cannot be analysed. Encourage staff not to underreport owing to misplaced feelings of guilt. Remind them that a high number of complications treated shows that women are coming to the facility and receiving care. Concerning the data that must be collected for the indicators, in accordance with the national data collection system, if one exists, various tools can be used such as antenatal care registers or cards, immunization registers or cards, etc.The best solution will have to be found for each programme depending on what is available on the spot.

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Monitoring an antenatal care programme

Checklists The purpose of checklists is to help determine training needs and the areas in which there is need for improvement. They must be practical to use and easy to analyse. A few examples are given in annexes I.D to I.F, pages 55-63. However, it is important to remember that any checklist will have to be adapted to the local situation.

Indicators The following monthly and annual indicators were chosen by the ICRC health unit in Geneva. They must be used for each programme, according to the local antenatal care package, (see page 18). Given the conditions in which the ICRC works in the field, some bias4 may be expected as a result of: - unreliable census figures - the definitions used - the methods of calculation used, etc. Other indicators may be used as well, since normally there are as many indicators as there are objectives, the number of which will depend both on the directives issued by the Ministry of Health and the level of antenatal care provided. Target population Pregnant women5 living in the health post catchment area: 4 % total population. TARGET POPULATION FOR CHILD AND MATERNAL CARE

4 Bias: a systematic distortion of a statistical result due to a factor not allowed for in its derivation. 5 The number of pregnant women (and expected number of deliveries) within the year is approximately equal to the number of births (deliveries) within the year = birth rate (number of births /1000 people X population size in the catchment area).If the national birth rate is unknown, the number of pregnant women in a given population can be estimated at 4%.

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Monitoring an antenatal care programme Monthly indicators 1.Total number of antenatal consultations Use: - Provides information on the overall volume of activities and the workload of staff members. - Provides a numerator for calculating the average number of antenatal consultations per woman. Source: antenatal care register. 2. Number of new patients (number of first consultations) Definition: a new patient is any pregnant woman who consults the antenatal care service for the first time. Use: - Provides information on the use of the antenatal care service. - Serves as a basis for calculating the antenatal care coverage rate (see page 34). - Provides a denominator for other indicators such as the detected risk rate and the proportion of patients who consulted the antenatal care service during the third trimester. Source: antenatal care register. 3. Number of third trimester consultations The third trimester is the best period for detecting risk pregnancies and deliveries. Use: - Provides information on the quality of the antenatal care service. - Provides a numerator for calculating the average number of consultations per woman during the third trimester. Source: antenatal care register. 4. Number of risk pregnancies detected Definition: according to national guidelines (see next page). Use: provides information on the quality of the service and its ability to detect risk. Source: antenatal care register. 5. Number of risk deliveries detected Definition: according to national guidelines (see next page). Use: provides information on the quality of the service and its ability to detect risk. Source: antenatal care register.

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Monitoring an antenatal care programme

SAMPLE LIST OF RISK PREGNANCIES AND DELIVERIES Risk pregnancies

Risk deliveries

ACUTE MALARIA ABNORMAL LIE ANTEPARTUM HAEMORRHAGE

ANTEPARTUM HAEMORRHAGE BREECH

HYDRAMNIOS

HYDRAMNIOS

MULTIPLE PREGNANCIES

MULTIPLE PREGNANCIES

PLACENTA PRAEVIA (if diagnosis possible)

PLACENTA PRAEVIA (if diagnosis possible)

PRE-ECLAMPSIA

PRE-ECLAMPSIA AND ECLAMPSIA

PREMATURE CONTRACTIONS

PREVIOUS CAESAREAN

PREVIOUS STILLBIRTH

STILLBIRTH or FOETAL DEATH

PREVIOUS VESICO-VAGINAL or RECTO-VAGINAL FISTULA

PREVIOUS VESICO-VAGINAL or RECTO-VAGINAL FISTULA PREVIOUS PERINEAL TEARS DEGREE 3 (anal sphincter ruptured) or DEGREE 4 (degree 3 + rectal mucous ruptured) PREVIOUS OBSTRUCTED LABOUR PREVIOUS RETAINED PLACENTA

SEXUALLY TRANSMITTED DISEASES

SEXUALLY TRANSMITTED DISEASES

UNTREATED TUBERCULOSIS URINARY TRACT INFECTION

This list will vary from country to country depending on the quality of medical care, the accessibility of health services and the existence of risks that are specific to certain countries (e.g. female genital mutilation). That is why it is important to attach the list drawn up for each antenatal care programme to the monitoring indicators.

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Monitoring an antenatal care programme Monthly indicators (contd.) 6. Number of patients who received five doses of tetanus toxoid before the first consultation Use: - Indicates how well the Expanded Programme of Immunization (EPI) is functioning. - Provides a numerator for calculating the overall immunization coverage of patients. Source: immunization card / antenatal care register 7. Number of patients who received at least a second dose of tetanus toxoid during pregnancy Use: - Provides information for monitoring the EPI. - Provides a numerator for calculating the percentage of women who were properly vaccinated. Source: immunization card / antenatal care register / monthly EPI data report. 8. Number of women referred to the second level of health care It can be useful to compare this indicator with the number of risk pregnancies/deliveries detected. Source: antenatal care register

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Monitoring an antenatal care programme Annual indicators In order to compare the results year by year, use the national norms if possible. If not, use the international ones. 1. Coverage rate Definition: the coverage rate is the percentage of women in the total target population who consulted the antenatal care service at least once during pregnancy. Method of calculation: aRoutine reporting system:

- Number of new patients (first visits) during the year x 100 - Divided by - Target population

aPopulation survey:

- Number of women who consulted the antenatal care service at least once before the birth of their most recent child (0 – 23 months) - Divided by - Total number of women having delivered within the last two years

Use: - Provides information on the accessibility of the service. - Provides information on the use made of the service. aA low coverage rate may indicate:

- poor accessibility - poor acceptability - poor availability - a problem within the target population Objective: By the end of 2003, 80% of the pregnant women in Yirol will have had at least one ANC consultation.

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Monitoring an antenatal care programme Annual indicators (contd.) 2. Average number of consultations per patient Objective: to ensure that all women have at least four consultations during pregnancy, as recommended by WHO. Method of calculation: aRoutine reporting system

- Total number of consultations during the year - Divided by - Total number of patients (= number of first consultations) during the year Use: provides information on the use and quality of the service. Source: routine reporting system - monthly data report. 3. Proportion of patients who consulted the antenatal care service during the third trimester of pregnancy A significant proportion of risk pregnancies and deliveries are detected during the third trimester of pregnancy. Method of calculation: - Number of patients who consulted the antenatal care service at least once during the third trimester X 100 - Divided by - Number of new patients (first consultations) Source: routine reporting system / population survey. If the data needed to calculate this indicator are unavailable, the following indicator can be used as proxy: Average number of third trimester consultations per patient Method of calculation: - Total number of third trimester consultations during the year - Divided by - Number of new patients during the year Source: routine reporting system - monthly data report.

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Monitoring an antenatal care programme Annual indicators (contd.) 4. Effective tetanus immunization coverage rate among patients Objective: to ensure that all antenatal care patients and their newborn babies are effectively protected against tetanus. Definition: patients effectively immunized until delivery are those who received five doses of tetanus toxoid before the first consultation or at least a second dose of tetanus toxoid during pregancy. Source: antenatal care register / immunization card. It is important to find a means of indicating that a vaccination has been registered so as to ensure that it will not be counted more than once. Method of calculation: - Number of patients effectively immunized until delivery - Divided by - Number of new patients (first consultations).

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second dose of tetanus toxoid during pregnancy

K Number of patients who received at least a

received five doses of tetanus toxoid before the first consultation

J Number of patients who had already

I Number of women referred to second level

H Number of risk deliveries detected

G Number of risk pregnancies detected

F Number of third trimester consultations

consultations)

C Population D Total number of antenatal consultations E Number of new patients (number of first

of pregnant women

E X 100 / B

Annual ANC coverage

B Target population = expected number

xx%

>=3

80%

Apr May Jun Jul Aug Sep Oct Nov Dec TOTAL

J+K / E

Effective tetanus immunization coverage

Jan Feb Mar

F/E

Average number of third trimester consultations per patient

% of patients who consulted the ANC service during the third trimester

Average number of consultations per patient D / E

Calculation

Objective of the year

A Total population (estimate)

M O N T H T LY / A N N U A L D AT A C O L L E C T I O N R E P O R T

Monitoring an antenatal care programme

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BASIC AND EMERGENCY EQUIPMENT The equipment used will depend on the budget, the place where patients will be examined and the qualifications and abilities of national staff. Above all, it is essential to have a place that affords privacy so that the patients cannot be seen (screens can be installed if necessary) or overheard during examinations.

List of basic equipment for antenatal care - a table and two chairs - a scale and a height gauge - a table or bed for examining patients - an obstetric wheel or calculator - an unwindable meter - a Pinard foetal stethoscope6 - a clock or watch with a second hand - a sphygmomanometer with a stethoscope - a thermometer - urine test strips - non sterile-gloves - lubricant gel - soap and a container with tap if no clean running water is available Drugs: see annexes I.G.1-2, pages 64-65 Patient records: see pages 69-71

Home delivery kits Depending on the situation, home delivery kits can be given to the traditional birth attendants or to the pregnant women themselves. Before distributing any equipment, it is important to consider: - the capacities of those who will be using it (are instructions required before use?) - the cost, especially when multiplied by the number of users - the importance of not creating needs (it is always preferable to use local products if they are suitable) - local conditions: cultural factors, weather conditions, availability or not of electricity and clean running water, etc. Contents of a basic home delivery kit - soap - razor blade - umbilical tape - non-sterile gloves - iodine - gauze - cotton - plastic sheet (one square meter, easy to clean) 6 The ICRC has a list of battery-operated Doppler devices that can be used like Pinard stethoscopes for monitoring foetal heart rate. Before requesting one, think about who will be using it as such instruments are expensive and not easy to repair on the spot.

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Basic and emergency equipment The quantities distributed will depend on the number of deliveries usually carried out by traditional birth attendants each month and on how often the items are received. Traditional birth attendants whose work is being monitored can also be given a tube of tetracycline and various other items depending on needs: a torch, if batteries and bulbs are available locally; a jerrycan for water; a basin; nail clippers (may be preferable to a razor blade); and of course a bag or box, solid and easy to clean, where the material can be stored. For health professionals who perform house calls, a medical satchel will be needed, or, better still and less expensive, a solid lightweight plastic toolbox with spacious compartments.

Emergency medical kit The following list of essential drugs and supplies is not exhaustive. The contents of an emergency medical kit will depend on the user’s skills and the health services available. Some drugs and supplies will already be available in the primary health care centre. Drugs (see annexes I.G.1-2, pages 64-65) Anaesthetic: Lidocaine/Lignocaine 2% (injectable) Analgesic: Paracetamol (tablets) Anticonvulsants: aDiazepam (injectable) aMagnesium sulfate (injectable) with antidote: calcium gluconate (injectable) Antibiotics (injectable): aAmpicillin aGentamicin aMetronidazole aProcaine benzyl penicillin aBenzathine penicillin aBenzyl penicillin (peni G, crystal peni) Antimalarials: aSulfadoxine/pyrimethamine (tablets) aQuinine dihydrochloride (injectable) Intravenous solutions: aDextrose 5% aSodium chloride 0.9% aRinger’s lactate aSterile water for injection Oral rehydration salts Oxytocics: aErgometrine/methylergometrine (injectable) aMisoprostol (tablets) aOxytocin (injectable) (Ergometrine and oxytocin have to be stored in a refrigerator, which can be the same one as is used for vaccines. If there is no refrigerator, just put the necessary vials in the medical kit.)

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Basic and emergency equipment Supplies

aAmbu bags and masks for adults and infants aBlood pressure cuff

aCannulas, needles and syringes of different sizes aDisinfectant solution: iodine povidone

aGauze compresses, sterile and non-sterile aGloves, sterile and non-sterile

aInfusion sets and three-way taps with a 10-cm extension aKidney dishes (two)

aMucus extractors for newborns

aStethoscope for adults and foetal stethoscope (Pinard or Doppler: see page 38, note 6 ) aTape, adhesive aTourniquet

aUmbilical ligature/tape

aUrinary catheters (Foley with balloon, CH 14) and bags (2 L)

aTwo pairs of scissors, two curved mosquito forceps and two Kocher

or Crile forceps (stored in covered stainless steel containers)

Remember that the user is responsible for keeping the medical kit in order. It must be kept clean and complete; items that have reached their expiry date must be replaced and used needles must be disposed of in safety containers.

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HEALTH EDUCATION Health education is usually aimed at getting people to change their behaviour. However, it is important to remember that people are not necessarily interested in changing their behaviour and that they do not always agree to do so. For many reasons (new scientific discoveries, financial considerations, national policies, etc.) the information given can change in the course of years, which means that it must be presented with due caution and humility. Moreover, it is all the more difficult to present such information convincingly when one comes from another culture. It is thus very important to ensure that experiences are shared in a climate of mutual trust and respect and that conclusions are drawn without judgement. Rather than focus on getting people to change their behaviour, the aim should therefore be to open a critical discussion aimed at examining problems and finding possible solutions together. Remember that learning is not a one-way street: people can give as well as receive information and it is up to them to take decisions on issues that affect their lives. When preparing a health education session, start by determining: awhat the customs and beliefs of local people are

awhere health care is placed on their scale of priorities among other issues such as food,

shelter and security (health being understood here in the broadest sense of the term as meaning physical, psychological and social health)

awhere antenatal care is placed on their scale of priorities among other health issues awhether local people have the means to improve or change their behaviour

if they want to

awho the target population should be awhat their school level is

awhat the best period of the year and time of day would be for holding a health education

session, taking such factors as weather conditions, agricultural or other work, walking distances, etc., into account

awhere the session should be held

awhat language local people speak

awhich local staff members might be best able to lead the session

awhether local staff require training, and if so who should give it to them awhat material will be needed awhat the available budget is

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Health education The above information can be used to organize health education sessions in such a way as to: atake the specific needs of the participants into account aadapt the content of the session and the teaching tools used to the level of the participants agive the participants the means to change their behaviour When preparing a health education session, do not hesitate to ask colleagues or other partners with experience in this field for information or for help in finding appropriate teaching tools.

Training traditional birth attendants Since most traditional birth attendants are illiterate and have never received any proper training leading to a diploma, they are usually not recognized by the health system. However, they can provide a very useful link between pregnant women and the health services since they live in rural areas and have extensive practical experience working there. Whatever the status of traditional birth attendants may be, it is important to comply with the national health policy regarding their use. Professionals who work with traditional birth attendants have a responsibility to train them, monitor their work and provide them with the materials needed for safe deliveries. At the same time, it is important to make sure that they do not engage in dangerous practices and that they understand their limits. Providing that they do, they can play a useful role in the referral system in case of complications. In places where traditional birth attendants do not exist, it would be better not to create them, especially if there is no referral system. Instead, hold health education sessions on the topic of pregnancy for the women of the villages. It is necessary to work with whatever and whomever is found on the spot and to accept that changes will only come slowly. Training sessions for traditional birth attendants Cultivation periods, weather conditions, security problems, walking distances and various other factors must be taken into account when deciding when and where traditional birth attendants should receive training. The duration of the training will depend on the available budget and on whether trainees can eat and sleep on the spot. If they cannot, it might be necessary to hold several sessions. Delivery and post-partum care must of course be dealt with in any training given to traditional birth attendants, but here the focus will be on antenatal care. Suggested topics:

aHygiene aNutrition, anaemia aSexually transmitted diseases aTetanus immunization aMalaria

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Health education aUrinary tract infection aVaginal discharge aPre-eclampsia aVaginal bleeding and its different causes aPremature contractions aPremature rupture of membranes aLoss of foetal movements aTwins, malpresentations aAny other local health problems that need to be discussed

With the exception of beginners, all traditional birth attendants already have some knowledge of these topics and it is important to build on it. Start by finding out what they know. Remember that the aim is not to turn traditional birth attendants into professionals, but to give them enough knowledge to be able to detect problems and refer cases in time. Since they will not be able to remember everything they are told, priority messages must be selected for each topic and duly emphasized. Teaching tips: aAs most traditional birth attendants can neither read nor write, it is essential to take a

very practical and visual approach.

aAsk the trainees to explain what they do and why they do it so as to find out what they

already know.

aIf possible, use an interpreter who is already familiar with the topic.

aTrainees must be given enough time to learn from one other and share experiences. aDo not hesitate to repeat the same message in different ways so as to be sure that it

is understood.

aLocal culture and beliefs must be respected. Remember that trainers can also learn

from trainees.

aWhen giving information, it is important to explain why you are giving it and to keep

things as simple as possible.

aMake trainees understand how important they are for their community by

emphasizing their knowledge and skills.

aAlthough this is a touchy issue, it is essential to make sure that everyone recognizes

his limits and knows when to ask for help.

aTaking time to observe the trainees carefully and being patient with them are

important aspects of good teaching.

aAlternate speakers so as to avoid monotony, using teams that already exist (e.g. ICRC

hygiene promotion teams) whenever possible.

aParticipatory dynamics can be very effective, especially if the trainers are acquainted

with different methods.

Since traditional birth attendants have been delivering babies for centuries, it will take time for them to understand why they have to acquire new skills, learn to recognize risk pregnancies or deliveries and refer pregnant women to the appropriate services.

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Health education

Example of teaching tool that can be made in the field: model built with material used for orthopaedic prosthesis (polypropylene)

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Health education

Health education for pregnant women When discussing health issues with pregnant women, it is essential to make sure that they can understand what is being said to them. With this in mind, it is important to: ause a good interpreter if one is necessary (preferably a person who is familiar with the

subject)

aadapt one’s explanations to the women’s level of understanding ause teaching tools such as drawings, pictures or dolls whenever necessary (such tools

can be made if they are unavailable)

achoose the most appropriate information to give to each woman, taking her specific

situation into account

agive the women time to ask questions and express any fears they might have.

Sometimes a pregnant women will only come for one antenatal consultation during her pregnancy. In such cases it is better to focus on the essential, bearing her particular situation in mind (culture, available health services, security conditions, local health problems, etc.) than to burden her with too much information. Often the best solution is to hold meetings with several women at the same time so as to benefit from the dynamics of group communication. Given the great number of subjects that will need to be discussed, however, this will take more time. Many meetings will usually be required and in addition it will be necessary to repeat things and ask questions to make sure that everyone has understood. For various reasons, some women will not be able to attend such meetings. In such cases, it may be possible to go to the villages and hold health education sessions on the spot, both for the women and – if the culture allows – for their husbands, who often have a lot to do with the decisions taken. It would be impossible to provide an exhaustive list of all the topics that may need to be discussed with a pregnant woman. However, a number of antenatal problems are dealt with in the second and third parts of these guidelines, each section of which contains a paragraph that explains what to say. Obviously, other topics (post-partum care, general health, etc.) may be discussed as well.

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PAGE BLANCHE

ANNEXES PART I Ante n at a l Ca re Pro g ra m m e s

ANNEX

I.A

I N T E R N AT I O N A L H U M A N I TA R I A N L AW

Source: Addressing the Needs of Women Affected by Armed Conflict. An ICRC Guidance Document. Annex to the Guidance Document. General and Specific Protection of Women under International Humanitarian Law (see bibliography) Health GC IV, Art. 91

Every place of internment must have an adequate infirmary. Isolation wards must be set aside for cases of contagious or mental diseases. Maternity cases and internees suffering from contagious diseases, or whose condition requires special treatment, surgical procedures or hospital care, must be admitted to an institution where adequate treatment can be given, and must receive care not inferior to that provided for the general population.

GC IV, Art. 16

The wounded and sick, as well as the infirm and expectant mothers, must be the object of particular protection and respect.

GC IV, Art. 17

GC IV, Art. 18

GC IV, Art. 50

Belligerents must endeavour to conclude agreements for the removal from besieged or encircled areas of the wounded, sick, infirm, elderly, children and maternity cases, and for the passage of medical personnel and equipment to such areas. Civilian hospitals organized to provide care for the wounded and sick, the infirm and maternity cases shall be protected from attack. In situations of occupation, the Occupying Power may not hinder the application of any preferential measures with regard to food, medical care and protection against the effects of war which may have been adopted prior to the occupation in favour of children under fifteen, expectant mothers and mothers of children under seven years of age.

AP1, Art. 8(a)

The definition of wounded and sick expressly includes maternity cases, newborn babies and other persons who may be in immediate need of assistance or care, such as expectant mothers, and who refrain from any act of hostility.

AP1, Art. 70(1)

In the distribution of relief consignments, including medical items, priority should be given to children, expectant mothers, maternity cases and nursing mothers.

GC: Geneva Convention

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AP: Additional Protocol

ANNEX

I . B. 1

P L A N N I N G f o r R E S U LT S ( P f R )

I M PAC T

I M PAC T

G . O.

O U TCO M E S

S . O.

OUTPUTS

PERFORMANCE = RESULTS

PfR EVALUATION

AC T I V I T I E S

MONITORING

INPUTS

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ANNEX

I . B. 2

P L A N N I N G f o r R E S U LT S ( P f R )

Desired impact: The desired impact is the statement of the long-term result expected. When this result is reached, humanitarian work, protection and assistance provided by international humanitarian actors, should be diminished or cease.This does not mean that all needs are definitely covered nor all problems are solved, but that the people and the local authorities and institutions are again selfreliant and able to cope with their daily life and to sustain the necessary basic social infrastructure. «GO» | Three elements defining the General Objective: Status: General Objectives have a range of validity of «one to several years». They represent the mid-term «outcome». Formulation of GO: In this section it is requested to formulate the outcome or midterm result according to what might reasonably be achieved in a time period from one to several years. The formulation must be as «SMART» as possible. Institutional strategy: This section exists only in headquarters PfR databases. The General Objectives can be linked to an institutional strategy. «SMART» criteria | General Objectives as well as Specific Objectives must be formulated as much as possible according to the SMART criteria outlined below: Specific: the objective/result is distinct from others and is as precisely defined as possible; Measurable: the objective/result mentions quantitative and qualitative elements concerning beneficiaries and the protection and assistance services offered; Achievable : the objective/result must be realistically attainable. It is not a hypothetical result nor an objective/result out of scope compared to what the ICRC is able to implement at its best; Relevant: the objective/result is appropriate and makes sense in relation with the target group and the problem assessed; Time-bound: any time element that indicates the necessary time for its implementation and situates the projected validity of the objective. «SO»| Specific Objectives linked to the «GO»: There number is not limited. Specific Objectives specify the short-term or output results within the year.

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ANNEX

I . B. 3

P L A N N I N G f o r R E S U LT S ( P f R )

GLOSSARY OF TERMS Impact: An examination of the wider long-term effects that the action contributes to social, economic, technical, environmental - individuals, communities, and institutions. Impact can be immediate and long-range, intended and unintended; positive and negative, macro and micro. Impact studies address the question what real difference has the action made in improving the capacity of communities to reduce their level of vulnerability? How many people have been affected, and how have they benefited from the action? Input: Organizational, human information, or physical/material, financial resources invested directly or indirectly to achieve results in favour of intended beneficiaries. Outcome: At the general objective level, these are the effects over the mid-term (one to several years). These intermediate benefits are generated over time and are directly linked to the accumulated achievement of programme outputs. Output: Short-term, tangible results of ICRC actions or programme inputs achieved within a 12-month period. Performance: The extent to which a programme, project, or operation is implemented in an effective, efficient and timely manner and produces expected results for an identified target population without causing unintended negative consequences. Result: A describable and/or measurable change in state, planned and unplanned, at the output, outcome, impact level, that can be attributed to ICRC action.

This annex “Planning for Results” (PfR) comes from: ICRC “Planning, Monitoring, Evaluation” database.

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SAMPLE ANC SERVICE INDICATORS

Utilization rate of ANC service during the third trimester of pregnancy

Increase from xx to xx the % of women who consult the ANC service at least once during the third trimester of pregnancy

Source of verification / Remarks

Source 2 : Routine reporting system N = Number of consultations during the third trimester D = total number of first consultations during the third trimester

Source 1: Population survey N = Number of mothers who said they had consulted the ANC service at least once during the last trimester of pregnancy before the birth of their most recent child 0-23 months D = Number of women having delivered within the last 2 years

Source 2: Routine reporting system average number of ANC per pregnant women N = Number of consultations during specified period D = Number of first consultations during specified period

Source 1: Population survey N = Number of mothers who said they had consulted the ANC service at least 4 times before the birth of their most recent child 0-23 months D = Number of women having delivered within the last 2 years

Source 2: Routine reporting system N = Total number of first consultations during the year D = Expected number of pregnant women in the health post (HP) catchment area

Source 1: Population survey Numerator (N) = Number of women who consulted the ANC service at least once before the birth of their most recent child 0-23 months Denominator (D) = Number of women having delivered within the last 2 years

Childbearing women (15-49 years) = 20% total population

Utilization rate of antenatal service

ANC coverage rate

Indicators

Increase from xx to xx the % of mothers who consult the ANC service at least 4 times

Increase from xx to xx the % of pregnant women receiving antenatal care

Verifiable objectives

To help improve and/or maintain the health of the target population 7

7 Pregnant women = 4% total population

Use reflects the demand for services

Coverage measures the proportion of the target population that has received a particular service

the ANC service for the target population

GENERAL To improve the OBJECTIVE coverage and use of

IMPACT

ANNEX I.C.1

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1) Geographical accessibility measures the extent to which services are accessible to the target population 2) Financial accessibility measures the extent to which people are able to pay for care 3) Cultural accessibility measures the extent to which access to health services is impeded by cultural taboos (e.g. reproductive health services use male physicians, ethnic minority services use staff from the dominant ethnic group) 4) Security How? By ensuring the availability of first-line health services able to provide the minimum package in accordance with national standards concerning infrastructure, equipment, medicines, medical skills and reference materials.

SPECIFIC To improve the target OBJECTIVE population’s access to the ANC service 1

Number of pregnant women per health service as compared with national / WHO standards

Increase from xx to xx the % of the target population that has physical access to the health services

ANC coverage

Distribution of health services in catchment area

Number of health posts supported by the ICRC providing ANC (minimum or maximum package to be defined)

Increase from xx to xx the number of facilities providing the key components of the minimum package

Indicators

See: General Objective

Source of verification / Remarks

SAMPLE ANC SERVICE INDICATORS

Verifiable objectives

ANNEX I.C.2

p | 54 Number of trained health providers managing health services properly (according to national standards)

Increase from xx to xx the % of cases of major local diseases (to be defined) that are detected and properly treated Increase from xx to xx % patients who can obtain all the medications prescribed (including vaccines) Increase the knowledge pregnant women have of health topics (to be defined)

- Infrastructure and equipment are maintained according to ICRC / national standards

- The ANC service has an uninterrupted supply of renewable high-quality materials, vaccines and drugs

- Medical and nonmedical staff have the skills required to manage patients

- The ANC service, through continuous monitoring and evaluation, meets the needs of the population

By ensuring that:

Number of EPI sessions that encountered shortages

Percent of patients who were unable to obtain all the medicines prescribed in the health unit owing to shortages

Number of health facilities reporting they had not run out of antibiotics / anti-malarial drugs, vaccines, needles, syringes and/or immunization cards for more than one week during the 3 previous months (or last period)

Population’s knowledge of health topics

Satisfaction of the target population with the services provided

% of patients managed properly (according to national standards)

Number of health services conforming to national standards concerning infrastructure, equipment, medicines and supplies, medical skills and reference materials

SPECIFIC To improve the quality OBJECTIVE of the ANC service 2 How?

Increase from xx to xx the number of health posts providing ANC according to national standards

Indicators

SAMPLE ANC SERVICE INDICATORS

Verifiable objectives

ANNEX I.C.3

- Quality of nursing care: % of patients presenting post-injection complications

For example: quality of diagnosis and treatment - % of high-risk pregnancies/deliveries correctly diagnosed - % of undetected high-risk pregnancies/deliveries

Form for evaluating the work of health providers

Reference materials: standard treatment guidelines, list of essential drugs, national EPI guidelines

Source of verification / Remarks

ANNEX

I.D

CHECKLIST FOR SAFE MOTHERHOOD SERVICES

In Emergency Phase:

aProvision of delivery kits: UNICEF midwifery kits for health centres and clean delivery

kits for home use

aIdentification of referral system for obstetric emergencies

- One health centre for every 30,000 - 40,000 people - One operating theatre and staff for every 150,000 - 200,000 people - Skilled health care providers trained and functioning ( one midwife for 20,000 30,000 people, one CHW/TBA for 2,000 - 3,000 people) - Community beliefs and practices relating to delivery are known - Refugee women are aware of service availability

Antenatal Services are in place:

aRecord systems in place (clinic and home-base maternal records) aMaternal health assessment routinely conducted aComplications detected and managed aClinical signs observed and recorded aMaternal nutrition maintained aSyphilis screening in pregnancy undertaken routinely aEducational activity related to antenatal care provision in place aPreventive medication given during antenatal services:

iron folate for anaemia, Vitamin A, tetanus toxoid, others as indicated (malaria)

aSTD prevention and management undertaken aMaterials available to implement antenatal care services

Delivery services are in place:

aProtocols for managing and referring complications in place and transport system

functioning

aTraining and supervision of TBAs and midwives undertaken aComplications are detected and managed appropriately aAwareness of warning signs of complications in pregnancy is widespread aStandard protocols are used to manage deliveries aMedical facilities are adequately equipped aBreastfeeding is supported

Postpartum services are in place:

aEducational activities undertaken (especially family planning and breast feeding) aComplications managed appropriately aIron folate and Vitamin A provided aNewborn weighed and referred for under-five services (e.g., EPI, growth monitoring)

This annex comes from:“Reproductive Health in refugees situations an Inter-agency Field Manual”, UNHCR, 1999.

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ANNEX I.E.1

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N E W WHO ANTENATAL CARE MODEL

ANNEX I.E.2

NEW WHO ANTENATAL CARE MODEL

CRITERIA FOR CLASSIFYING WOMEN FOR THE BASIC COMPONENT

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ANNEX I.E.3

NEW WHO ANTENATAL CARE MODEL BASIC COMPONENT CHECKLIST

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A N N E X I . F. 1

ANTENATAL CARE QUALITY SERVICE ASSESSMENT

This checklist is intended for use in supervision and monitoring of antenatal services provided by health workers, community-based health workers, and traditional birth attendants. The list is comprehensive and includes some clinical tasks that the traditional birth attendants and other peripheral workers do not routinely carry out.The checklist should be modified and simplified according to the local situation. This checklist is intended for use in the observation of service delivery. It is recommended that you review the checklist carefully before using it to be sure that you understand the questions and know how to use the form. For observation of service delivery, mark “yes” if the service provider carries out these activities during service delivery. For interview questions, mark “yes” if the respondent answers correctly. 1. Health facility

3. Date

2. Service provider

4. Observer/supervisor

Reproductive history Did the service provider: 5. YES NO Review obstetric record or family health card? Did the service provider update information on the following: 6. YES NO Age? 7. YES NO Date of last menstrual period? 8. YES NO Date of last delivery? 9. YES NO Number of previous pregnancies? 10. YES NO Outcome of each pregnancy? 11. YES NO Complications during previous pregnancies?8 12. YES NO Current or past breast-feeding? Did the service provider ask about risk factors: 13. YES NO Spotting/bleeding during current or past pregnancies? 14. YES NO Burning on urination? 15. YES NO Foul smelling vaginal discharge? 16. YES NO Diabetes? 17. YES NO Cardiovascular problems? 18. YES NO Renal problems? 19. YES NO Female circumcision? 20. YES NO Previous injuries, especially to pelvis? 21. YES NO Medications currently being taken? 22. YES NO Smoking? 23. YES NO Alcoholism? 24. YES NO Drug abuse? 25. YES NO Any other problems associated with current pregnancy? Ask about preventive actions taken : 26. YES NO Immunization against tetanus? 27. YES NO Malaria prophylaxis? 28. YES NO Plans for delivery? 8 Complications include bleeding, toxaemia, infection, prolonged labour, RH incompatibility, Caesarean section, stillbirth, and spontaneous abortion.

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A N N E X I . F. 2

ANTENATAL CARE QUALITY SERVICE ASSESSMENT

Physical exam Did the service provider: 29. YES NO Take pulse? 30. YES NO Take blood pressure? 31. YES NO Correctly measure height and weight? 32. YES NO Correctly examine legs, face, and hands for signs of oedema? 33. YES NO Calculate expected date of delivery? 34. YES NO Assess adequacy of pelvic outlet? Routine preventive services for pregnant women Did the service provider: 35. YES NO Immunize or arrange for immunization against tetanus? 36. YES NO Administer or prescribe iron supplements? 37. YES NO Administer or prescribe nutrition supplements? 38. YES NO Administer or prescribe anti-malarial drugs if indicated? Referral Did the service provider: 39. YES NO Encourage mother to attend prenatal sessions at the local health facility? 40. YES NO Refer high-risk pregnancies for additional medical attention? 9 41. YES NO Recommend hospital birth for high-risk pregnancies? 42. YES NO Refer for urine examination (sugar and protein) if medically indicated? 43. YES NO Refer for blood test (glucose, haemoglobin/haematocrit or malaria diagnosis) if medically indicated? 44. YES NO Refer for blood test for RH factor determination? 45. YES NO Refer for syphilis serology test (per local norms or if medically indicated)?

9 Referral is indicated if: 1) one or more high-risk factors (see reproductive history) are present; 2) there is a history of complications during pregnancy or birth; 3) the woman is older (per local norms) or has had many pregnancies (number determined by local norms). Referral is also indicated for obstetric and medical problem(s) and emergencies, ectopic pregnancy, infection or bleeding from abortion, and other prenatal problems and emergencies, especially haemorrhage, sepsis and eclampsia. Guidelines for referral should follow local norms.

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A N N E X I . F. 3

ANTENATAL CARE QUALITY SERVICE ASSESSMENT

Counselling Did the service provider: 46. YES NO Explain the importance of continuing prenatal care during pregnancy? 47. YES NO Explain the benefits of weight gain during pregnancy? 48. YES NO Discuss the types of foods to include in diet during pregnancy 49. YES NO Explain how to take iron tablets/nutrition supplements? 50. YES NO Warn about dangers of alcohol, smoking, drugs? 51. YES NO Explain the importance of tetanus toxoid immunization during pregnancy? 52. YES NO Explain the importance of having delivery attended by a trained health worker? 53. YES NO Explain the dangers of abortions performed by unqualified individuals? 54. YES NO Explain danger signs which require immediate attention?10 55. YES NO Tell pregnant woman to have family seek assistance or transport her to clinic/hospital if danger signs of obstetric emergencies or complications of labour occur? 56. YES NO Tell pregnant woman where and when to go for next prenatal visit? 57. YES NO Verify that pregnant woman understood key messages? 58. YES NO Ask if she has any questions? Supplies Ask the service provider about the following supplies: 59. YES NO Do you have a working scale (to weigh the pregnant woman)? 60. YES NO Do you have a measuring tape? 61. YES NO Do you have a stethoscope and blood pressure cuff? 62. YES NO Do you have a watch with a second hand to take pulse? 63. YES NO Do you have tetanus toxoid vaccine? 64. YES NO Do you have iron tablets (per local policy)? 65. YES NO Do you have drugs for malaria prophylaxis (per local policy)? 66. YES NO Do you have forms or health cards to record the antenatal visit?

10 Danger signs include swelling of hands and face, severe or prolonged dizziness, bleeding from vagina, sharp or constant abdominal pain, fever, vaginal odour or discharge.

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A N N E X I . F. 4

ANTENATAL CARE QUALITY SERVICE ASSESSMENT

Interview with pregnant woman Mark “yes” if the respondent answers correctly: 67. YES NO Do you plan to have a trained health worker attend your birth? 68. YES NO What are the danger signs during pregnancy that require medical attention? 69. YES NO When and where is your next prenatal visit? If pregnant woman is at high-risk for any reason: 70. YES NO Do you plan to seek further medical attention? 71. YES NO Do you plan to have your baby at a hospital? Interview with service provider Mark “yes” if the respondent answers correctly: 72. YES NO What are the danger signs during pregnancy that require medical attention? 73. YES NO Do you refer high-risk pregnancies? 74. YES NO Do you have a way of tracking high-risk pregnancies? 75. YES NO Do you follow up pregnant women who do not return to prenatal sessions?

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A N N E X I . F. 5

ANTENATAL CARE QUALITY SERVICE ASSESSMENT

This checklist is intended for rapid assessment of service quality in the observation of service delivery of antenatal care. To use the checklist, mark "yes" if the service provider carries out the task during service delivery. For interviews, mark "yes" if the respondent answers correctly. If you would like to assess this service in more detail, please refer to the appropriate service quality checklist. The checklist item numbers below correspond to that list.

1. 3. 4.

Health facility Observer/supervisor Date

Did the service provider: 5. 6-12.

YES YES

NO NO

13-25.

YES

NO

29-34. 35. 43.

YES YES YES

NO NO NO

52.

YES

NO

54. 56.

Yes Yes

No No

Review and update obstetric record or family health card? Ask at least two questions about reproductive history risk factors? Ask at least two questions about risk factors associated with this pregnancy? Perform at least 1 physical exam activity? Immunize or arrange for immunization against tetanus? Do a blood test (glucose, haemoglobin/haematocrit and malaria) if medically indicated? Discuss the importance of having the delivery attended by a trained health worker? Explain danger signs which require immediate attention? Tell pregnant woman when and where to go for next prenatal visit?

This annex “Antenatal Care Quality Service Assessment” comes from: Aga Khan Foundation, Primary Health Care Management Advancement Programme, Assessing the Quality of Service, Module 6, User’s Guide, Aga Khan Foundation, Thailand, 1997.

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ANNEX I.G.1

LIST OF DRUGS WITH THEIR ICRC ORDER CODE

ORAL Albendazole 400 mg

DORAALBE 4T

Amoxycillin 250mg

DORAAMOX 2T

Cefixime 200mg

DORACEFI 2T

Erythromycin 250mg

DORAERY 2T 11

Ferrous sulfate 200mg + folic acid 0,4mg

DORAFERF 20T

Fluconazole 50mg

DORAFLUC 5T

Mebendazole 100mg

DORAMEBE 1T

Methyldopa 250mg

DORAMETY 2T

Metronidazole 250mg

DORAMETN 25T

Misoprostol 200mcg = 200µg

DORAMISO 2T

(for emergency medical kit)

Multivitamins12

DORAMULT 1T

Oral rehydration salts, sachet 27,9g/1 litre

DORAORSA 1S

Paracetamol 500mg

DORAPARA 5T

Sulfadoxine 500mg + pyrimethamine 25mg

DORASULP 5T

Nevirapine 200mg

DORANEVI 2T

EXTERNAL Nystatin 100 000 IU (intra-vaginal)

DEXTNYST 1T

INFUSION (for emergency medical kit) Dextrose 5%, 500 ml

DINFDEXT 505

Ringer Lactate, 1 litre

DINFRINL 1

Sodium Chloride 0,9%, 500 ml

DINFSODC 905B

11200mg of ferrous sulfate corresponds to 60mg of ferrous which is in line with WHO recommendations. 12 Composition: Retinol: 2500 IU, Thiamine B1: 1mg, Riboflavine B2:0,5mg, Nicotinamide B3: 7,5mg,

VitaminC: 15mg, Colecalciferol D3: 300 IU

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ANNEX I.G.2

LIST OF DRUGS WITH THEIR ICRC ORDER CODE

INJECTABLE (for emergency medical kit) Ampicillin, 1g, powder vial

DINJAMPI 1V

Calcium Gluconate, 100mg/ml, 10ml, amp.

DINJCALG 1A

Ceftriaxone, 250mg, powder vial

DINJCEFT 2V

Diazepam, 5mg/ml, 2ml, amp.

DINJDIAZ 1A

Ergometrine / methylergometrine, 0,2mg/ml, 1ml, amp.

DINJERGM 2A

Gentamicin, 40mg/ml, 2ml, amp.

DINJGENT 8A

Hydralazine, 20mg, powder amp.

DINJHYDA 2A

Lidocaine / Lignocaine 2%, 20ml, vial

DINJLIDO 2V2

Magnesium sulfate, 0,5g/ml, 10ml, vial

DINJMAGS 5V

Metronidazole (infusion) 5mg/ml, 100ml

DINFMETN 501

Oxytocin, 10 IU/ml, 1ml, amp.

DINJOXYT 1A

Penicillin Benzyl 1 MIU + Procaine 3 MIU, powder vial

DINJPENIF 4V

Penicillin Benzathine, 2,4 MIU, powder vial

DINJPENIB 2V

Penicillin Benzyl (peni G, crystal peni), 1 MIU, powder vial DINJPENIG 1V Quinine di-hydrochloride, 300mg/ml, 2ml, amp.

DINJQUIN 6A

Sterile water for injection, 10ml, plastic amp.

DINJWATE 1A

For more information on the content of the emergency medical kit, see pages 39-40

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Antenatal Consultations

2

Of all the rights of women, the greatest is to be a mother. Lin Yutang

ANTENATAL CONSULTATIONS

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Part II : Antenatal consultations Medical records Diagnosis of pregnancy and Calculation of term Physiological changes in pregnancy Initial medical assessment Standard antenatal consultation Cases to be referred for delivery Emergency obstetric care General information Emotional and psychological support Management of emergency cases: - Convulsions or loss of consciousness (schedules for magnesium sulfate and diazepam enclosed)

- Fever - Respiratory distress - Vaginal bleeding - Abdominal pain - Prolapsed cord - Unsatisfactory progress in labour - Trauma Annexes II.A.1-5 Controlled cord traction with illustrations of placental delivery II.B

Guidelines for rehydration

MEDICAL

RECORDS

To ensure proper follow-up of the pregnant woman, it is useful to have a file recording basic information, both medical and other. With a well-organized filing system, pertinent information can be obtained on previous pregnancies. Here again, certain adjustments are necessary.

The records must : abe in the local language abe adapted to the professional abilities of the local staff and to their writing skills (capital letters, etc.) abe well-spaced, easy to use, and printed on stiff paper that remains in good condition abe affordable afocus on specific antenatal information acover the entire duration of the pregnancy, which may mean recording a number of consultations As for the filing of obstetric records, it is important to find a system which suits the professionals using them and which makes it easy to find a specific file on the basis of information given by the patient (name, village, number, etc.). Depending on the situation, the best method might be to send the woman home with the file, especially if she has the opportunity to attend different health facilities. In other cases, however, this would not be a good idea because the file might be lost or damaged, or the woman might forget to bring it with her at the next visit. This is not because she does not have a responsible attitude; it may be because the antenatal file is not the most important concern among the many other worries of the family concerned, or because the family’s living conditions do not allow her to keep the file in good condition.

If the woman has to be referred, it is advisable to have a standard referral letter in which you just have to fill in the spaces.

Please, see the illustrations, « Examples of obstetric records » on next pages.

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Medical records

« AN * ( see note)

EX AMPLE OF OBSTETRIC RECORDS

NAME:

AGE:

VILLAGE:

HEIGHT:

GRAVIDA:

PARA:

PREMATURE:

»

WEIGHT: ABORTION:

STILLBIRTH:

PREVIOUS DELIVERIES: (place, year, sex, weight, episiotomy, caesarean, time of breast-feeding ...)

MEDICAL AND/OR SURGICAL HISTORY:

HISTORY OF ACTUAL PREGNANCY - DATE OF LAST MENSTRUATION :

DATE :

MONTHS :

DATE :

MONTHS :

WEIGHT :

B P:

WEIGHT :

B P:

FINDINGS AND/OR COMPLAINTS:

FINDINGS AND/OR COMPLAINTS:

* Inscription for : name or village or number, etc... your method for «filing system». p | 70

Medical records

«

ANOTHER EX AMPLE OF OBSTETRIC RECORDS

»

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DIAGNOSIS OF PREGNANCY AND C A L C U L AT I O N O F T E R M Pregnancy is diagnosed on the basis of the symptoms, the date of the last menstrual period and the clinical signs.

Possible symptoms of pregnancy

aAmenorrhoea (but there can be some spotting) aTense and sensitive breasts aNausea aSleepiness aPollakiuria

Last menstrual period: LMP If the woman knows the date of the first day of her last menstrual period, the number of weeks of pregnancy and the expected date of delivery (EDD) can be calculated.If necessary, check for Hegar’s sign (with an empty bladder).

Menstrual age, conceptional age and prenatal events Term

Preterm

0

4 0

Fertilised ovum

Preconception

8 4 Embryo

Legal viability

12 8

16 12

20 16

24 20

32

28 24

Posterm

Expected date of delivery

28

40

36 32

36

44 40

Foetus

Pregnancy

Clinical signs At a certain stage, pregnancy is obvious and easy to confirm by abdominal palpation. If necessary, check for Hegar’s sign (with an empty bladder)

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44

WEEKS FROM CONCEPTION

WEEKS FROM LMP

Last menstrual period (LMP) Conception First missed period

D iagnosis of pregnanc y and calculation of term

Diagnosing pregnancy aIf the woman has regular periods, presents secondary amenorrhoea, knows the exact date of the LMP and shows the symptoms listed above, it is easy to make a diagnosis of pregnancy. aIf the woman does not have regular periods, does not know the date of the LMP

and has some chronologically abnormal bleeding, it is more difficult to be sure about the diagnosis, especially if she has no clear symptoms. Note

Always check first for pregnancy in case of abnormal bleeding or amenorrhoea.

Pregnancy test The urine test should be performed only if there is a need to know the result as quickly as possible (in case of rape, before treatment contraindicated during pregnancy, ectopic or molar pregnancy, etc.). Usually, however, it is not necessary and the clinical evolution will confirm the pregnancy. (For the test to be reliable, the instructions must be followed scrupulously).

Different methods of calculating EDD If the date of the first day of the LMP is unknown, the calculation will be approximate. The easiest way of calculating the EDD is by using an obstetric wheel or calculator. Otherwise, choose the most appropriate method of calculation from the following examples (bearing in mind that none of them is exact, but that delivery at term takes place between 37 and 42 weeks of pregnancy) : aLMP + 40 weeks = EDD aLMP – 3 months = X + 1 year = EDD aLMP + 7 days = X + 9 months = EDD aLMP + 10 days = X – 3 months = EDD aLMP + 280 days = EDD or 10 months of 28 days (lunar cycle) In some countries women are used to calculating according to the moon. This corresponds to the last method listed above, the moon having a cycle of 28 days. Thus if the woman has regular periods, when she has missed the first period she has already gone through one cycle of 28 days. She will look at the moon and count nine more cycles of the same phase of the moon to know approximately when she will deliver.

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PHYSIOLOGICAL CHANGES IN PREGNANCY The physical and psychological changes that occur in a pregnant woman are often due to the effects of specific hormones : human chorionic gonadotrophin, oestrogen, progesterone, human placental lactogen.

Cardiovascular and haematological changes FINDINGS (FOR INFORMATION)

OUTSIDE PREGNANCY

PREGNANCY AT TERM

Blood volume (mL) Plasma volume (mL) Corpuscular volume (mL)

4000 2600 1400

5500 3800 1700

Venous haematocrit (%) Haemoglobin (g/L) Leucocytes (x10 /L) Platelets (x10 /L) Fibrinogen (g/L) Serum iron (mol/L)

35 115 - 150 6-8 150 - 300 2-4 13 - 27

30 100 - 125 10 - 15 115 -300 4 - 6, 5 11 - 21

Cardiac flow (L/min) Cardiac rate (b/min) Uterine flow (ml/min)

4.8 60 - 100 85

8.7 +15% 500

The consequences of these changes during pregnancy are as follows : aHaemodilution, leading to physiological anaemia compensated by an increase

in red cell mass in response to the extra oxygen requirements of maternal and placental tissue. aIncreased cardiac output :

- leading to heart enlargement - leading to an increase in ejection volume - but offset by reduced peripheral resistance (arterial walls relax and dilate, capacity of veins and venules may increase by a litre).

aThe excess blood flow, directed mainly to the uterus, goes to the placenta. aChanges in clotting factors increase clotting capacity during pregnancy, resulting

in greater risk of thrombosis or embolism. In the event of complications, disseminated intravascular coagulation or clotting failure may occur, with a high risk of maternal death if no appropriate treatment is available.

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Physiological changes in pregnanc y

Blood pressure (see page 92) In advanced pregnancy women should avoid lying on their back, as this can cause deep hypotension because of the pressure of the gravid uterus on the vena cava. As a result, cardiac output is reduced and there may be feelings of faintness and paresthesia of the fingers, and even a risk of maternal shock which will precipitate changes in the foetal heart rate.

Vena cava

Oedema (see page 92) The combination of a higher level of proteins and haemodilution during pregnancy leads to a decrease in osmotic pressure and moderate oedema of the lower limbs. This is considered to be physiological and the prognosis is favourable.

Respiratory system Changes are necessary in order to maximize maternal oxygen intake and ensure efficient carbon dioxide excretion for the mother and hence for the foetus. These changes are as follows:

aThe respiratory rate (<20/min) does not change, but the tidal volume

increases by approximately 40%.

aOxygen consumption increases by 20% during pregnancy. aIn later pregnancy, the ribs spread in order to compensate for the effect of

pressure of the enlarged uterus on the diaphragm, and thus to maintain the capacity of the thoracic cavity. There is often nasal congestion due to increased vascularization during pregnancy, and nosebleeds are common.

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Physiolo gical changes in pregnanc y

Gastrointestinal system MOUTH

aOwing to a hygroscopic effect, gums may become spongy and there may be

some bleeding. Dental problems that occur may be due to gingivitis rather than to dental caries. aThere may be an increase in salivation (ptyalism). aWomen often experience changes in their sense of taste, leading to dietary changes or even food cravings (“pica”: craving for non-food substances such as coal or earth, is rare).

OESOPHAGUS

aHeartburn is common and associated with gastric reflux (60% of pregnancies)

due to relaxation of the lower sphincter. n

Advise the mother to: - divide meals into smaller separate portions - avoid spicy, fatty or acid foods, alcohol, coffee, fizzy drinks, etc. - raise the head of the bed

Diaphragm

The raised abdominal pressure at the end of pregnancy favours heartburn and sliding hiatal hernia.

Stomach

Uterus or Womb

Heartburn

(ie: Oesophageal reflux)

Hiatal hernia Diaphragm Oesophageal hiatus Stomach

Hiatal hernia

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Physiolo gical changes in pregnanc y

STOMACH aGastric emptying and peristalsis are slowed in order to maximize absorption

of nutrients, and acidity is reduced. aNausea and vomiting occur in 50% of pregnancies, mainly during the first

trimester. This can be more severe in cases of multiple pregnancy or hydatiform mole. n

Advise the mother to : - divide meals into separate small portions throughout the day - avoid food which is difficult to digest or irritates the stomach Complication : hyperemesis gravidarum (1-2% of pregnancies), which means severe vomiting associated with dehydration, loss of weight and electrolytic disturbances that can lead to icterus or renal failure, refer the pregnant woman.

SMALL BOWEL Increased absorption of calcium and iron.

LARGE BOWEL Increased absorption of water. aConstipation is the result of sluggish gut motility. n

Advise the mother to : - drink at least 2 litres per day - eat fibre-rich foods, fresh or dry vegetables and fruits.

aHaemorrhoids, which may occur as a result of relaxation of the smooth

muscles of the vein wall, can be exacerbated by constipation.

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Physiolo gical changes in pregnanc y

Urinary system During pregnancy, pollakiuria occurs as bladder capacity is restricted by the growth of the uterus. On average, the urinary flow increases by 25%. Renal blood flow : - 500 mL/min in normal conditions - 700-800 mL/min during pregnancy Glomerular filtration : - 100 -130 mL/min in normal conditions - 150 mL/min during pregnancy Owing to hormonal action, there is dilatation of the renal cavities and ureters.This leads to urinary stasis which, together with compression of the ureters by the gravid uterus, increases the risk of infection. n

Advise the mother to: - drink at least 2 litres per day - pass urine frequently.

As a result of increased glomerular filtration in the prone position, urine output is greater at night.

Kidney

Ureter

Bladder Urethra

The renal tract

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Kidney

Ureter

Bladder

Urethra

Dilated, kinked ureters in pregnancy

Physiological changes in pregnanc y

SAGGITAL SECTION OF THE PELVIS SHOWING THE RELATIONS OF THE BLADDER Ureter Sacrum Recto-uterine pouch of Douglas Rectum

Peritoneum Uterus Utero-vesical pouch Bladder Symphysis pubis Urethra

Anus Perineal body

Skin changes Increased activity of the melanin-stimulating hormone causes deeper pigmentation during pregnancy. Chloasma: patchy colouring on the face, resembling a mask. Linea nigra: pigmented line running from the pubis to the umbilicus. The nipples and perineal area also become darker. Striae gravidarum or stretch marks: red streaks on breasts, abdomen, and areas with fat deposits such as the thighs during pregnancy, fading to residual white streaks about 6 months after delivery. Increased blood supply to the skin causes sweating, and women often feel hot during pregnancy.

Skeletal changes Relaxation of ligaments and muscles occurs in pregnancy, with maximum effect during the last weeks. This relaxation enables the pelvis to increase its capacity so as to facilitate the descent of the foetus at term and during labour. The symphysis pubis softens, as do the sacroiliac joints. The sacrococcygeal joint loosens, allowing the coccyx to be displaced backwards. This can cause pain in the joints and pelvic ligaments.

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Physiolo gical changes in pregnanc y

Immune system Systematic maternal immunodepression during pregnancy has not been confirmed, but many studies suggest it may occur.

How infection in the mother can affect the foetus : A

a

b E

D B

C Possible means of foetal infection during pregnancy: n n

Direct transplacental infection by blood A Secondary endometritis site D, transmitted by blood B or by ascending (eg. vagina) infection C

From this site D, the infection can spread:

ato the placenta and reach the foetus by way of the umbilical cord a ato the amniotic fluid b which can infect the foetus by digestive or respiratory way

E : Endometritis site remained quiescent during pregnancy.

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Physiological changes in pregnanc y

Uterus Uterus sizes Before pregnancy: size of a fresh fig

At one month: size of a tangerine

At two months: size of an orange

At three months: size of a grapefruit, and the fundus (upper part) of the uterus may be palpated above the symphysis pubis.

Braxton-Hicks contractions: These begin at two months and can be felt by the mother at four; they are painless and sporadic. They continue throughout pregnancy, becoming more intense and painful at the later stage, and eventually lead to labour contractions. At 36 weeks the uterus reaches the level of the xiphisternum. Softening of the pelvic floor tissues together with good uterine tone and the formation of the lower uterine segment encourages the foetus to sink into the lower pole of the uterus. This is described as “lightening”: aIn the primigravida, this process also encourages the beginning of a gradual descent

into the pelvis (uterine height decreases), and the foetal head becomes engaged.

aIn the multiparous woman, descent often occurs only when labour starts.

Cervix The cervix acts as an effective barrier against infection and also retains the pregnancy. The thickened mucus secreted by the endocervical cells forms a cervical plug called the operculum, which provides protection from ascending infection. Cervical vascularity increases during pregnancy and the cervix becomes softer.

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Physiolo gical changes in pregnanc y

Summary of foetal development 0 - 4 weeks after conception

16 - 20 weeks

- Rapid growth - Formation of the embryonic plate - Primitive central nervous system forms - Heart develops and begins to beat - Limb buds form

- «Quickening» – mother feels fetal movements - Fetal heart heard on auscultation - Vernix caseosa appears - Fingernails can be seen - Skin cells begin to be renewed

4 - 8 weeks - Very rapid cell division - Head and facial features develop - All major organs laid down in primitive form - External genitalia present but sex not distinguishable - Early movements - Visible on ultrasound from 6 weeks 8 - 12 weeks - Eyelids fuse - Kidneys begin to function and the foetus passes urine from 10 weeks - Fetal circulation functioning properly - Sucking and swallowing begin - Sex apparent - Moves freely ( not felt by mother) - Some primitive reflexes present 12 - 16 weeks - Rapid skeletal development – visible on X-ray - Meconium present in gut - Lanugo appears - Nasal septum and palate fuse

20 - 24 weeks - Most organs become capable of functioning - Periods of sleep and activity - Responds to sound - Skin red and wrinkled 24 - 28 weeks - Survival may be expected if born - Eyelids reopen - Respiratory movements 28 - 32 weeks - Begins to store fat and iron - Testes descend into scrotum - Lanugo disappears from face - Skin becomes paler and less wrinkled 32 - 36 weeks - Increased fat makes the body more rounded - Lanugo disappears from body - Head hair lengthens - Nails reach tips of fingers - Ear cartilage soft - Plantar creases visible 36 - 40 weeks after conception (38-42 weeks after LMP) - Term is reached and birth is due - Contours rounded - Skull firm

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Physiological changes in pregnanc y

cm 10 3 weeks

4 weeks 6 weeks

9 8 7 6 5

7 weeks

4 3 2 1 8 weeks

12 weeks

0

Sizes of embryos and foetus between 3 and 12 weeks gestation

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Physiolo gical changes in pregnanc y

Vagina Vascularity of the vagina increases during pregnancy. The muscle layer hypertrophies, and changes in the surrounding connective tissue make the vagina more elastic.These changes enable it to dilate during the second stage of labour so as to accomodate the descending foetus. There is marked desquamation of the superficial epithelial cells, which increases the amount of normal white vaginal discharge called leucorrhoea. The epithelial cells also have increased glycogen content, which interacts with Döderlein’s bacillus, a normal commensal of the vagina, to produce a more acid environment. This provides an extra degree of protection against some organisms, but unfortunately causes increased susceptibility to others, such as Candida albicans.

Breast changes in chronological order 3 - 4 weeks Prickling, tingling sensation due to increased blood supply particularly around nipple. 6 weeks Developing ducts and glands cause the breasts to be enlarged, painful and tender particularly in women who normally experience pre-menstrual changes. 8 weeks Bluish surface veins are visible. 8 - 12 weeks Montgomery’s tubercles become more prominent on the areola. These sebaceous glands secrete sebum which keeps the nipple soft and supple. The pigmented area around the nipple darkens and may enlarge slightly. This area is known as the primary areola. 16 weeks Colostrum can be expressed. Further extension of the pigmented area occurs and is often mottled in appearance, secondary areola. Late pregnancy Colostrum may leak from the breasts; progesterone causes the nipple to become more prominent and mobile.

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Physiological changes in pregnanc y

Psychological changes Although for most women pregnancy is a time of great joy and satisfaction, as they have fulfilled a biological function, many experience a period of anxiety. Decisions have to be made about the future, and motherhood has to be accepted as a new status. A loving, supportive relationship in which the two partners communicate and discuss their feelings will help resolve these early anxieties. Mood swings are common because of hormonal changes, and can often be frightening for both partners. Libido is likely to decrease, not only because of changes in the body but also because of fear of harming the baby. It must be borne in mind that this is a time when a woman requires a great deal of support and sensitivity. The mother often feels a unique and exclusive closeness with the foetus. Her partner may feel left out, as he is unable to share this experience. She also becomes increasingly aware of her new responsibilities and realizes that she will lose some of her freedom. Much depends on the circumstances:

a whether the woman is primigravida or multiparous aher cultural, social and economic situation awhether the pregnancy was desired or otherwise awhether there are major security problems where she lives.

Even women without any psychiatric history may suffer from specific conditions such as depression during pregnancy, or depression or psychosis during the post-partum period.This has nothing to do with what is called «baby blues», which is a very common and less serious problem.

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INITIAL MEDICAL ASSESSMENT This section focuses on the general state of health of the pregnant woman. More specific details of the antenatal check-up will be given in the following section « Standard antenatal consultation ». It is important to keep in mind that, depending on the local medical services, it may not be possible to treat all the health problems encountered. Laboratory tests and other procedures such as ultrasound examinations and complicated surgery will in most cases be unavailable or very expensive to organize.

THUS FOCUS ON CLINICAL FINDINGS First check the general appearance of the pregnant woman: - Is she able to walk properly or does she need assistance? - Is she alert or apathetic? - Does she present signs of malnutrition or skin lesions? More detailed examination of functions or organs: - Evaluation of breathing and heartbeat - Screening for:

aanaemia aicterus aoedema afemale genital mutilation afever asexually transmitted diseases aany other disease, such as: goitre, malaria or tuberculosis ...

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S TA N D A R D A N T E N ATA L C O N S U LTAT I O N When, and how many times, is a pregnant woman supposed to attend an antenatal consultation ? WHO recommendations are as follows: aThe first consultation during the first trimester, or before 12 weeks aThe second around 26 weeks or 6-7 months aThe third around 32 weeks or 7-8 months aThe fourth around 38 weeks or 8-9 months Such recommendations concern only physiological pregnancies without complications or risk of complications requiring closer and more specific attention. In conflict situations, lack of security or accessibility and other problems often make it difficult or impossible for pregnant women to keep to such a schedule.

What are the priorities ? n

As most maternal deaths occur around the time of delivery, the most important consultation is the one that takes place during the last month of pregnancy, as it allows screening of cases to be referred to hospital for delivery. This does not mean, however, that the previous consultations are not important; they are also useful for detecting and preventing the complications outlined below.

n

Health education activities focusing on antenatal care should be carried out at every opportunity and pregnant women should be encouraged to take part (see pages 41-45). It should be borne in mind that pregnant women will attend antenatal consultations only if they themselves are convinced that this is in their interest to do so.

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Standard antenatal consultation

What has to be checked at each antenatal consultation, whatever the stage of pregnancy ?

Body weight aTaken together with height, this provides an indication of the mother’s

nutritional status.

aThis assessment makes basic follow-up possible : vomiting, diarrhoea or

reduced food intake may decrease body weight, whereas oedema, water retention or hydramnios may increase it. During pregnancy there is an increase in basic metabolism, more specifically of carbohydrates, as the main source of energy for the foetus is glucose. Needs in terms of calories are in the order of 2500 cal/day.

Kg Breasts

0.5

Fat

3.5

Placenta

0.6

Foetus

3.4

Amniotic fluid

0.6

Uterus (increased)

0.9

Blood vol (increased) 1.5 Extracellular fluid

1.0

Total 12.0

Distribution of weight gain in pregnancy

Uterine height (during second and third trimester) aUterine height will depend on the size of the foetus, which varies according to

the ethnic origin of the parents, the mother’s diet and other factors.

aIt will also vary according to foetal lie

(longitudinal, oblique or transverse, see figure d, next page).

aThis is useful only if several consultations take place to monitor progress (foetal growth retardation, screening for foeto-pelvic disproportion, twins, hydramnios, etc.).

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Standard antenatal consultation HOW TO MEASURE THE UTERINE HEIGHT

a

b a and b. Using a measuring tape 1 2

c

d Two mistakes not to be made 1. The end of the tape is not on the symphysis 2. The measure is taken beyond the uterine fundus

A difference can exist depending on the way of measuring : - Uterine axis or - Umbilical -symphysis axis

Uterine height (cm)

UTERINE HEIGHT VALUES AT WEEKS OF GESTATION

PERCENTILE 90 PERCENTILE 50

*

PERCENTILE 10

Weeks of gestation

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Standard antenatal consultation

Palpation (during second and third trimester) aThis makes it possible to detect multiple pregnancies. aIt also indicates the presentation of the foetus, so as to:

- facilitate foetal auscultation by localization of the foetal chest - refer the mother to hospital for delivery in case of malpresentation (remember that foetal presentation can change up to the last month)

aIt allows assessment of:

- foetal weight - the amount of amniotic fluid - uterine contractions P A L P A T I O N S

Walking the finger tips across the abdomen to locate the position of the foetal back.

Pawlik’s manoeuvre. The lower pole of the uterus is grasped with the right hand, the midwife facing the woman’s head.

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Pelvic palpation. If the hands are in the correct position, the outstreched thumbs will meet at about umbilical level. The fingers are directed inwards and downwards.

Method of pelvic palpation used to determine a position in a vertex presentation. The higher cephalic prominence (the cincipital) will be on the side opposite to the back.

Standard antenatal consultation

Auscultation of the foetal heart aThis is possible from 20 weeks or 5 months of pregnancy using an obstetric

stethoscope such as the Pinard stethoscope (a sort of ear trumpet, see below). aNormal rate : between 120 and 160 beats per minute, but not regular; there is a

baseline rate specific to each foetus with some accelerations in between. Abnormal rate : decelerations, bradycardia or tachycardia occur more often during labour or delivery, so are not dealt with in this work. aThe aims of auscultation are:

- to check that the foetus is alive - to confirm foetal presentation - to check the foetal cardiac rhythm in order to detect any distress. aAuscultation can be difficult to perform because of:

- uterine contractions - a large amount of amniotic fluid - a thick layer of abdominal subcutaneous fat - extensive foetal movement - pulsations of the maternal aorta (to distinguish between the foetus and the mother, compare the pulse on the mother’s wrist with foetal auscultation) - pulsations of the umbilical cord (funicular souffle), which is more a murmur than a beat.

Looking at the second hand of a watch permits to count the foetal heartbeats. Auscultation of the foetal heart.

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Standard antenatal consultation

Vital signs of the mother Blood pressure: normal <140/90 mmHg When taking the mother’s blood pressure, avoid placing her in a position that causes compression of the vena cava (see page 75). This means that the mother should be in a semi-seated position, especially in the last months of pregnancy, and not in left lateral decubitus, as this can give an erroneously good result. The procedure makes it possible to screen for hypertension and pre-eclampsia. Pulse: normal between 60 and 100 beats per minute. A higher rate may be due to anaemia, haemorrhage, fever, anxiety or other conditions. Temperature: Should be taken if relevant symptoms and signs observed (suspicion of infection being the main reason).

Urine test strips To be used when indicated by symptoms or by complaints from the mother, in order to check for proteinuria (in case of hypertensive disorders) or urine infection (presence of leucocytes and/or nitrites) and as a diagnostic aid. Note that if the urine is contaminated with blood, infected vaginal secretions or amniotic fluid, proteinuria may test positive. The same applies to examination for urine infection: when infected vaginal secretions are present in the urine, the test for leucocytes may be positive.

Oedema (see page 75) If oedema is observed in the lower extremities, hands or face, this indicates an increase in plasma volume and/or poor blood circulation. Oedema associated with high blood pressure and proteinuria indicates pre-eclampsia, (see pages 148-151).

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Standard antenatal consultation

Procedures for: First-trimester consultation

aIf possible, confirm the pregnancy and calculate the term. aTake action and give advice in accordance with the findings, the mother’s complaints and medical history, and local community health problems. aCheck tetanus vaccination status. aGive prophylaxis for anaemia (see page 139). aSet a date for the next appointment, making it clear that the mother should attend at once should any problem arise in the meantime. aAnswer any questions.

Second-trimester consultation

aSame procedure as for the first-trimester consultation, adapted to the mother’s situation. aGive prophylaxis for malaria if in an endemic zone (see pages 143-146).

Third-trimester consultation

aSame procedure as for the first-trimester consultation, adapted to the mother’s situation. aGive prophylaxis for malaria if in an endemic zone. aGive mebendazole 500mg or albendazole 400mg to every pregnant woman once in 6 months (do not give it in the first trimester). aDetermine whether the mother will have to deliver in hospital and give appropriate advice.

Comments concerning health services The quality of a health service depends on: - the qualifications of staff - their professional experience and skills - the technical resources available These guidelines are intended for nurses, midwives and doctors dispensing antenatal care.

Note Not everyone has the expertise needed to perform all the procedures involved in the clinical examination of a pregnant woman, whether presenting complications or otherwise. Some of those procedures are deliberately omitted from this work because they have to be acquired by practice and not merely by reading a book. But that does not mean they cannot be performed by someone who has the necessary expertise and resources, if this is in the interest of the pregnant woman. Those who lack expertise in certain procedures can try to acquire it with the help of a more experienced colleague. In some cases the latter may even be a mother-and-child health worker or a traditional birth attendant. But remember that in all circumstances it is better to ask for advice in case of doubt rather than to risk doing something without the necessary expertise.

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Standard antenatal consultation

Talking with women and their families Pregnancy is typically a time of joy and anticipation. It can also be a time of anxiety and concern. Talking effectively with a woman and her family can help build the woman’s trust and confidence in her health-care providers. Women who develop complications may find it difficult to talk to the providers and to explain their problems. It is the responsibility of the entire health-care team to treat the woman concerned with respect and to put her at ease. This means:

arespecting the woman’s dignity and her right to privacy; abeing sensitive and responsive to the woman’s needs;

abeing non-judgmental about the decisions that the woman

and her family have made thus far regarding her care. It is understandable that health personnel may disapprove of a woman’s risky behaviour or of a decision which has resulted in delay in seeking care. It is not acceptable, however, to show disrespect for a woman or to disregard a medical condition that is a result of her behaviour. Corrective counselling should be given after the complication has been dealt with, not before or during management of the problem. RIGHTS OF WOMEN

Providers should be aware of the rights of women receiving maternity care services: aEvery woman receiving care has a right to information about her health.

aEvery woman has the right to discuss her concerns in an environment in which

she feels confident.

aA woman should know in advance the type of procedure that is going to be

performed.

aA woman (or her family, if necessary) should give informed consent before the

provider undertakes any procedure.

aProcedures should be conducted in an environment (e.g. labour ward) in which

the woman’s right to privacy is respected.

aA woman should be made to feel as comfortable as possible when receiving

services.

aA woman has the right to express her views about the services she receives.

When a provider talks to a woman about her pregnancy or a complication, he or she should use basic communication techniques. These techniques help the provider to establish an honest, caring and trusting relationship with the woman. If a woman trusts the provider and feels that the provider has her best interests at heart, she will be more likely to return to the facility for delivery or to come early if there is a complication.

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Standard antenatal consultation COMMUNICATION TECHNIQUES

Speak in a calm, quiet manner and assure the woman that the conversation is confidential. Be sensitive to any cultural or religious considerations and respect her views. In addition: aEncourage the woman and her family to speak honestly and to give a full account

of events surrounding the complication. aListen to what the woman and her family have to say and encourage them to

express their concerns; try not to interrupt. aRespect the woman’s sense of privacy and modesty by closing the door or

drawing curtains around the examination table. aLet the woman know that she is being listened to and understood. aUse supportive non-verbal means of communication such as nodding and

smiling. aAnswer the woman’s questions directly in a calm, reassuring manner. aExplain what steps will be taken to manage the situation or complication. aAsk the woman to repeat the key points to ensure that she has understood.

If a woman must undergo a surgical procedure, explain to her the nature of the procedure and the risks involved, and help to reduce her anxiety. Women who are extremely anxious have a more difficult time during surgery and recovery.

This section «Talking with women and their families» comes from : Integrated Management of Pregnancy and Childbirth Managing Complications in Pregnancy and Childbirth : A guide for midwives and doctors. Department of Reproductive Health and Research, WHO, Geneva, 2003

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C A S E S TO B E R E F E R R E D F OR D E L I V E RY This section describes all the indications for referral to hospital at the time of delivery.

Screening for cephalopelvic disproportion Measurement of the mother’s pelvis requires special skills. Anthropoid

Android

Gynaecoid

Platypelloid (flat)

Characteristic inlet of the 4 types of pelvis. (For information)

Without going into details, the parameters to be considered are: a The presumed foetal weight (determined by palpation) a Pelvic assessment of the mother

(see «Another way of assessing the mother’s pelvis», next page)

a Problems occur if there is a disproportion between foetal weight and pelvic

measurement. Prognosis remains difficult, however, as such disproportion is not always obvious and may become evident only during labour. a Any history of previous pregnancy with cephalopelvic disproportion or related complications, such as obstructed labour or vesico-vaginal or recto-vaginal fistula. (For information) A) Outlet of android pelvis.The head does not fit into the acute pubic arch and is forced backwards onto the perineum. A

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B

B) Outlet of gynaecoid pelvis. The head fits snugly into the pubic arch.

Cases to b e referred for deliver y

Another way of assessing the mother’s pelvis One simple method of detecting women at risk of cephalopelvic disproportion (CPD) is to measure, using a measuring tape, the mother’s height and the transverse diagonal of the Michaelis sacral rhomboid area.13 This method may be very useful in peripheral antenatal clinics for identifying such cases and referring them to district hospitals before the onset of labour.

Maternal height <150 cm or transverse diagonal <9.5 cm indicates a risk of CPD.

A B

D

A) Lumbar vertebra n°5 B - D) Transverse diagonal between the

two dimples of the Michaelis sacral rhomboid area.

13 Liselele H.B. et al., “Maternal height and external pelvimetry to predict cephalopelvic disproportion in nulliparous African women: a cohort study”, British Journal of Obstetrics and Gynaecology, August 2000, Vol. 107, pp. 947-952.

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Cases to b e referred for deliver y

Indications for referral to hospital for delivery This list is not comprehensive, as many factors play a role: - quality of medical care - accessibility to a hospital - the mother’s own wish to give birth in hospital or at home, etc. Previous history of:

acaesarean section aobstructed labour avesico-vaginal or recto-vaginal fistula aretained placenta aperineal tear

- degree 3 (anal sphincter ruptured) - degree 4 (degree 3 + rupture of rectal mucous membrane) Previous case of:

atwin pregnancy aabnormal lie abreech presentation acongenital hip dislocation or any other pelvic problem afemale genital mutilation (see next page & pages 140-142) ateenage pregnancy ahydramnios aante-partum haemorrhage aplacenta praevia (if detected) apre-eclampsia and eclampsia acardiac failure or any other medical condition placing the mother at risk

Pregnant women with HIV/AIDS Many factors have to be considered in this case:

aIs HIV/AIDS suspected or proved? aIs serological testing available? aWhat does the national HIV/AIDS policy recommend for pregnancy and

delivery?

aIs there a referral hospital?

The decision whether or not to recommend a Caesarean section will be taken on a case by case basis (for more information on HIV/AIDS, see pages 169-170).

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Cases to b e referred for deliver y

TWO

E X A M P L E S O F F LOW C H A RTS F OR T H E R E F E R R A L O F P R E G N A N T W O M A N I N T H E P R E S E N C E O F F E M A L E G E N I TA L M U T I L A T I O N ( F G M ) A) Care of pregnant women with FGM in areas where types lll and lV are uncommon: Maternity room village All cases assessed to determine degree of mutilation TYPE ll

TYPE l

TYPE lV

TYPE lll

Reduced vaginal orifice

Simple

Maternity hospital town All cases assessed by midwife; most cases of types l and ll managed by midwife. Sightly reduced vaginal orifice

Very reduced vaginal orifice

TYPES lll - lV

Doctor/midwife with appropriate skills

Episiotomy

Opening up Delivery Delivery Sick baby

Safe baby

Paediatrician B) Care of pregnant women with FGM in areas where type lll is universal:

VILLAGE Trained TBA assesses degree of mutilation - Severe scarring

- Minor moderate scarring Trained TBA performs opening up during labour Previous history of extensive perineal trauma

D I S T R I C T H E A LT H C A R E Reassessment by midwife - Severe scarring: incision by midwife during labour/delivery - Very severe scarring

H O S P I TA L

Delivery with expert care. Opening up before or during labour. Delivery with expert care. Caesarian section may be necessary.

Credit: Dr. Harry Gordon

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EMERGENCY OBSTETRIC CARE These guidelines to antenatal care are intended for nurses, midwives and doctors who work in health centres with very low technical input. The centre concerned may be the only one or the nearest one accessible to the local community.This means that it will receive not only antenatal patients but also obstetric emergencies. Such cases will have to be referred to a hospital, but if skilled staff and some medical supplies are available first aid can be given to improve the prognosis and possibly avoid maternal death. In this section the following topics are covered: - general information on obstetric emergencies - emotional and psychological support for women and their families - what can be done in different obstetric emergencies

General information The following information on obstetric emergencies draws attention to some matters that should be taken into consideration when an initial assessment is being carried out prior to setting up an antenatal care programme. Before offering a new service to pregnant women, it is important to know exactly what can and cannot be done in order to avoid raising false hopes. WHO definition of maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental cause. Women can die during any of the following three periods: athe antenatal period, which lasts from conception until the beginning of labour athe intrapartum period, which lasts from the beginning of labour until after the delivery of the afterbirth (placenta and membranes) athe postnatal period, which conventionally lasts for 42 days (6 weeks) from after the completion of the intrapartum period. In any “safer motherhood” project, the first priority should be to ensure that essential emergency obstetric care is: aavailable aaccessible aaffordable

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Emergenc y obstetric care There are many reasons why a pregnant woman can die. One of them may be a problem with the «three delays», which are: Delay in deciding to seek care, due to: - ignorance of the seriousness of the condition - low status of the sick woman - cost of care Delay in reaching care once the decision has been made to seek it, due to: - cost of travel - distance to the health facility - impracticalities of travel - the need to secure permission to travel from an absent family member Delay in receiving care on reaching the reference hospital, due to: - bureaucratic mismanagement/poor-quality care - attending the wrong health facility (e.g., a caesarean section is required and is only available at the district hospital, not at the reference hospital to which the woman has come, so a further transfer is required)

The three levels of technical care are: Level 1 : the community health centre, with the lowest level of technical input Level 2 : the reference hospital, with skilled staff able to deliver basic emergency obstetric care Level 3 : the district hospital, which should provide the highest technical level of care Essential emergency obstetric care (EEOC) includes basic emergency obstetric care (BEOC) and comprehensive emergency obstetric care (CEOC). The crucial procedures or “signal functions” of basic emergency obstetric care are: aadministration of parenteral (intravenous or by injection) antibiotics aadministration of parenteral oxytocic drugs aadministration of parenteral anticonvulsants amanual removal of placenta aremoval of retained products aassisted vaginal delivery (vacuum extraction, forceps delivery)

The signal functions of comprehensive emergency obstetric care are: aall six basic signal functions asurgery (caesarean section) – requiring anaesthesia ablood transfusion

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Emergenc y obstetric care

Emotional and psychological support Emergency situations are often very distressing for all concerned and give rise to a range of emotions that can have significant consequences.

EMOTIONAL AND PSYCHOLOGICAL REACTIONS

How each member of the family reacts to an emergency situation depends on: - the marital status of the woman concerned and her relationship with her partner; - the social status of the woman/couple and their cultural and religious practices, beliefs and expectations; - the personalities of the people involved and the quality and nature of social, practical and emotional support; - the nature, gravity and prognosis of the problem and the availability and quality of health-care services. Common reactions to obstetric emergencies or death include: - denial (feelings of «it can’t be true»); - guilt regarding possible responsibility; - anger (frequently directed towards health-care staff but often masking anger that parents direct at themselves for their «failure»); - bargaining (particularly if the patient hovers for a while between life and death); - depression and loss of self-esteem, which may be prolonged; - isolation (the feeling of being different or separate from others), which can be reinforced by care-givers who may avoid people who experience loss; - disorientation.

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Emergenc y obstetric care GENERAL PRINCIPLES OF COMMUNICATION AND SUPPORT

While each emergency situation is unique, the following general principles offer guidance. Communication and genuine empathy are probably the most important keys to effective care in such situations. At the time of the event aListen to those who are distressed. The woman/family will need to discuss her/their

hurt and sorrow. aDo not change the subject and move on to easier or less painful topics of

conversation. Show empathy. aTell the woman/family as much as you can about what is happening. Understanding

the situation and its management can reduce their anxiety and prepare them for what will happen next. aBe honest. Do not hesitate to admit what you do not know. Maintaining trust matters

more than appearing knowledgeable. aIf language is a barrier to communication, find a translator. aDo not pass the problem on to nursing staff or junior doctors. aEnsure that the woman has a companion of her choice and, where possible, the same

care-giver throughout labour and delivery. Supportive companionship can enable a woman to face fear and pain and help reduce loneliness and distress. aWhere possible, encourage companions to play an active role in care. Position the

companion at the bedside to allow him or her to focus on looking after the woman’s emotional needs. aBoth during and after the event, provide as much privacy as possible for the woman

and her family.

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Emergenc y obstetric care After the event aGive practical assistance, information and emotional support. aRespect traditional beliefs and customs and accommodate the family’s needs as far

as possible. aProvide counselling for the woman/family and allow for reflection on the event. aExplain the problem, so as to help reduce anxiety and guilt. Many women/families

blame themselves for what has happened. aListen and express understanding and acceptance of the woman’s feelings. Non-

verbal communication may speak louder than words: a squeeze of the hand or a look of concern can say an enormous amount. aRepeat information several times and give written information if possible. People

experiencing an emergency will not remember much of what is said to them. aHealth-care providers may feel anger, guilt, sorrow, pain and frustration in the face of

obstetric emergencies, and this may lead them to avoid the woman/family. Showing emotion is not a weakness. aRemember to care for staff who may themselves experience guilt, grief, confusion and

other emotions.

This section «Emotional and psychological support» comes from: Integrated Management of Pregnancy and Childbirth Managing Complications in Pregnancy and Childbirth : A guide for midwives and doctors Department of Reproductive Health and Research, WHO, Geneva, 2003

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Emergenc y obstetric care

Management of emergency cases Management of emergency cases will depend on different factors, the most important being the professional skills of staff and the availability of materials. Note The skills of a nurse, a midwife and a doctor will naturally be different, which means that the contents of their medical kits may also be different. This section outlines what each of these three professionals can do at health-centre level. They themselves will then add any further procedures that they know and can perform. Remember that if the professional concerned lacks the required expertise, it is better to do nothing than to put the woman at even greater risk by doing the wrong thing.

For further information on the above subject, see: «Comments concerning health services» (page 93).

Find on next pages how to take care of women in different obstretic emergencies at primary health care level.

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Emergenc y obstetric care

RAPID INITIAL ASSESSMENT IN CASE OF CONVULSIONS OR LOSS OF CONSCIOUSNESS ASSESS aAsk

Pregnant ? Length of gestation ?

aExamine

Blood pressure: systolic > 140 mm Hg OR diastolic > 90 mm Hg Temperature: 38° C or more STABILIZE

aShout for help - Never leave the woman alone.

aProtect the woman from injury, but do not actively restrain her. aIf she is unconscious

- Check the airway. - Position the woman lying down on her left side with two pillows supporting her back. - Check for neck rigidity.

aIf she is convulsing, turn her on her side to minimize the risk of aspiration should she vomit and to ensure that an airway is open. CONSIDER

aEclampsia aTetanus aEpilepsy aComplicated malaria (see management on next page)

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Emergenc y obstetric care

HEADACHE, BLURRED VISION, CONVULSIONS, OR LOSS OF CONSCIOUSNESS

If a pregnant woman or a woman who has recently given birth complains of severe headache, blurred vision or has elevated blood pressure, test her urine for proteinuria. A small proportion of women with eclampsia have normal blood pressure. Treat all women with convulsions as if they have eclampsia until another diagnosis is confirmed. If a pregnant woman living in a malarial area has fever, headaches or convulsions and malaria cannot be excluded, it is essential to treat the woman for both malaria and eclampsia.

SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Convulsions, blood pressure >140/90 mm Hg after 20 weeks of pregnancy Proteinuria 2+ or more

Eclampsia

Stabilize according to magnesium sulfate schedule on next page and see management page 151. Refer urgently.

Difficulty opening mouth and chewing

Tetanus

Convulsions Past history of convulsions Normal blood pressure

Epilepsy

If the woman is convulsing Give diazepam 10 mg IV slowly over 2 minutes. Repeat if convulsions recur after 10 minutes. Refer urgently

Fever (38° C or more) Chills/rigors Headache Muscle/joint pain Coma Anaemia

Complicated malaria

If convulsions occur Give diazepam 10 mg IV slowly over 2 minutes.

Control spasms with diazepam 10mg IV slowly over 2 minutes. Remove the cause of sepsis. Give benzyl penicillin 2 million units IV every 4 hours. Refer urgently.

If eclampsia is not ruled out Prevent subsequent convulsions with magnesium sulfate. Refer urgently. If complicated malaria is diagnosed and the woman is conscious Give three tablets of sulfadoxine pyrimethamine OR chloroquine. Refer urgently.

M pressure because it increases the risk of convulsions and intracranial haemorrhage. Do not give ergometrine to women with pre-eclampsia, eclampsia, or high blood

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Emergenc y obstetric care

MAGNESIUM SULFATE14 SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Loading dose aMagnesium sulfate solution 4 g IV over 5 minutes. aFollow promptly with 10 g of magnesium sulfate solution, 5 g in each buttock as deep IM injection with 1 mL of 2% lignocaine in the same syringe. Ensure that aseptic technique is practiced when giving magnesium sulfate deep IM injection. Warn the woman that a feeling of warmth will be felt when magnesium sulfate is given. aIf convulsions recur after 15 minutes or more, give an additional 2 g magnesium sulfate IV over 5 minutes. Maintenance dose a5 g magnesium sulfate + 1 mL of 2% lignocaine IM every 4 hours into alternate buttocks. Continue treatment with magnesium sulfate for 24 hours after childbirth or the last convulsion, whichever occurs last. aIf 50% solution is not available, give 1g of 20% magnesium sulfate solution IV every hour by continuous infusion (only if you can control the rate). CLOSELY MONITOR THE WOMAN FOR SIGNS OF TOXICITY

aBefore repeat administration, ensure that: Respiratory rate is a least 16 breaths per minute. Patellar reflexes are present. Urine output is at least 30 mL per hour over preceding 4 hours.

aWithhold or delay drug if: Respiratory rate falls below 16 breaths per minute. Patellar reflexes are absent. Urine output falls below 30 mL per hour over preceding 4 hours.

aKeep antidote ready: In case of respiratory arrest: Assist ventilation (mask and bag). Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly to antagonize the effects of magnesium sulfate until respiration restarts. aIf referral is delayed or the woman is in late labor Continue treatment with magnesium sulfate: - Give magnesium sulfate 5 g IM plus 1 mL of 2% lignocaine (in alternate buttock) every 4 hours. - Continue treatment for 24 hours after the birth or after the last convulsion, whichever occurs last. Monitor urine output. 14 Magnesium sulfate comes in different concentrations (e.g., 20%, 40%, 50%). When giving injections IM,

it is best to use higher concentrations (e.g., 50%) to decrease the total volume required. In the ICRC, the concentration of 50% is the only one provided.

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Emergenc y obstetric care

DIAZEPAM SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Use diazepam only if magnesium sulfate is not available. INTRAVENOUS ADMINISTRATION

Loading dose aGive diazepam 10 mg IV slowly over 2 minutes. aIf convulsions recur, repeat loading dose. Maintenance dose If woman is in late labour or referral is delayed, give a maintenance dose as follows:

aGive diazepam 40 mg in 500 mL IV fluids (Ringer’s lactate or normal saline) over 6-8 hours, titrated to keep the woman sedated but rousable aStop the maintenance dose if respirations drop below 16 breaths per minute. Maternal respiratory depression may occur when dose exceeds 30mg in 1 hour. aDo not give more than 100 mg of diazepam in 24 hours.

RECTAL ADMINISTRATION WHEN IV ACCESS IS NOT POSSIBLE

Loading dose aGive 20 mg in a 10 mL syringe: - Remove the needle, lubricate the barrel and insert the syringe into the rectum to half its length. - Discharge the content and leave the syringe in place, holding the buttocks together for 10 min to prevent expulsion of the drug. - Alternatively, the drug may be instilled in the rectum through a catheter. aIf convulsions are not controlled within ten minutes, administer an additional 10 mg or more, depending on the size of the woman and her clinical response. Be prepared to assist ventilation.

The two schedules above come from: Integrated Management of Pregnancy and Childbirth Managing Complications in Pregnancy and Childbirth : A guide for midwives and doctors. Department of Reproductive Health and Research, WHO, Geneva, 2003

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Emergenc y obstetric care

RAPID INITIAL ASSESSMENT IN CASE OF FEVER (TEMPERATURE OF 38°C OR MORE) ASSESS

aAsk Weak, lethargic? Frequent, painful urination?

aExamine Unconscious Temperature: 38°C or more Neck: stiffness Lungs: shallow breathing, consolidation Abdomen: extreme tenderness Vulva: purulent discharge Breasts: tender STABILIZE If the woman is in very bad general state: (signs of sepsis: fever, foul-smelling vaginal discharge, low blood pressure, signs of shock) GIVE ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently. Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse Ringer’s lactate or normal saline at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. CONSIDER

èFever during pregnancy and labour aSeptic abortion aAmnionitis aComplicated malaria aTyphoid èFever after childbirth aMetritis aWound cellulitis aComplicated malaria aTyphoid aMastitis

(see management on following pages)

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FEVER DURING PREGNANCY AND LABOUR (TEMPERATURE OF 38°C OR MORE) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Fever/chills

Septic abortion

Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until woman is fever-free for 48 hours. Prior to 16 weeks Refer urgently after giving antibiotics for manual vacuum aspiration (MVA). After 16 weeks Refer urgently after giving antibiotics.

Fever/chills Foul-smelling, watery discharge after 22 weeks Abdominal pain

Amnionitis

Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours. Refer for childbirth.

Fever/chills Headache Confusion or coma Anaemia Convulsions

Complicated malaria

If woman is conscious Give three tablets of sulfadoxine/pyrimethamine OR chloroquine and refer urgently. If woman is unconscious or convulsing Give diazepam 10 mg IV slowly over 2 minutes. Refer urgently.

Fever Headache Dry cough Malaise Anorexia Enlarged spleen

Typhoid

Give ampicillin 1 g by mouth 4 times per day OR amoxicillin 1 g by mouth three times per day for 14 days. Alternative therapy will depend on local sensitivity patterns. Refer urgently.

Foul-smelling vaginal discharge in first 22 weeks Tender uterus

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Emergenc y obstetric care

FEVER AFTER CHILDBIRTH (TEMPERATURE OF 38°C OR MORE) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Fever/chills Lower abdominal pain Purulent, foul-smelling Iochia Tender uterus

Metritis Delayed or inadequate treatment may result in: Pelvic abscess Peritonitis Septic shock Deep vein thrombosis Pulmonary embolism Chronic pelvic infection Tubal blockage and infertility

Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours, PLUS metronidazole 500 mg IV every 8 hours until woman is fever-free for 48 hours. Refer urgently.

Painful and tender wound Erythema and oedema beyond edge of incision

Wound cellulitis

Immediately give penicillin G 2 million units IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently.

Symptoms and signs of uncomplicated malaria Coma Anaemia

Complicated malaria

Infuse quinine dihydrochloride 20 mg/kg body weight in IV fluids (5% dextrose, normal saline, or Ringer’s lactate) over 4 hours. Wait 4 hours after completing the loading dose. Then, infuse quinine dihydrochloride 10 mg/kg body weight over 4 hours. Repeat every 8 hours. Refer urgently.

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Emergenc y obstetric care

FEVER AFTER CHILDBIRTH (contd.) (TEMPERATURE OF 38°C OR MORE) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Fever Headache Dry cough Malaise Anorexia Enlarged spleen

Typhoid

Give ampicillin 1g by mouth 4 times per day OR amoxicillin 1g by mouth 3 times per day for 14 days.

One or more adjacent breast segments are inflamed and appear as a wedge-shaped area of redness and swelling, usually affecting only one breast, 3-4 weeks after delivery.

Mastitis

Fever General malaise Main cause: cracked nipple(s) if infective, milk stasis if non-infective

Alternative therapy will depend on local sensitivity patterns. Refer urgently.

Can be infective or not. Different from engorgement, which can occur between the second and fourth day postpartum and affect both breasts.

Antibiotic treatment in both cases, whether infective or not. Give cloxacillin 500 mg by mouth four times per day for 10 days OR erythromycin 250 mg by mouth three times per day for 10 days. Give paracetamol 500 mg by mouth as needed. Do not stop breastfeeding. Give the mother advice on good feeding technique. Complication: breast abscess (antibioticsurgery-stop breastfeeding temporarily from the breast concerned).

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Emergenc y obstetric care

RAPID INITIAL ASSESSMENT IN CASE OF RESPIRATORY DISTRESS ASSESS

aLook for Absence of breathing Rapid breathing (30 breaths or more per minute) Obstructed breathing or gasping Pale or bluish (cyanotic) skin colour aExamine Mouth for foreign bodies (such as pieces of food) Lungs for wheezing or rales STABILIZE If the woman IS NOT breathing

aShout for help. a Keep the woman in supine position with her head tilted backwards. a Lift her chin to open the airway. aInspect her mouth for foreign body and remove if found. aClear secretions from her throat. a Ventilate with bag and mask until she starts breathing. If the woman IS BREATHING BUT still in respiratory distress

aShout for help. a Rapidly evaluate vital signs (blood pressure, pulse, breathing). aPosition the woman lying down on her left side with two pillows supporting her back. a Give oxygen at 4-6 L per minute if available. aRefer urgently. CONSIDER

a Severe anaemia a Heart failure due to anaemia a Heart failure due to heart disease

(see management on next page)

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Emergenc y obstetric care

DIFFICULTY IN BREATHING SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Difficulty in breathing

Severe anaemia (see page 139)

Start an IV infusion using a large-bore cannula or needle.

Pallor of conjunctiva, tongue, nail beds, and/or palms

Infuse normal saline or Ringer’s lactate at the rate of 1 L over 8 hours. Refer urgently for transfusion.

Haemoglobin 7 g/dL or less Haematocrit 20% or less Symptoms and signs of severe anaemia, plus

Heart failure due to anaemia

Start an IV infusion using a large-bore cannula or needle.

Oedema Infuse normal saline or Ringer’s lactate at the rate of 1 L over 8 hours.

Cough Rales

Refer urgently for transfusion.

Swelling of legs Enlarged liver Prominent neck veins Difficulty in breathing Diastolic murmur and/or Harsh systolic murmur with palpable thrill

Heart failure due to heart disease

Start an IV infusion using a large-bore cannula or needle. Infuse normal saline or Ringer’s lactate at the rate of 1 L over 12 hours. Position the woman on her left side. Give oxygen at 4-6 L per minute if available. Refer urgently.

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RAPID INITIAL ASSESSMENT IN CASE OF VAGINAL BLEEDING ASSESS aAsk

Pregnant? Length of gestation? Abdominal pain? After 22 weeks of pregnancy or childbirth, ask if: Recently given birth, date of childbirth Placenta was delivered completely with the membranes or not Bleeding slow and continuous (how long), or sudden onset

aExamine

Vulva: amount of bleeding, trauma Vagina: lacerations, placenta Cervix: products of conception, lacerations Uterus: retained placenta, atony Bladder: full (If it is the case, the bladder has to be emptied spontaneously or with a catheter) STABILIZE The aim is to stop the bleeding. Assess the cause of bleeding on the basis of the stage of gestation and treat accordingly. CONSIDER

èVaginal bleeding in early pregnancy, up to 22 weeks aEctopic pregnancy aMolar pregnancy aAbortion

èVaginal bleeding after 22 weeks of pregnancy or during labour before childbirth aAbruptio placentae aPlacenta praevia aRuptured uterus èVaginal bleeding after childbirth aAtonic uterus aTears of cervix, vagina or perineum aRetained placenta or placental fragments aInverted uterus aDelayed postpartum haemorrhage (see management on following pages)

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VAGINAL BLEEDING IN EARLY PREGNANCY (UP TO 22 WEEKS) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Light bleeding Abdominal pain

Ectopic pregnancy (see pages 183-184)

Arrange for immediate transport for laparotomy.

Closed cervix

Unruptured:

If unruptured (woman not in shock)

Uterus slightly larger than normal

- Symptoms of early pregnancy - Abdominal and pelvic pain

- Insert IV line and infuse Ringer’s lactate or normal saline 1L in 6-8 hours

Ruptured:

If ruptured (woman in shock)

- Signs of shock - Collapse, weakness - Pulse 100 beats per minute or more - Systolic blood pressure of 90 mm Hg or less - Acute abdominal, pelvic pain - Rebound tenderness - Pallor

- Insert IV line and infuse normal saline or Ringer’s lactate 1L in 15-20 minutes (as rapidly as possible).

Molar pregnancy (see page 185)

If diagnosis is uncertain

Uterus softer than normal

Heavy bleeding Dilated cervix Uterus larger than dates Uterus softer than normal Partial expulsion of products of conception, which resemble grapes

- Repeat 1 L every 30 minutes until pulse slows to less than 100 beats per minute and systolic BP increases to 100 mm Hg or more then 1L in 6-8 hours - Record time and amount of fluids given.

Stabilize and refer urgently for MVA. (Manual vacuum aspiration)

IF UNSAFE ABORTION IS SUSPECTED aExamine for signs of infection or uterine, vaginal, or bowel injury.

aIf infection is present, begin antibiotics before referring for manual vacuum aspiration (MVA).

aIf uterine, vaginal, or bowel injury is present, infuse IV fluids and refer urgently for surgery and MVA. aIf herbs, local medications or caustic substances were used, thoroughly irrigate the vagina to remove them. More information on abortion follow.

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ABORTION SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Light bleeding Closed cervix Uterus corresponds to dates Cramping /lower abdominal pain Uterus softer than normal

Threatened abortion

Medical treatment usually not necessary; follow-up in antenatal clinic.

Heavy bleeding Dilated cervix Uterus corresponds to dates or smaller Cramping /lower abdominal pain Tender uterus No expulsion of products of conception

Inevitable abortion

Pregnancy may continue

Woman should avoid hard work and intercourse. If bleeding does not stop: REFER (may be ectopic pregnancy, twins, or molar pregnancy).

Pregnancy will not continue and will proceed to incomplete or complete abortion

Incomplete abortion Heavy bleeding Dilated cervix Products of conception are Uterus smaller than dates partially expelled Cramping /lower abdominal pain Partial expulsion of products of conception

Stabilize and refer urgently. Give ergometrine 0.2 mg IM (repeat after 15 minutes if necessary) OR misoprostol 400 µg orally (repeat once after 4 hours if necessary). If pregnancy is greater than 16 weeks Await spontaneous expulsion of products of conception. If necessary to help expulsion, infuse oxytocin 40 units in 1 L normal saline or Ringer’s lactate 40 drops per minute. If bleeding is light to moderate and pregnancy is less than 16 weeks remove products of conception protruding through cervix in the vagina with your fingers. Give ergometrine 0.2 mg IM (repeat after 15 minutes if necessary) OR misoprostol 400 µg by mouth (repeat once after 4 hours if necessary). If bleeding is heavy and pregnancy is less than 16 weeks - Refer urgently. If bleeding is heavy and pregnancy is greater than 16 weeks Stabilize and refer urgently. Give ergometrine 0.2 mg IM (repeat after 15 minutes if necessary) OR misoprostol 400 µg by mouth (repeat once after 4 hours if necessary)

Light bleeding Complete abortion Closed cervix Products of conception are Uterus smaller than dates completely expelled and softer than normal Slight cramping/ lower abdominal pain History of expulsion of products of conception (ask or check if complete)

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Evacuation of uterus usually not necessary. Observe for heavy bleeding. Give ergometrine 0.2 mg IM or misoprostol 400 µg orally. Refer if bleeding does not stop immediately.

Emergenc y obstetric care

VAGINAL BLEEDING AFTER 22 WEEKS OF PREGNANCY OR DURING LABOUR BEFORE CHILDBIRTH SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Bleeding Intermittent or constant abdominal pain Severe abdominal pain

Abruptio placentae (see pages 188-189) Ruptured uterus Placenta praevia (see pages 186-187)

Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Refer urgently.

VAGINAL BLEEDING AFTER CHILDBIRTH SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

Increased vaginal Actonic uterus bleeding within the first (if it is certain that placenta 24 hours after childbirth. and membranes are completely out, if it is not Uterus soft and the case, see next page) not contracted.

MANAGEMENT Massage the fundus of the uterus through the woman’s abdomen (see annex II.A.1, page 130). Administer oxytocin IV: infuse 20 units in 1 L normal saline or Ringer’s lactate at 60 drops per minute until uterus is contracted, then 20 units in 1 L normal saline or Ringer’s lactate at 40 drops per minute. Do not give more than 3 L. PLUS IM: 10 units If oxytocin not available Administer ergometrine/methylergometrine (do not use if signs/symptoms of pre-eclampsia, hypertension, or heart disease). (see page 107) IM or IV: slowly infuse 0.2 mg. Repeat 0.2 mg IM after 15 minutes. If required, give 0.2 mg IM or IV (slowly) every 4 hours. If bleeding does not stop Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Refer urgently.

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VAGINAL BLEEDING AFTER CHILDBIRTH (contd.) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Increased vaginal bleeding within the first 24 hours after childbirth

Tears of cervix, vagina, or perineum

Examine the woman carefully to detect any tears in the vagina or perineum. If the placenta and the membranes are completely out, the uterus is well contracted, the blood is not coming from tears of the vagina and/or the perineum, and the bleeding does not stop, there may be a tear in the cervix. Refer. If bleeding does not stop: Refer urgently.

Placenta not delivered within 30 minutes after childbirth Portion of maternal surface of placenta missing, or torn membranes with vessels (there may be no bleeding)

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Retained placenta or placental fragments

Ensure that the bladder is empty (catheterize if necessary). If you can see the placenta Ask the woman to push it out (see pages 130-134). If you can see placental fragments in the vagina: remove by hand (wear sterile or high-level disinfected gloves; wrap sterile gauze around fingers). If placenta is not expelled and cannot be seen or felt. Give oxytocin 10 units IM. If placenta is undelivered after 30 minutes of oxytocin and the uterus is contracted Attempt controlled cord traction (see pages 130-134). If controlled cord traction is unsuccessful Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Refer urgently. If signs of infection Give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. If placenta or placental fragments cannot be removed OR bleeding does not stop immediately. Refer urgently.

Emergenc y obstetric care

VAGINAL BLEEDING AFTER CHILDBIRTH (contd.) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Uterine fundus not felt on abdominal palpation

Inverted uterus

Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Give a single dose of prophylactic antibiotics: ampicillin 2g IV PLUS metronidazole 500 MG IV. OR Give cefazolin 1 g IV PLUS metronidazole 500 mg IV. Refer urgently. If there is fever and/or foul-smelling vaginal discharge give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently.

Delayed postpartum haemorrhage

Administer oxytocin IV: infuse 20 units in 1 L normal saline or Ringer’s lactate at 60 drops per minute until uterus is contracted, then 20 units in 1 L normal saline or Ringer’s lactate at 40 drops per minute. Do not give more than 3 L. PLUS IM: 10 units.

Slight or intense pain

Bleeding occurs more than 24 hours after childbirth Uterus softer and larger than expected for time elapsed since childbirth

If oxytocin is not available Administer ergometrine/methylergometrine (do not use if signs/symptoms of pre-eclampsia, hypertension, or heart disease). IM or IV: slowly infuse 0.2 mg. Repeat 0.2 mg IM after 15 minutes. If required, give 0.2 mg IM or IV (slowly) every 4 hours. Refer urgently. If there is fever and/or foul-smelling vaginal discharge give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently.

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RAPID INITIAL ASSESSMENT IN CASE OF ABDOMINAL PAIN ASSESS

aAsk Pregnant? Length of gestation? aExamine Blood pressure: diastolic 90 mm Hg or less Temperature: 38°C or more Uterus: length of gestation or date of childbirth

CONSIDER

èAbdominal pain in early pregnancy (up to 22 weeks) aAbortion (see pages 117-118) aEctopic pregnancy (see pages 117 & 183-184) aPeritonitis (see below) èAbdominal pain in later pregnancy or childbirth aAbruptio placentae aRuptured uterus aAmnionitis aMetritis aPeritonitis (See management on next page)

ABDOMINAL PAIN IN EARLY PREGNANCY (UP TO 22 WEEKS) SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Low-grade fever/chills

Peritonitis

Start an IV infusion using a large-bore cannula or needle.

Lower abdominal pain Absent bowel sounds

Infuse normal saline or Ringer’s lactate at the rate of 1L in 6-8 hours unless patient in shock. Immediately give penicillin G 2 million units IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently.

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ABDOMINAL PAIN IN LATER PREGNANCY OR CHILDBIRTH SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

Intermittent or constant abdominal pain

Abruptio placentae (see pages 119 & 188-189)

Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Refer urgently

Severe abdominal pain (may decrease after rupture) Bleeding (intra-abdominal and/or vaginal)

Ruptured uterus

Start an IV infusion (two if possible) using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour.

Abdominal pain Foul-smelling, watery vaginal discharge after 22 weeks of pregnancy Fever/chills

Amnionitis

Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours. Refer for childbirth.

Lower abdominal pain Fever/chills Purulent, foul-smelling lochia Tender uterus

Metritis

Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until woman is fever-free for 48 hours. Refer urgently.

Low-grade fever/chills Lower abdominal pain Absent bowel sounds

Peritonitis

Provide nasogastric suction. Start an IV infusion using a large-bore cannula or needle. Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L in 15-20 minutes. Give at least 2 L of fluid in the first hour. Immediately give penicillin G 2 million units IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours. Refer urgently.

Bleeding (intra-abdominal and/or vaginal)

Refer urgently.

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Emergenc y obstetric care

PROLAPSED CORD Definition The cord lies in front of the presenting part or alongside it following rupture of the membranes. It may remain in the vagina or be visible outside.

Aetiologies aTransverse lie aBreech presentation aPrematurity aPremature rupture of membranes aPlacenta praevia aMultiple pregnancy aHydramnios aMultiparity aLong cord aAmniotomy

Diagnosis - Suspected in case of ruptured membranes with abnormal foetal heart sounds (deceleration, bradycardia). - Established if the cord is visible inside or outside the vagina.

Management Refer the pregnant woman if foetal heart sounds can no longer be heard and one of the following complications is present: - Multiple pregnancy: the first foetus may be dead but not necessarily the other(s) - Malpresentation of the foetus, which needs to be delivered in hospital or by caesarean section - Bleeding, which can be due to placenta praevia (rare) Wait for delivery if there are no more foetal heart sounds and none of the above complications is present, it is a case of foetal death. Refer the pregnant woman if there are foetal heart sounds and/or the cord is pulsating: - Replace the cord inside the vagina if it is protruding, in order to avoid arterial spasm due to temperature difference. - Never attempt to replace the cord inside the uterus, because failure is guaranteed and the additional manipulations increase the risk of spasm.

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Prolapsed cord

Woman in the knee-chest position. Thighs must be straight. The foetus gravitates towards the fundus and pressure on the cord is relieved. This position is not useful during transportation.

Woman in the exaggerated Sims’ position. Two large foam-rubber wedges or pillow elevate the buttocks further.

UNSATISFACTORY PROGRESS IN LABOUR SIGNS/SYMPTOMS

PROBABLE DIAGNOSIS

MANAGEMENT

In labour for more than 12 hours

Obstruction

Start an IV infusion using a large-bore cannula or needle.

Presentation other than vertex

Malpresentation or malposition

Infuse Ringer’s lactate or normal saline at the rate of 3 mL/minute over 6 hours with glucose 5% in order to maintain the glucose level of the foetus, which can be low in this situation. Refer urgently.

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TRAUMA IN PREGNANCY Introduction Trauma of any kind is the most frequent cause of maternal death which is not obstetric in origin. Maternal compromise and the severity of the injury are the principal factors in traumarelated foetal demise. In such cases, attention is often focused on the abdomen because of the pregnancy. However the pregnancy may not easily be detected, especially if it is at an early stage and the woman is unable to make herself understood.

Principles of trauma management a«Save the mother, save the foetus»

In fact, the mother takes priority over the foetus. This does not mean that the foetus does not have to be considered in the management of maternal trauma, but the mother’s health will be the first concern. It must be remembered that a woman is in charge of the family.

aPregnant women are more vulnerable to injury.

aInitial treatment priorities for an injured pregnant patient remain the same as for a

non-pregnant patient: A, B, C, etc.

Finally, trauma during pregnancy does not necessarily put the health of the foetus at risk. This will depend on: - which part(s) of the mother’s body are affected (whether or not the abdomen or lower back is involved) - whether there is haemodynamic problem - whether the trauma causes uterine contractions that can lead to premature birth, vaginal bleeding, etc.

Aetiologies

aBlunt trauma may be caused by:

- road accidents - assaults - falls

Common consequences are abruptio placentae, foetal skull fracture, rupture of the uterus, premature labour. aPenetrating trauma may be caused by:

- gunshot wounds - stab wounds - shrapnel injuries

aBurns

In general, the survival of the mother allows survival of the foetus.

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Risks for the mother aComplications are related to the stage of the pregnancy and the corresponding physiological changes. Uterus: larger, becoming intra-abdominal after 12 weeks with higher blood flow Placenta: lack of elasticity (abruptio placentae), decreased blood flow with maternal hypotension. Pelvis: venous engorgement. Gastrointestinal tract: intestinal displacement into upper quadrant, gastric emptying time extended (full stomach). Respiratory tract: elevated diaphragm, hypocapnia (alkalosis), decreased tolerance of hypoxaemia. Cardiovascular system: increased heart rate, increased cardiac input, increased plasma volume, signs of ongoing haemorrhage delayed.

aThe hypervascularization of pelvic organs increases the risk of haemorrhage.

aUterine rupture is rare and is more likely to occur at the end of pregnancy. Foetal death is inevitable, unless the woman can immediately undergo caesarean section. Maternal death, however, depends more on associated lesions and the availability of treatment.

Risks for the foetus aabortion afoetal injury apremature birth

afoetal death aabruptio placentae afoeto-maternal haemorrhage

Management

aIn triage conditions a pregnant woman has priority.

aThe best early treatment for the foetus is optimum resuscitation of the mother. aDo not attempt foetal assessment in the field. aBefore referring the pregnant woman:

- Follow «The guidelines for Rehydration» (see annex II.B, page 135). - To avoid compression syndrome on the vena cava (see page 75), place the patient on her left side for transport. If this is not possible, let her lie on her back and raise her right buttock so that she can lean on her left side, or manually displace the uterus to the left side. - Dress the wound(s) as appropriate. - Raise her legs for better venous return.

aPremature contractions

Uterine contractions frequently start secondary to trauma, but in most cases they will cease with rest and good intravenous hydration (as long as the cervix is not already excessively dilated), and delivery remains exceptional. In case of imminent delivery, let the woman deliver before transferring her, especially if the referral hospital is far away.

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ANNEXES PART II Ante n at a l Co n s u l t at i o n s

ANNEX II.A.1

CO N T R O L L E D CO R D T R AC T I O N

aClamp the cord close to the perineum using sponge forceps within 1 minute of birth. Hold the clamped cord and the end of the forceps with one hand. aPlace the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter-traction during controlled cord traction. This helps prevent inversion of the uterus. aKeep slight tension on the cord and await a strong uterine contraction (2-3 minutes). aWhen the uterus becomes rounded or the cord lengthens, pull downward on the cord very gently to deliver the placenta. Do not wait for a gush of blood before applying traction on the cord. Continue to apply counter-traction to the uterus with the other hand. aIf the placenta does not descend during 30 to 40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord. - Gently hold the cord and wait until the uterus is well contracted again. If necessary, use sponge forceps to clamp the cord closer to the perineum as it lengthens. - With the next contraction, repeat controlled cord traction with counter-traction. Note

Never apply cord traction (pull) without applying counter-traction (push) above the pubic bone with the other hand.

aAs the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and gently turn it until the membranes are twisted. aSlowly pull to complete the delivery. aIf the membranes tear, gently examine the upper vagina and cervix wearing highlevel disinfected or sterile gloves and use sponge forceps to remove any pieces of membrane that are present. aLook carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placental fragments. aIf you can feel the placenta or placental fragments in the vagina, remove by hand (wear sterile or high-level disinfected gloves; wrap sterile gauze around fingers). aIf uterine inversion occurs, try to immediately replace the uterus. If failure, refer. aIf the cord is pulled off, manual removal of the placenta may be necessary.I

UTERINE MASSAGE

aImmediately massage the fundus of the uterus through the woman’s abdomen until the uterus is contracted. aRepeat uterine massage every 15 minutes for the first 2 hours. aEnsure that the uterus does not become relaxed (soft) after you stop uterine massage. Please, see the illustrations of placental delivery on next pages. This annex II.A.1 (only page 130) comes from : Integrated Management of Pregnancy and Childbirth. Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors. Department of Reproductive Health and Research, WHO, Geneva, 2003

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ANNEX II.A.2

CO N T R O L L E D CO R D T R AC T I O N

P L AC E N TA L D E L I V E RY

2 1 3

Physiological position of the placenta.

1. The placenta has not separated. 2. The placenta has now separated and has descended into the lower segment of the uterus. 3. The contracted uterus after expulsion of the placenta.

After delivery, the umbilical cord is outside of the vagina, the placenta has not yet separated.

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ANNEX II.A.3

CO N T R O L L E D CO R D T R AC T I O N

P L AC E N TA L D E L I V E RY

Manoeuvre to check for separation of the placenta: the hand is placed above the pubic bone, exerting upward pressure. If the cord follows the same movement, the placenta has not yet separated.

The placenta has now separated. When exerting upward pressure above the pubic bone, the cord does not go back up.

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ANNEX II.A.4

CO N T R O L L E D CO R D T R AC T I O N

P L AC E N TA L D E L I V E RY

After ensuring that the placenta has separated, the hand supports the uterus fundus and lightly puts pressure on it.

One hand presses firmly downwards, expelling the placenta at the same time (simultaneously asking the mother to push if the placenta is not coming easily). The placenta is cupped in the other hand.

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ANNEX II.A.5

CO N T R O L L E D CO R D T R AC T I O N

P L AC E N TA L D E L I V E RY

The expulsion of the placenta is helped along by pressure above the pubic bone. Never pull on the cord, just keep it under tension.

When the placenta is out of the vagina but part of the membranes are still inside, do not pull out, just hold the placenta in yours hands below the vagina and turn it on itself until all the membranes are expelled.

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ANNEX II.B

G U I D E L I N E S F O R R E H Y D R AT I O N

GUIDELINES FOR STARTING IV INFUSION OR GIVING ORAL REHYDRATION SOLUTION (ORS) Start an IV infusion (two if possible): - Use a large-bore needle (16-gauge or largest available). - Rapidly infuse Ringer’s lactate or normal saline at the rate of 1 L in 15-20 minutes. - Give at least 2 L of fluid in the first hour. Note

If shock is due to bleeding, aim to replace two to three times the estimated fluid loss.

ONLY if unable to start an IV infusion (for whatever reason), give the woman ORS according to the following guidelines: aIf the woman is able to drink, is conscious, and is not having (or has not recently

had) convulsions, give ORS 300-500 mL in 1 hour by mouth.

Note Unless the woman is fully conscious and alert, do NOT give fluid by mouth. aIf the woman is unable to drink, is unconscious, or is having (or has recently had)

convulsions, give ORS 500 mL rectally over 20-30 minutes, according to the following procedure: - Fill an enema bag/can with 500 mL of fluid. - Run water to the end of the tube and clamp off. - Insert the lubricated tube about 10 cm (3-4 inches) into the rectum. - Run the water in slowly.ladder).

Note It will take 20-30 minutes for the water to run into the patient. If you run it in too rapidly, she will get abdominal cramps and push the water out. I

This annex II.B comes from: Integrated Management of Pregnancy and Childbirth. Managing Complications in Pregnancy and Childbirth : A guide for midwives and doctors. Department of Reproductive Health and Research, WHO, Geneva, 2003

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Antenatal Problems

3

M is for the million things she gave me, O means only that she’s growing old, T is for the tears she shed to save me, H is for her heart of purest gold, E is for her eyes, with love-light shining, R means right, and right she’ll always be, Put them all together, they spell mother, a word that means the world to me. Howard Johnson

ANTENATAL PROBLEMS

Part III: Antenatal problems

3 p | 138

Anaemia Female genital mutilation (FGM) Fever Malaria Urinary tract infection Hypertensive disorders in pregnancy Management of mild or severe chronic hypertension Management of pregnancy - induced hypertension Mild pre-eclampsia Management of severe pre-eclampsia and eclampsia Loss or diminution of foetal movements Foetal death Foetal growth retardation Malpresentations Breech Transverse Pregnancy after rape / Rape of pregnant woman Pregnancy in detention Pregnancy in teenagers Prelabour rupture of membranes (PROM) Sexually transmitted diseases Viral hepatitis HIV/AIDS Gonorrhoea Chlamydia trachomatis Syphilis Tetanus prophylaxis Threat of premature delivery / Preterm labour Twin pregnancy Vaginal bleeding Abortion Ectopic pregnancy Molar pregnancy Placenta praevia Abruptio placentae Vaginal discharge Vitamin A deficiency Annexes III.A.1-2 Vaccination and pregnancy III.B Vitamin A, Iron and Folic Acid food sources

ANAEMIA Definition Diminution below normal values of the erythrocyte count in the circulating blood, measured either as the number of erythrocytes per cubic millimetre or, more often, by the haemoglobin level in g/dl. Anaemia may be due, among other reasons, to ferrous or folic acid deficiencies. Folic acid deficiency results from low intake of meat and fresh vegetables, multiple or close pregnancies, alcoholism, or hyperemesis gravidarum (see page 77). A fall in the haemoglobin level during pregnancy is physiological and secondary to an increase in plasma volume. A haemoglobin level of ≥11g/dl is considered normal.

Symptoms and signs Moderate anaemia: pallor of palms and conjunctiva, dizziness, tachycardia Severe anaemia: severe palmar and conjunctival pallor associated with: - breathing frequency of ≥ 30 breaths per minute - fatigue - breathlessness at rest

Diagnosis Anaemia is diagnosed by observation of clinical symptoms and signs, confirmed by haemoglobin level: - 7-11 g/dl: moderate anaemia - < 7 g/dl: severe anaemia Haemoglobin testing kits suitable for use at primary health-care level may be ordered from the standard ICRC medical list: - haemoglobin colour scale, starter kit (WHO) - haemoglobin test strips, refill kit 2,000 strips (WHO)

Treatment Iron and folate tablets: 60 mg iron with 400 mcg folic acid (this is often lacking in women's diet) Preventive treatment: 1 tab daily for three months Curative treatment: 1 tab twice daily for three months Remember that malaria and worms can also cause anaemia, so it is important to take preventive measures, or to give curative treatment if necessary, for those conditions as well.

Management Refer the woman in case of severe anaemia (see page 115). Depending on her nutritional status and the local availability of food she can afford to buy, advise her on what she should eat (see annex III.B, page 196).

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FEMALE GENITAL MUTILATION (FGM) WHO CLASSIFICATION OF FEMALE GENITAL MUTILATION FGM encompasses all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reasons. The different types of female genital mutilation known to be practised are as follows: Type I Excision of the prepuce, with or without excision of part or all of the clitoris Type II Excision of the clitoris with partial or total excision of the labia minora. Type III Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation). Type IV Unclassified : includes pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purposes of tightening or narrowing it; and any other procedure that falls under the definition of female genital mutilation given above. Antenatal complications in presence of FGM • Antepartum haemorrhage: FGM can hinder appropriate assessment and management • Pre-eclampsia Difficulty in evaluating proteinuria because urine is contaminated by vaginal secretions • Spontaneous abortion A tight introitus may lead to serious infection due to retention of products in the vagina • Urinary tract infection Difficulty of obtaining a clean sample of urine because contaminated by vaginal secretions • Vaginal infection A tight opening (1 cm or less) will: - hinder pelvic examination - hamper the taking of the necessary samples for testing - prevent appropriate treatment

Management During the antenatal period, refer the pregnant woman every time she presents a complication that makes it necessary to open up the scarring. Depending on the type of FGM and the proximity of health services, it is also better to refer the pregnant woman for delivery in order to avoid possible complications (see WHO recommendations, page 99).

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Female genital mutilation ( F G M )

Structure of normal external female genitalia

Excision of the prepuce (the fold of skin above the clitoris) with the tip of the clitoris.

Clitoris Labium minus

Labium majus

Vagina

External urethral orifice

Anus

Fourchette Perineum

Type 1: May consist of removal of the prepuce without damage to the clitoris.

Type 2: Excision of the prepuce and clitoris.

Type 3: Excision of the prepuce, clitoris and labia minora.

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Female genital mutilation ( F G M )

WHO recommendations for the antenatal period Prevention of FGM and management of its complications should be included in antenatal care. During the antenatal period, women and couples should be provided with appropriate information about the timing of opening up the scar tissue of type III FGM, and possible complications in labour and at delivery. It is essential to develop a rapport with clients and obtain consent before attempting to undertake a physical examination. The introitus should be examined at the first antenatal visit to establish the extent of mutilation. Local guidelines for antenatal opening up of type III FGM should be established, taking into account the prevalence of type III, the travelling distances involved and access to medical and midwifery services. Midwives and doctors should receive adequate training in safe techniques for opening up the scar tissue of type III FGM and a tight introitus. Midwives and doctors should receive training in psychosexual counselling and communication skills so that women and couples can be given education and counselling on the health consequences of FGM.

A typical Type III Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation).

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FEVER MALARIA Definition A communicable disease caused by a parasite called plasmodium (four species: vivax, malariae, ovale, falciparum) and transmitted by the mosquito.

Symptoms and signs • Fever • Chills/rigors • Headache • Muscle/joint pain • Enlarged spleen • Anaemia

Risks for the foetus • Spontaneous abortion • Prematurity • Foetal growth retardation • Foetal death • Congenital malaria (rare) • Neonatal death

Effects of malaria in newborns15 Maternal infection: - Low birth weight - Pre-term delivery Placental infection: - Low birth weight - Increased risk of anaemia at two months of age - Increased risk of malaria at four to six months of age It is much more common to find parasitized red cells in the placenta than in the mother’s peripheral circulation. Congenital: - Neonatal fever - Neonatal death - Fever, anaemia, splenomegaly at three to eight weeks of age.

15 Philip R. Fischer, «Malaria and newborns», Journal of Tropical Pediatrics, Vol. 49, No. 3, June 2003

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Fe ver

MALARIA

(contd.)

Diagnosis Rapid detection test (RDT) (see the ICRC Malaria Guidelines: two tests are available on the ICRC standard list). The “gold standard” test for diagnosing malaria remains the blood smear (thick/thin blood examination), but this is rarely available at health-centre level. Note Pregnant women who live in high-transmission areas, and who therefore have a degree of pre-existing immunity, often develop asymptomatic infections. In many asymptomatic cases, few or no parasites may be detected in the peripheral blood although the placenta is heavily infected. Thus a negative blood film or RDT in a pregnant woman does not rule out malaria; always treat the woman if you suspect malaria.

Preventive measures For all protective measures against exposure to the mosquito, see the ICRC Malaria Guidelines. Prophylaxis: Fansidar (500 mg sulfadoxine with 25 mg pyrimethamine per tablet: SP) - second trimester, 3 tablets, single dose - third trimester, 3 tablets, single dose If the pregnant woman can attend antenatal consultations more regularly, give her the first dose (3 tablets) after 16 weeks, because it is contraindicated before, and another two doses at least one month apart.

Treatment Note «Pregnant women are more attractive to mosquitoes than are non-pregnant women or children. During pregnancy, the acquired anti-malaria immunity of a woman residing in a malaria-endemic area is decreased. The result of these immune modifications is that not only do pregnant women get more malaria, they also get sicker when they get malaria.» (“Malaria and newborns”, op. cit.).

Thus malaria prophylaxis during pregnancy is highly recommended, as well as immediate treatment in case of malaria attack, according to the national guidelines.

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Fever

MALARIA /Treatment (contd.) Some drugs are potentially toxic to the foetus and must be discarded: NOT DURING FIRST TRIMESTER OF PREGNANCY

Amodiaquine

● ●*

Artemether



Artesunate

NOT DURING PREGNANCY

NOT LAST FOUR MONTHS OF PREGNANCY

Sulfadoxine pyrimethamine (Fansidar) Sulfalene pyrimethamine (Metakelfine)



Mefloquine (Lariam, Mephaquine)



Sulfadoxine pyrimethamine mefloquine (Fansimef ) Halofantrine (Halfan)

● ● ●

Doxycycline (Vibramycin) Artemether lumefantrine (Riamet, Coartem)



Atovaquone proguanil (Malarone)



* If combined with artesunate.

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Fe ver

MALARIA /Treatment (contd.) ANTIMALARIAL DRUGS TYPE OF DRUGS

QUININE *

CHLOROQUINE *

PROGUANIL *

(Chloroquine, Nivaquine Resochine, Aralen, Agaquin, Serviquin, etc....)

(Paludrine)

Presentation

tab, amp.iv (different dosages)

tab (100 ou 150 mg base) and syrup

tab. 100 mg

Main side effects

Tinnitus, rarely giddiness, nausea, vomiting Hypoglycemia

Visual Gastro-intestinal disorders Pruritis, Dreams, etc. iv/im : risk of shock

Mouth ulcers, Gastric intolerance

Prophylaxis

0

Adult: 100 mg/d (6d/7) or 300 mg /week

>12 years: 200 mg/d

Curative dosage

8-10 mg/kg/8 h. (max.1’800 mg/24H)

10 mg/kg/day during 3 days

0

Contraindications

None

Compromised liver function Psoriasis

0

* no contraindication during pregnancy

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Fever

URINARY TRACT INFECTION Definition Infection at any level of the urinary tract from renal calyces to urethral meatus. Urinary tract infection occurs very frequently in pregnant women (see pages 78 & 92).

Diagnosis On the basis of clinical signs and urine test strip (leucocytes and/or nitrates positive).

Symptoms and signs Cystitis: Dysuria, abdominal pain Increased frequency and urgency of urination Retropubic/suprapubic pain Pyelonephritis: Same as cystitis, plus fever/chills Low back pain Anorexia, nausea, vomiting

Treatment If there is any doubt it is always better to treat. Cystitis: Amoxycillin 500 mg by mouth 3 times/day for 3 days Pyelonephritis: The pregnant woman must be referred for IV treatment

Management It is important to bear in mind that urinary tract infection which is not properly treated can lead to premature contractions and hence premature birth. It is also important for a pregnant woman to drink at least two litres of water per day in order to flush out the urinary tract.

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HYPERTENSIVE DISORDERS IN PREGNANCY SYMPTOMS AND SIGNS TYPICALLY PRESENT

SYMPTOMS AND SIGNS SOMETIMES PRESENT

Mild chronic hypertension (management: see next page)

Two readings 4 hours apart of systolic blood pressure >140 and/or diastolic blood pressure > 90 mmHg before 20 weeks of gestation Two readings 4 hours apart of systolic blood pressure >160 and/or diastolic blood pressure >110 mmHg before 20 weeks of gestation

• Two readings 4 hours apart of systolic blood pressure >140 and/or diastolic blood pressure > 90 mmHg after 20 weeks of gestation • No proteinuria

PROBABLE DIAGNOSIS

Severe chronic hypertension (management: see next page)

In this case there may be no symptoms and the only sign may be hypertension

Pregnancy-induced hypertension (management: see next page)

For more information on symptoms and signs, (see page 150)

Mild pre-eclampsia (management: see page 151)

• Systolic blood pressure >160 and/or diastolic blood pressure >110 mmHg

• Headache (increasingly frequent, unrelieved by regular analgesics)

Severe pre-eclampsia16 (management: see page 151)

after 20 weeks of gestation • Proteinuria 3+ or more

• Blurred vision • Oliguria (passing less than

• Two readings 4 hours apart of systolic blood pressure >140 and/or diastolic blood pressure > 90 mmHg after 20 weeks of gestation • Proteinuria up to 2+

400 mL urine in 24 hours)

• Upper abdominal pain (epigastric pain or pain in right upper quadrant)

• Pulmonary oedema • Convulsions • Systolic blood pressure

>140 and/or diastolic blood pressure > 90 mmHg

• Coma (unconscious) • Other symptoms and signs

Eclampsia (management: see page 151)

of severe pre-eclampsia

after 20 weeks of gestation • Proteinuria 2+ or more 16 If a woman has any one of the symptoms or signs listed under severe pre-eclampsia, diagnose severe

pre-eclampsia.

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Hyp er tensive disorders in pregnanc y

MANAGEMENT OF MILD OR SEVERE CHRONIC HYPERTENSION • Recommend additional periods of rest. • High levels of blood pressure maintain renal and placental perfusion in chronic hypertension; reducing blood pressure may reduce perfusion. Blood pressure should not be brought down below its pre-pregnancy level (if this is known). There is no evidence that aggressive treatment to bring blood pressure down to normal levels improves either foetal or maternal outcome. aIf blood pressure is > 160 and/or > 110 mmHg, treat with hydralazine. Give 5 mg IV slowly every five minutes until blood pressure is lowered. Repeat hourly as needed, or give hydralazine 12.5 mg IM every two hours as needed. The aim is to achieve diastolic blood pressure of 85-100 mmHg17 in order to prevent cerebral haemorrhage. Follow with treatment by methyldopa (see below). aIf blood pressure is > 140 and/or > 90 mmHg, treat with methyldopa. Give 250 mg by mouth three times per day • Monitor once a week and adapt management in accordance with findings and/or complaints. Remember that this condition may cause foetal growth retardation. • Treatment in case of mild hypertension is controversial.

MANAGEMENT OF PREGNANCY- INDUCED HYPERTENSION Monitor once a week and adapt management in accordance with findings and/or complaints (always search for proteinuria).

17 There are two sets of guidelines, one recommending diastolic blood pressure between

85 and 90 mmHg and the other between 90 and 100 mmHg. Studies are ongoing.

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Hyp er tensive disorders in pregnanc y

MILD PRE-ECLAMPSIA Definition Hypertension of >140 or > 90 mmHg (occurring after 20 weeks of gestation) with proteinuria (1 or 2+, may appear later). When measuring the mother’s blood pressure, ensure that she is not lying in a position that causes compression of the vena cava (see page 75). This means that she should be in a seated or semi-seated position, especially in the last months of pregnancy, and not in left lateral decubitus because this can lead to underestimation of blood pressure.

Risk factors • Chronic hypertension • Multiple pregnancy • Primiparity • Family or personal history of pre-eclampsia

Symptoms and signs Mild pre-eclampsia often has no symptoms • Oedema of hands and face • Generalized oedema • Epigastric pain • Weight gain • Headache • Blurred vision • Oliguria • Nervousness, agitation • Hyperreflexia • Trouble of consciousness state Oedema of the feet and lower extremities is not considered to be a reliable sign of preeclampsia. It is often due to an increase in plasma volume with impaired venous return in pregnant women (see pages 75 & 92).

Diagnosis Proteinuria may be detected using urine test strips.Try to obtain a clean sample of urine uncontaminated by blood, infected vaginal secretions or amniotic liquid, which can give a positive test result. However, consider also the symptoms and signs. Increasing proteinuria, which may be difficult to quantify, is a sign of worsening pre-eclampsia.

Risks for the foetus • Foetal growth retardation • Premature birth • Foetal death • Early neonatal death

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Hyp er tensive disorders in pregnanc y

MILD PRE-ECLAMPSIA

(contd.)

Risks for the mother • Severe pre-eclampsia (> 160 or > 110 mmHg) • Eclampsia (convulsions) • Abruptio placentae, clotting failure • Detachment of the retina • Cerebral haemorrhage • Subcapsular haematoma of the liver • Perinatal death Some other complications of pre-eclampsia may be difficult to diagnose without access to a laboratory for proteinuria measurement and other blood tests (e.g. HELLP syndrome: Haemolysis, Elevated Liver enzymes and Low Platelets).

Preventive measures Inform every pregnant woman and her family about the danger signals indicating preeclampsia or eclampsia. Restricting calories, fluid and salt intake does not prevent pregnancy-induced hypertension and may be harmful to the foetus. The beneficial effects of aspirin, calcium and other agents in preventing pregnancyinduced hypertension have not yet been proved. Encourage the pregnant woman to take additional periods of rest.

Treatment and management To help in making the decision whether to refer or not, it is better to take blood pressure after the pregnant woman has been at rest for a while, and every 15 minutes over a 4-hour (or at least 2-hour) period. Once the diagnosis of pre-eclampsia is established, refer the woman unless delivery is imminent and blood pressure is under control.

MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Refer the pregnant woman as soon as possible after giving the loading dose of magnesium sulfate (see page108 for MgSO4 schedule). All cases of severe pre-eclampsia and eclampsia should be managed actively and in the same way, with the exception that delivery should occur: - within 12 hours of the onset of convulsions in eclampsia - within 24 hours of the onset of symptoms in severe pre-eclampsia Remember that MgSO4 is an anticonvulsive drug, but one of its secondary effects is to lower blood pressure. So in cases where referral is deferred and systolic blood pressure is still > 160 mmHg or diastolic blood pressure > 110 mmHg after MgSO4 treatment, give also an anti-hypertensive drug (see schedule of hydralazine treatment, page149) in order to keep diastolic blood pressure below 110 mmHg. One third of women with eclampsia have normal blood pressure. Treat all women with convulsions as if they have eclampsia until another diagnosis is confirmed.

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LOSS OR DIMINUTION OF FOETAL MOVEMENTS FOETAL DEATH Definition Intrauterine death means death of the product of conception before expulsion or complete extraction.

Aetiologies • Chromosomal abnormalities • Abnormalities other than chromosomal • Infections (e.g. malaria, syphilis, rubella, typhoid) • Maternal causes (e.g. trauma, pre-eclampsia, alcohol, tobacco, history of foetal death, unfavourable socio-economic conditions) • Other causes (e.g. cord accident, placenta praevia, abruptio placentae) • Chronic foetal distress, intrauterine growth retardation

Symptoms and signs • Foetal movements and foetal heart sounds are undetectable Possible additional findings: • Symptoms of pregnancy gradually disappear • Symphysis-fundal height decreases, uterus decreases in size

Diagnosis Symptoms and signs give a hint for the diagnosis of foetal death, which can be confirmed by loss of hearth tones or ultrasound.

Treatment Ask the woman when she ceased feeling foetal movements, and await spontaneous onset of labour during the following four weeks. Reassure the woman that in 90% of cases the foetus is spontaneously expelled during this period with no complications. The main complication which may occur (4% of all cases) after four to six weeks of foetal death is coagulopathy in the woman, but access to a laboratory is necessary to screen for this.

Management Refer the woman if there is any additional problem, such as heavy bleeding or failure to deliver after four weeks following foetal death. For psychological support see next page, but in any case respect the national culture, customs and the desire of the mother.

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Loss or diminution of fo etal movements

Neonatal mortality or morbidity While general principles of emotional support for women experiencing obstetrical emergencies apply, when a baby dies or is born with an abnormality some specific factors should be considered. Intrauterine death or stillbirth Many factors will influence the woman’s reaction to the death of her baby.These include those mentioned above (see page ... and ...) as well as : • the woman’s previous obstetric and life history • the extent to which the baby was «wanted» • the events surrounding the birth and the cause of the loss • previous experiences with death. At the time of the event • Avoid using sedation to help the woman cope. Sedation may delay acceptance of the death and may make reliving the experience later – part of the process of emotional healing – more difficult. • Allow the parents to see the efforts made by the care givers to revive their baby. • Encourage the woman/couple to see and hold the baby facilitate grieving. • Prepare the parents for the possibly disturbing or unexpected appearance of the baby (red, wrinkled, peeling skin). If necessary, wrap the baby so that it looks as normal as possible at first glance. • Avoid separating the woman and baby too soon (before she indicates she is ready), as this can interfere with and delay the grieving process. After the event • Allow the woman/family to continue to spend time with the baby. Parents of a still born still need to get to know their baby. • People grieve in different ways, but for many remembrance is important. Offer the woman/family small mementos such as a lock of hair, a cot label or a name tag. • Where it is the custom to name babies at birth, encourage the woman/family to call the baby by the name they have chosen. • Allow the woman/family to prepare the baby for the funeral if they wish. • Encourage locally-accepted burial practices and ensure that medical procedures (such as autopsies) do not preclude them. • Arrange a discussion with both the woman and her partner to discuss the event and possible preventive measures for the future.

This section «Neonatal mortality or morbidity» comes from : Integrated Management of Pregnancy and Childbirth Managing Complications in Pregnancy and Childbirth : A guide for midwives and doctors. Department of Reproductive Health and Research, WHO, Geneva, 2003

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Loss or diminution of fo etal movements

FOETAL GROWTH RETARDATION Definition Decreased foetal growth, usually diagnosed as weight below a given percentile for gestional age.

Main aetiologies Foetal causes • Chromosomal abnormalities • Other abnormalities • Infection Maternal causes • Anaemia • Malaria • Nutritional deficit (extreme) • Pre-eclampsia and hypertension • Cardiorespiratory problems/diseases Placental causes • Multiple pregnancy

Main risks for the foetus • Acute foetal distress • Foetal death • Perinatal morbidity or mortality • Neonatal hypothermia and hypoglycaemia

Risk factors • History of foetal growth retardation, foetal death or repeated abortion • Unfavourable socio-economic conditions • Addiction to smoking • Insufficient weight gain

Symptoms and signs (not very reliable) • Poor progress of uterine height and the estimated weight of the foetus • Decrease in foetal movements because the foetus is in chronic distress

Diagnosis Symptoms and signs give a hint for the diagnosis, which can be confirmed only by ultrasound.

Management The mother should rest, lying on her left side as much as possible, and have a sufficient food intake. Give prophylaxis or treatment for anaemia and malaria.

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MALPRESENTATIONS Definition All presentations of the foetus other than the normal one (the foetus head down in the mother’s pelvis, in a well-flexed position). Only breech and transverse lie presentations are discussed here; there are many other malpresentations which are usually diagnosed at the time of delivery.

BREECH PRESENTATION Definition When the buttocks and/or the feet are the presenting parts.

Complete breech

Frank breech

Footling presentation

Knee presentation

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Malpresentations

BREECH PRESENTATION (contd.) Aetiologies • Prematurity • Foetal malformation • Multiple pregnancy • Placenta praevia • Uterine malformation • Mother pelvic anomalies (e.g. congenital dislocation of a hip) • Hydramnios or oligoamnios

Risks for the foetus in vaginal breech delivery • Cord prolapse and/or compression • Perinatal anoxia or death • Intracranial haemorrhage • Nerve lesions or broken neck • Fractures or dislocations of arms • Damage to abdominal organs • Testicular haematoma or torsion

Management Advise the mother to deliver in hospital because of the risks for the foetus if she is not attended by an experienced person. Whether or not to perform a caesarean section will be decided by the hospital team in each specific situation. If the foetus is dead, a caesarean will not be performed. Look at page 158 for more information.

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Malpresentations

TRANSVERSE LIE PRESENTATION Definition When the long axis of the foetus is transverse. The shoulder is typically, but not always, the presenting part.

Shoulder presentation,dorso-anterior.

Shoulder presentation, dorso-posterior.

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Malpresentations

TRANSVERSE LIE PRESENTATION (contd.) Aetiologies • Hydramnios • Multiparity or atonic uterus • Praevia obstacle • Second twin • Uterine malformation • Pelvic anomaly

Risks for the foetus Cord prolapse Foetal death

Management Vaginal delivery is not possible and the mother has to be referred for caesarean section which will be performed even if the foetus is dead.

General management in both situations • Do not attempt external version This procedure involves a degree of risk for the foetus and the mother. It can be done only by a skilled person in a hospital where a caesarean section can be performed in the event of any complication, such as abruptio placentae. • Never rupture the membranes artificially because of the risk of cord prolapse. This will be done, if necessary, only at the hospital. • Remember that foetal presentation may change throughout pregnancy until the onset of labour.

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PREGNANCY AFTER RAPE / RAPE OF PREGNANT WOMAN In your work in situations of war or civil strife you will often encounter cases of women who have been raped. Here we will discuss management of women coming to antenatal consultations who are already pregnant, and not the period immediately following the rape of a woman who was not already pregnant. In accordance with ICRC guidelines, management of such cases will depend on national health policies and standards. At present the ICRC’s operational framework is based on the WHO publication «Clinical management of survivors of rape». (See bibliography) Psychological approach Although the approach to caring for a pregnant victim of rape is naturally the same as the usual approach for any pregnant woman (see pages 94, 95 & 102-104), there are also some specific points to be considered. These points are briefly outlined here, but for further information see the WHO guidelines mentioned above. A woman should not be questioned in this regard: it is her choice whether or not to say that she has been raped. When a woman says that she has been raped, the health professional taking care of her should encourage discussion and establish a climate of confidence without making judgements or making her feeling guilty. This means giving her time to speak, accepting her silences, and perhaps following the physical consultation by a further period of discussion. Remember that confidentiality must be respected. It is also important to determine what information is needed to care for a woman, without obliging her to say any more.

What must be considered in case of: Pregnancy following rape The woman’s history in relation to the rape: • Whether it was her first intercourse, and her age • The circumstances of the rape • Did she try to terminate the pregnancy? • The physical consequences of the rape Problems specific to her situation: • Post-traumatic manifestations - insomnia - nightmares - muteness - emotional lability, etc.

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Pregnanc y af ter rap e / Rap e of pregnant woman

Pregnancy following rape

(contd.)

Problems specific to her situation: • The social consequences of the rape for the woman - fear of reprisals - was she already married, or will she be married to the rapist? - has she been cast out by her family or community? - any other problem relating to her culture and/or religion • The consequences for her baby’s future - does the mother want to take care of the baby or not? - taking into account her culture, religion, financial resources, etc., what social choices are open to her in regard to the child’s upbringing?

Rape of pregnant woman The woman’s history in relation to the rape: • The circumstances of the rape • The physical consequences of the rape for her and her baby (miscarriage, intrauterine foetal death or any other condition which will make her lose her baby) Problems specific to her situation • Post-traumatic manifestations - insomnia - nightmares - muteness - emotional lability, etc. • The social consequences of the rape for the woman - fear of reprisals - is her husband aware of the rape, and what are the repercussions for their relationship? - was the child desired or not? - does she want to terminate the pregnancy, and is it possible? - has she been cast out by her family or community? - any other problem relating to her culture and/or religion • The consequences for her baby’s future - does the mother want to take care of the baby or not? - taking into account her culture, religion, financial resources, etc., what social choices are open to her in regard to the child’s upbringing? Depending on the local circumstances, the culture and the religion of the woman, the national health services and policies, etc., it may or may not be possible to help the woman concerned. In any event, try to do your best. Last but not least, there are usually more women than men giving antenatal consultations, but obviously in these circumstances it is always better to have a woman.

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Pregnanc y af ter rap e / Rap e of pregnant woman

Special procedures in antenatal consultations If the fact that the woman has been raped is overlooked, she is like any other pregnant woman and will need the same care (for any problems, see the corresponding section in this document). Remember that this document is intended for the primary health care level, which means that there will be no laboratory and if necessary the woman will have to be referred. Any special procedures during the consultation will depend on whether or not: • There is a national policy on rape • The woman had a consultation specifically concerning the rape before her first antenatal consultation • The woman has some genital injury caused by the rape, especially if she had undergone female genital mutilation The special procedures are: • To take steps to avoid the risk of sexually transmitted diseases (see pages 168-174) • To monitor the healing of any physical injury(ies) caused by the rape • To check that the woman is immunized against tetanus (see pages 175-177)

Management Refer pregnant rape victims whenever you feel this is necessary, depending of course on the health services available to her under the national health policy on rape. For any other problem about the pregnancy itself, see the recommendations for management given in the section concerned. If psychological support is available, always propose it.

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PREGNANCY IN DETENTION As prison visits are one of the ICRC’s main activities, delegates will sometimes encounter pregnant women prisoners. If the fact of being pregnant is the only aspect considered, a woman in prison is like any other pregnant woman. Being in detention, however, brings its own problems and several matters have to be taken into consideration in order to keep a detained pregnant woman in good health. Here we will not discuss the general rights of women prisoners with regard to special conditions of detention (see ICRC Prison Health Manual), but focus on the specific services that should be available to a detained pregnant woman.

Diet A pregnant woman does not have to eat for two, but it is important that she have a varied diet divided into at least three meals during the day.This will allow her to absorb the different nutrients such as carbohydrates, fats, proteins and micro-nutrients essential for good foetal development and enable her to avoid feeling weak or suffering from hypoglycaemia. The diet must be adapted to the circumstances in the country concerned.

Work Pregnancy is not a disease or a handicap as long as there are no complications. Nevertheless, heavy work and insufficient rest will put foetal and maternal health at risk. The woman should be allowed to: - move around rather than remaining in the same position for hours - rest in a comfortable position during her daily work, if only for a few minutes.

Antenatal care A detained pregnant woman should have access to the same level of health services as any other pregnant woman in the outside community, which means: - having as many antenatal consultations as necessary, according to her obstetric situation, inside or outside the prison - being referred if necessary - if she is to deliver in prison, delivering in the same conditions as if she were at home (privacy, with a traditional birth attendant or a midwife and, if possible, at least one member of her family present).

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Pregnanc y in detention

Psychological health By the very fact of being in prison and thus deprived of freedom, no detainee is in a good psychological state. In this situation the detainee can be afraid of many things, one of the main fears often being violence in prison. A pregnant woman feels more vulnerable, and is afraid of having medical problems and of the difficulties involved in obtaining appropriate medical attention. While female prisoners should always be completely separated from men during their detention, pregnant women, who are also worried about their babies, require even more protection and assistance. Pregnancy is a special period in a woman’s life. The pregnant woman prisoner needs support from her family, so family visits should be encouraged and allowed with increased frequency.

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PREGNANCY IN TEENAGERS What is the meaning of the term “teenager”? In some countries adolescence is not recognized as a special time of life. Defining the beginning and the end of adolescence is controversial. Here we define adolescence as starting with the first menstrual periods (menarche) and ending with complete growth and pelvic development.

What problems relating to war or civil strife are specific to adolescent girls? Violence and insecurity bring with them: - the fear of being killed, abducted or sexually abused - the need to adapt to the situation by changing behaviour, especially as regards bathing, toilet facilities, lack of privacy and the danger involved in seeking privacy, and lack of medical care and protection - being a young woman in a conflict situation considerably increases vulnerability in daily life and in contacts with men Poverty, which can lead to: - trading of sex for food or washing products - elopement - early marriage Loss of social points of reference due to: - disruption of schooling - lack of family support, especially if the family has been dispersed or some members have disappeared - the risk of being orphaned - lack of friendship or community support - bad behaviour on the part of adults, who are no longer good role models In short, this kind of situation deeply undermines the psychological well-being and physical integrity of adolescent girls.

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Pregnanc y in teenagers

During antenatal consultations, teenagers will be treated in the same way as other women, but two further matters have to be taken into consideration. A specific approach is necessary Even if the monitoring of the pregnancy (see page ..) is carried out in the same way as for older women, special attention has to be given to young girls who are pregnant as they can be shy and frightened, or feel guilty and think they are being censured for being pregnant at their age. Therefore staff, preferably female, dealing with teenagers have to create a climate of confidence by being patient and accepting silences and without making the girl feel guilty. The risk is that if the teenager does not feel comfortable during her antenatal consultation she will not come back. There is an increased risk of some complications of pregnancy in teenagers: - Sexually transmitted diseases, because most often they have had sexual relations with men older than themselves - Hyperemesis gravidarum - Pre-eclampsia - Delivery by caesarean necessitated by cephalo-pelvic disproportion, because a teenager’s pelvis is not yet completely developed (risk of vesico- or recto-vaginal fistula)

Management Refer the teenage girl for delivery.

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PRELABOUR RUPTURE OF MEMBRANES (PROM) Definition Rupture of membranes before the beginning of labour; this can occur either when the foetus is mature (at term, > 37 weeks) or immature (preterm, < 37 weeks).

Risk factors • Vaginal or cervical infection • Hydramnios • Contractions • Cervical incompetence

Diagnosis The condition will be diagnosed on the basis of signs reported by the pregnant woman, her medical history and the type of vaginal discharge observed. If no discharge is present: - A gush of fluid may be induced by asking the woman to cough. - A vaginal pad is placed over the vulva and examined (aspect and smell) one hour later (if the woman has no premature contractions, she can walk about during this hour). Do not perform a digital vaginal examination, as it does not help establish the diagnosis and can introduce infection. Rule out urinary incontinence by observing the colour, smell and origin (urinary or vaginal) of the discharge, and also by taking medical history into account (e.g. vesicovaginal fistula or multiparity with history of urine loss).

Risks for the foetus • Chorioamnionitis • Cord prolapse or compression • Premature birth • Complications due to oligoamnios • Abruptio placentae • Foetal or perinatal death

Risks for the mother • Abruptio placentae, clotting failure • Chorioamnionitis • Maternal death due to sepsis

Treatment and management If there are premature contractions, hydrate and refer the pregnant woman. Give antibiotics in order to reduce maternal and neonatal infective morbidity and possibly delay the delivery.

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Prelab our rupture of membranes (PR OM)

< 37 weeks

With signs Contractions of infection

( fever, No foul-smelling vaginal Contractions discharge )

With no signs of infection

Contractions

No Contractions

Hydrate the pregnant woman (see annex II.B, page135) Give ampicillin 2 g IV every six hours plus gentamicin 5mg/kg body weight IV every 24 hours Refer the pregnant woman

> 37 weeks Give penicillin G 2 million units IV every six hours until delivery or ampicillin 2 g IV every six hours until delivery Wait for the delivery*

Give ampicillin 2g IV Give penicillin G every six hours plus 2 million units IV gentamicin 5 mg/kg body every six hours until delivery weight IV every 24 hours or ampicillin 2 g IV every Refer the pregnant woman six hours until delivery Refer the pregnant woman* Hydrate the If the membranes have been pregnant woman ruptured for more (see annex II.B, page135) than 18 hours, give: Give ampicillin 2 g IV every penicillin G 2 million units IV six hours every six hours until delivery plus gentamicin 5mg/kg or ampicillin 2 g IV every body weight IV six hours until delivery every 24 hours Wait for the delivery* Refer the pregnant woman If the membranes have been Give erythromycin ruptured for more than 18 250 mg by mouth hours, give: three times per day or amoxicillin 500 mg by mouth penicillin G 2 million units IV every six hours until delivery three times per day or ampicillin 2 g IV Refer the pregnant woman every six hours until delivery Refer the pregnant woman*

If the pregnant woman shows signs of sepsis (fever, foul-smelling vaginal discharge, low blood pressure, signs of shock) add to ampicillin and gentamicin IV: - metronidazole 500 mg IV every 8 hours. *Consider referral of a pregnant woman presenting PROM at > 37 weeks of pregnancy: • with signs of infection if: - no delivery within 6 hours • with no signs of infection if: - no delivery within 12 hours - no delivery within 6 hours if membranes already ruptured >18 hours

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SEXUALLY TRANSMITTED DISEASES VIRAL HEPATITIS There are five different types of viral hepatitis (hepatitis A, B, C, D and E), which cannot be differentiated clinically. Specific serological tests are necessary. Hepatitis A and E are spread by the faecal-oral route, while the other three (B, C and D) are transmitted via the blood (intravenous drugs, blood transfusion, delivery or sexual activity). Hepatitis A Vertical transmission to the foetus does not occur, whatever the stage of maternal infection. There is a risk of premature delivery in case of infection during the third trimester. Immunization by inactivated vaccine can be performed during pregnancy (refer to the national health policy and standards). Hepatitis E This is rare, but the risk of developing fulminating hepatitis is ten times higher during pregnancy. Epidemics have been observed. HEPATITIS B The virus persists in about 10% of infected immunocompetent adults and in as many as 90% of infants infected perinatally, depending on the ethnic group of the mother. Maternal morbidity and mortality are higher in developing countries, where fulminating hepatitis is five times more frequent. Approximately 25% of all patients with chronic hepatitis will progress to cirrhosis, and about 20% of those with cirrhosis will develop hepatocellular carcinoma. Symptoms and signs • Acute hepatitis B is often anicteric and asymptomatic • Severe illness with jaundice may occur • Acute liver failure may develop Risks for the foetus • Premature birth when the mother contracts hepatitis during the second or third trimester of pregnancy • Transplacental transmission is very weak • Transmission of the virus occurs more often during delivery Diagnosis Based on serology. Treatment Curative: only symptomatic Preventive: inactivated vaccine is not contraindicated during pregnancy (refer to the national health policy and standards)

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S exually transmitted diseases Management Reasons for referring the mother: - for confirmation of the diagnosis by serological testing - for delivery, if it is possible for the newborn to receive passive and active immunization (hepatitis B immunoglobulins and vaccine) before breastfeeding In developing countries, breastfeeding of the baby even without immunization is better than giving any other animal or artificial milk. Remember to arrange for serological testing, if possible, of the man with whom the woman has sexual relations so as to give appropriate advice. HEPATITIS C Hepatitis C is responsible for 5% of hepatitis cases and 50% of chronic hepatic cases. 95% of people suffering from hepatocellular carcinoma are carriers of hepatitis C antibodies. Symptoms and signs 75% of cases are asymptomatic 25% show non-specific symptoms such as fever, icterus, faintness and abdominal pain Diagnosis Based on serology. Treatment There is no treatment for hepatitis C and no vaccine at this stage. Risks for the foetus • In cases of chronic maternal infection or acute hepatitis during the third trimester, the risk of vertical transmission is about 5%. • Maternal HIV infection favours hepatitis C transmission • Infant hepatitis is rare but leads to a chronic asymptomatic condition Management Give advice on how to prevent further contamination (e.g. no blood donation). Breastfeeding is not contraindicated.

HIV/AIDS - HUMAN IMMUNODEFICIENCY VIRUS/ ACQUIRED IMMUNE DEFICIENCY SYNDROME Definition HIV infection leads, after a long, silent incubation period, to a progressive deficiency of the immune system (attested by the declining number of CD4 lymphocytes). This, after some years, leaves the patient open to tuberculosis reactivation and to a variety of opportunistic infections such as parasitic, fungal and viral infections which would not normally cause disease in an immunocompetent person. Certain tumours (lymphomas, Kaposi’s sarcoma) and neurological disorders may also occur.

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S exually transmitted diseases HIV/AIDS - HUMAN IMMUNODEFICIENCY VIRUS/ ACQUIRED IMMUNE DEFICIENCY SYNDROME (contd.) HIV/AIDS is transmitted: - by sexual contact (hetero- or homosexual) - by transfusion of infected blood or blood products - by contaminated injection or surgical material - from infected mothers to their infants: mother-to-child transmission (MTCT) (during pregnancy, delivery or breastfeeding) Diagnosis: Based on serology. Risks for the foetus Transmission during pregnancy (vertical transmission) or during delivery from a HIVpositive mother occurs in 15 to 30% of cases. The risk of vertical transmission is increased in the case of premature rupture of membranes (> 4 to 6 hours before delivery). In order to reduce the risk of transmission during delivery, caesarean section is recommended but of course is not always possible. Furthermore, when the serological status of the mother is not known, caesarean section is seldom performed as a preventive measure. The infant may be contaminated during pregnancy, during delivery or while breastfeeding. Apart from the risk of contamination, there are no specific complications for the foetus of an HIV-positive mother. Risks for the mother Pregnancy does not influence the evolution of the disease as long as the mother is not in an advanced stage of AIDS. However, owing to the suppression of her immune response, the mother may present various opportunistic infections. Treatment To date there is no vaccine and no curative treatment available for HIV/AIDS. Anti-retroviral therapy (ARV), a combination of different drugs, may only prolong the asymptomatic phase of the disease. Comply with the national health policy and standards, if any. Due to the high level of resistance of HIV to Nevirapine observed, WHO does not recommend any longer the use of Nevirapine taken alone to reduce MTCT. Various combinations of drugs (including or not Nevirapine) are presently under study and new WHO guidelines will be produced, and sent immediately to all ICRC delegations. Thanks for keeping in touch with the ICRC Health Unit at Head Quarters before developing or introducing any protocol for MTCT reduction. Management If caesarean section is possible, refer the pregnant woman to the hospital. «The ICRC’s operational framework in regard to HIV/AIDS for victims of armed conflict» is the official ICRC reference document concerning HIV/AIDS.

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S exually transmitted diseases

GONORRHOEA / CHLAMYDIA TRACHOMATIS GONORRHOEA Definition Gonorrhoea occurs when the bacterium Neisseria gonorrhoea colonizes the epithelial surfaces of the male and female uro-genital tract, conjunctiva, pharynx, rectum or synovium. Human beings are the only natural hosts of gonorrhoea, which is a sexually transmitted disease. Symptoms and signs • Men: thick yellow urethral discharge • Asymptomatic infections are much more frequent in women • Women: vaginal discharge may be observed (as N. gonorrhoeae infects the endocervix rather than the vagina, it is less associated with vaginal discharge) • Dysuria • Vulvar itching or burning, local oedema • Salpingitis during the first trimester of pregnancy • Infections of the pharynx or the rectum, mostly asymptomatic, may result from orogenital or/and genito-anal sexual contact. However, the rectum is easily infected by vaginal discharge. • Children may be infected by sexual abuse or infected fomites and show symptoms of vulvo-vaginitis. Diagnosis History and signs. Gram-negative bacteria seen by microscopy in purulent discharge. Risks for the foetus • Chorioamnionitis • Septic abortion • Premature rupture of membranes • Premature birth • Foetal growth retardation • Gonococcal arthritis possible, but rare • Neonatal infection during delivery from an infected mother. This can lead to gonococcal conjunctivitis (acute bilateral purulent conjunctivitis), occurring in the first month of life and often in the first week, which is a major cause of blindness. Risks for the mother • Infection of the paraurethral and Bartholin’s glands • Chronic pelvic inflammatory disease • Infection of the uterus (endometritis) and fallopian tubes (salpingitis) caused by abortion, delivery, or insertion of intrauterine device • Increased risk of ectopic pregnancy • Postpartum upper genital tract infection • Sterility • Disseminated gonococcal infection: arthritis • Ocular gonococcal infection (hand-borne autoinoculation), which can lead to blindness

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S exually transmitted diseases GONORRHOEA / CHLAMYDIA TRACHOMATIS (contd.) Treatment See drugs prescribed on next page. Preventive measures The major obstacle to gonorrhoea control is the large reservoir of asymptomatic carriers and the frequency of clinically non-specific infections. Insufficient or inappropriate treatment also increases the incidence of resistance to antibiotics. The most effective preventive measure is promotion of the use of condoms and of safe sex. Sexual partner(s) should be checked and treated. No vaccine is available.

CHLAMYDIA TRACHOMATIS Definition Sexually transmitted infection due to the bacterium Chlamydia trachomatis. Symptoms and signs Similar to those of gonococcal infection in men and women. Males: - urethritis, epididymo-orchitis - late sequela: urethral stricture Females: - chlamydial cervicitis is often asymptomatic - possible mucopurulent vaginal discharge Risks for the mother Endometritis, salpingitis, pelvic inflammatory disease, all of them facilitated by trauma to the cervix caused by abortion, delivery, or insertion of an intra-uterine device. Symptoms of chlamydial pelvic inflammatory disease are often mild. Patients may present only when the sequelae are irreversible (damage to the fallopian tubes leading to infertility, ectopic pregnancy). Risks for the foetus The same as for gonorrhoea, even during the neonatal period. A small proportion of infants develop chlamydial pneumonitis, usually occurring between the ages of six weeks and three months with cough and tachypnoea but no fever.

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S exually transmitted diseases GONORRHOEA / CHLAMYDIA TRACHOMATIS (contd.) Treatment for gonorrhoea and chlamydia Because co-infection with Neisseria gonorrhoeae and Chlamydia trachomatis is common, it is generally advisable to treat for both when a specific diagnosis cannot be established. For chlamydia erythromycin: 500 mg orally, 4 times daily for 7 days or amoxycillin: 500 mg orally, 3 times daily for 7 days For gonorrhoea cefixime: 400 mg orally as a single dose or ceftriaxone: 125 mg by intramuscular injection as a single dose For gonococcal conjunctivitis: the intramuscular injection above. Ciprofloxacin is contraindicated in pregnancy.

SYPHILIS Definition Sexually transmitted infection caused by Treponema pallidum bacteria. Symptoms and signs Syphilis is divided into primary, secondary and tertiary stages of the disease. Primary stage or chancre: after an incubation period of 10 to 70 days (median 21 days) - A chancre develops at the site of inoculation. This is an ulcerated lesion with a clean base and raised edge which is painless and indurated and does not bleed on contact. - There is usually a single lesion, on the penis in males and on the cervix or vulva in females, often accompanied by inguinal lymphadenopathy (glands are hard and painless). If not treated at this stage, the disease will evolve to secondary syphilis. The chancre generally resolves spontaneously over several weeks. Secondary syphilis: between 3 and 6 weeks after the primary chancre - Annular lesions on the skin - Papular, macular or pustular lesions affecting palms and soles without itching - Lesions often show desquamation - In moist areas (e.g. perineum, axilla) soft, raised condylomata lata may be seen - Possible mucous patches or oral ulceration - May cause fever, malaise, nephritis, hepatitis, generalized lymphadenopathy, meningitis, uveitis. If treated, the lesions of secondary syphilis resolve after a few weeks. Without proper treatment, the lesions resolve and disappear but the condition leads to tertiary syphilis, usually years later.

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S exually transmitted diseases SYPHILIS (contd.) Tertiary syphilis: may present as - Gumma: painless «punched out» ulcer, mostly cutaneous (can involve bone or, rarely, viscera). Most cases occur within 15 years of first infection - Cardiovascular disease, with onset typically 30 to 40 years after infection - Central nervous system disease, 20 to 30 years after infection Diagnosis Primary syphilis (chancre) may be misdiagnosed as it resembles other genital ulcerations, but is usually rather typical. Treponema pallidum can be seen under the microscope in exsudate taken from the chancre. Risks for the foetus Stillbirth, neonatal death, congenital syphilis Congenital syphilis The risk for the foetus is highest when the mother presents with primary or secondary syphilis during pregnancy, and diminishes along with the duration of latent syphilis. Symptoms and signs: bullous rash, anaemia, jaundice, hepatosplenomegaly, foetal growth retardation. Poor prognosis if signs of congenital syphilis are already apparent at birth. More commonly, the baby appears normal at birth and then in the first three months develops: - failure to thrive - bullous rash with desquamation on palms and soles - persistent nasal discharge - anaemia - hepatosplenomegaly - pseudoparalysis of one or more limbs The prognosis is better if signs of congenital syphilis appear during the post-neonatal period. Late congenital syphilis in children or adolescents corresponds to tertiary syphilis in adults. Manifestations include bone and dental abnormalities and inflammatory lesions of cornea and joints. Treatment Infection of no more than two years duration Penicillin benzathine, 2.4 million IU by intramuscular injection in a single dose (because of the volume involved, this dose is usually given as two injections at separate sites) Alternative for pregnant patients allergic to penicillin: - erythromycin 500 mg orally, 4 times daily for 14 days Infection of more than two years duration Same intramuscular injection as above, once weekly for 3 consecutive weeks Alternative for pregnant patients allergic to penicillin: - erythromycin 500 mg orally, 4 times daily for 30 days

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TETANUS PROPHYLAXIS The infectious agent is the anaerobic bacterium Clostridium tetani. The disease occurs when a cutaneous wound becomes infected with the spores of Cl. tetani, which turn into tetanus bacilli in the necrosed tissue. The toxin produced by Cl. tetani spreads through the central nervous system and binds to receptors on nerve endings, where it is unaffected by the tetanus antitoxin. It accumulates in the central nervous system and interferes with the release of neurotransmitters, blocking inhibitor impulses. This leads to painful muscular contractions, especially contractions of the masticatory muscles (lockjaw or trismus). Neonatal tetanus can occur when the umbilical cord is severed with a dirty instrument or when solutions contaminated with tetanus spores are used in the care of the newborn infant. It usually gives rise to suckling difficulties, progressing to generalized rigidity and spasms. Mortality is very high (65-90%). Tetanus immunoglobulins Human tetanus immunoglobulins are used to treat injured patients with deep wounds that are more than 24 hours old. In the absence of any written proof of previous vaccination, it is assumed that the patient has not been vaccinated. In this case, the tetanus vaccine should be accompanied with: - one dose of human tetanus immunoglobulin (500 IU) by way of prophylaxis; or - one dose of human tetanus immunoglobulin (6,000 IU) by way of initial treatment should the clinical symptoms of tetanus appear. Tetanus vaccines • Vaccination of adults Single antigen tetanus toxoid vaccine or double antigen tetanus-diphtheria vaccine • Vaccination of children Triple antigen diphtheria-tetanus-pertussis (whooping cough) vaccine or double antigen diphtheria-tetanus vaccine Immune response Since tetanus antitoxins belong to the IgG class, they can easily cross the placental barrier and spread through the blood system and extravascular tissues. They can neutralize tetanus toxin in an infected wound. Note A small quantity of tetanus toxin is enough to cause tetanus without stimulating the production of antibodies. Persons who have contracted the disease must therefore be vaccinated with tetanus toxoid, either on diagnosis or during their convalescence.

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Tetanus prophylaxis Vaccination is the only means of inducing immunity to tetanus toxin. A person is protected when he has enough antibodies to neutralize the toxin18. Tetanus toxoid is 80 to 100 percent effective19. Recovery from clinical tetanus does not ensure protection against infection in the future. The level and duration of immunity increase with the number of toxoid injections. TETANUS PROPHYLAXIS AT CHILDBEARING AGE OR DURING PREGNANCY Dose

When given

Period of protection

TT1

At first contact with women of childbearing age, or as early as possible in pregnancy.

No protection

TT2

At least 4 weeks after TT1

3 years

TT3

At least 6 months after TT2

5 years

TT4

At least 1 year after TT3

10 years

TT5

At least 1 year after TT4

Throughout childbearing years

Transplacental passage of tetanus antitoxin • IgG antibodies can pass through the human placenta from mother to child. • IgG levels rise steadily in the foetus from the fourth month of pregnancy to its term. • At birth, a baby’s antibody titres are identical to and sometimes higher than those of the mother. Vaccination failures Cases of neonatal tetanus have been reported in babies whose mothers said they had been vaccinated. These situations may be due to: • An imprecise and undocumented vaccination history • An unsuitable immunization schedule: - if pregnancy is announced too late and a second dose of toxoid is administered too close to term, a mother-to-be cannot develop an adequate immune response. - two doses of toxoid protect only 80% of women. It is therefore advisable to administer a third dose so as to secure a sufficient level of protection. • The weak immunogenic potential of vaccines that are of poor quality or have been improperly stored. • Over-exposure to the toxin: - If the umbilical stump is highly contaminated and the mother has received only two doses of vaccine, a newborn infant might be unable to neutralize an excessively large amount of tetanus toxin. 18 The minimum protective level is 0.01 IU/ml of serum. 19 If tetanus toxoid is ineffective, production, storage or transport problems may be the cause.

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Tetanus prophylaxis WHO recommendations Prevention of neonatal tetanus Vaccinating the mother protects the foetus from neonatal tetanus since antitoxins cross the placental barrier. Note The policy of the Expanded Programme on Immunization is to start vaccination of mothers-to-be as early in pregnancy as possible so that the second dose is sufficiently far from the date of delivery.

If a mother has received only two doses of tetanus toxoid during her pregnancy, a third dose should be administered six to 12 months after the first two injections (or, if necessary, when she becomes pregnant again) so that any future children will be better protected. Note All women of childbearing age ought to have received five injections of tetanus toxoid.

Vaccination of HIV-infected persons against tetanus Vaccination with tetanus toxoid, either in the form of single antigen or combined antigen vaccine, is advised for children and adults infected with HIV, irrespective of any AIDS symptoms. Any vaccine prepared with inactivated viruses or bacteria may be used as well.

For more information on vaccines for pregnant women, see annexes III.A.1-2

This section «Tetanus prophylaxis» comes from: ICRC Expanded Programme of Immunization guidelines, to be published in 2005.

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THREAT OF PREMATURE DELIVERY/PRETERM LABOUR Definition Beginning of labour before term, i.e. when gestation is less than 37 weeks. Risk factors, among others: • Chorioamnionitis • Pre-eclampsia • Foetal growth retardation • Premature rupture of membranes • Haemorrhage • Dilated cervix • Multiple pregnancy • Uterine malformations • Poor nutritional status • Excessive physical activity • Addiction to smoking or alcohol Diagnosis Presence of regular uterine contractions (> 3 in a 30-minute period). Do not perform a digital vaginal examination, as this can introduce infection. Remember that a pregnant woman can present light bleeding due to the opening cervix if she is in labour. Risks for the newborn, in case of birth: • Neonatal complications due to immaturity • Infection contracted in utero • Neonatal death Risks for the mother will depend on the reason for the premature contractions. Remember that there are prostaglandins in sperm that can facilitate the maturation of the cervix, which causes uterine contractions. Thus intercourse should be prohibited if the pregnant woman has already had some regular and painful contractions during the pregnancy. Treatment It is not possible to do much at primary health care level, except to hydrate the patient by giving her (preferably) oral rehydration salts or water to drink (around one litre in half an hour, followed by one more litre in one hour, especially if the weather is hot). In fact good hydration often helps to reduce the contractions (see guidelines for rehydration, page 135). Treat infection as in the case of prelabour rupture of membranes < 37 weeks of pregnancy (see page 167). Management Refer the pregnant woman if anything can be done to stop the contractions or to ensure proper management of the preterm baby.

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TWIN PREGNANCY Definition Presence in the uterus of two foetuses rather than one.

Twin pregnancy, bichorial, biamniotic

The second foetus is not shown in order to clearly demonstrate that each twin develops within its own sac (of two membranes) and with an individual placenta.

Diagnosis • By abdominal palpation (presence of four foetal poles) • By measurement of uterine height, which is higher than usual for the length of gestation Risks for the mother Higher rate of maternal morbidity and mortality • Hyperemesis gravidarum • Pre-eclampsia • Urinary tract infections • Low placental implantation • Anaemia • Uterine atony • Complications during delivery • Venous insufficiency Risks for the foetuses Higher rate of perinatal or neonatal morbidity and mortality • Abortion • Vanishing twin syndrome (death of one twin during the first trimester) • Congenital malformations • Stuck twin syndrome (hydramnios and high weight of one twin with oligamnios and low weight for the other) • Foetal growth retardation • Hydramnios • Atypical presentations • Premature birth • Premature rupture of membranes • Cord prolapse • Foetal death

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Twin pregnanc y Management In order to screen for complications and refer if necessary, the twin pregnancy should be regularly monitored, with at least one consultation per month during the last four months. Refer the pregnant woman for delivery in all cases. If the death of one twin is diagnosed during pregnancy, check that the other one has good foetal heart sounds and movements and that the mother feels well. In such cases prudence is called for: ask the mother to come back two weeks later for another consultation or if there is any change necessitating referral, such as: - premature contractions (page 178) - vaginal bleeding (pages 182-189) - loss of foetal movements (pages 152-154) - prelabour rupture of membranes (pages 166,167) - maternal fever or any other physical problem Never attempt an external version in twin pregnancy. Multiple pregnancy It is possible to encounter a spontaneous pregnancy with three foetuses. The risks for the mother and the foetuses are correspondingly greater that in twin pregnancy, but the management will be the same.

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Twin pregnanc y

Embryogenesis and placentation of monozygous twins (For information). Implantation at distance

Zygote

Bichorial - biamniotic 32%

Blastomere

4 days Closed implantation

Morula

Blastocyte 7 days Monochorial - biamniotic 66% Amnion

Monoamniotic 1-2%

13 days Conjoined twin 0.25% F. Le Roy, in R. Vokaer et Coll,“Traité d’Obstétrique”, Tome I, Masson, Paris, 1983.

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VAGINAL BLEEDING The possible causes of bleeding differ according to the stage of pregnancy. First trimester

aAbortion (pages 117, 118) aEctopic pregnancy (pages 117 & 183, 184)

Second trimester

aMolar pregnancy (pages 117 & 185) aLate abortion aPlacenta praevia (pages 119 & 186-187) aAbruptio placentae (pages 119 & 188-189) aPremature contractions (page 178)

Third trimester

aPlacenta praevia aAbruptio placentae aPremature contractions Other causes of vaginal bleeding, which can occur at any time during pregnancy, are trauma or infection (sexually transmitted diseases) of the cervix or vagina. There are also two cases in which slight bleeding may occur without any serious consequences : - After intercourse a woman may present vaginal bleeding due to cervical ectopia during the pregnancy - A woman in labour may present vaginal bleeding due to the opening of the cervix.

Definitions Light bleeding: a clean pad or cloth takes five minutes or longer to be soaked Heavy bleeding: a clean pad or cloth takes less than five minutes to be soaked

Management If the pregnant woman is fainting and/or presenting heavy bleeding, management should begin without delay even in the absence of a clear diagnosis. For more details, see "Rapid initial assessment for vaginal bleeding" page 116. In case of vaginal bleeding an examination by speculum is indicated, per vaginal examination is contraindicated, but may be performed caustiously by an experienced person.

Which cases have to be referred ?

aIf there is heavy bleeding aIf there is light bleeding, which may be repetitive, with or without abdominal pain (similar to dysmenorrhoea or contractions) aIf there is a history of obstetrical or surgical problems, or if the woman’s general status is deteriorating.

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Vaginal bleeding

ABORTION Refer to " Vaginal bleeding in early pregnancy" (pages 117, 118)

ECTOPIC PREGNANCY Definition Pregnancy in which implantation occurs outside the uterine cavity. The fallopian tube is the most common site of ectopic implantation (more than 90% of cases). Possible outcomes of tubal pregnancy

Tubal abortion

Tubal mole

Ruptured tubal pregnancy

Diagnosis Check if the woman knows that she is pregnant or if she has missed a period and, if possible, perform a urine pregnancy test. A gentle bimanual examination (per vaginal and abdominal) should be performed only by an experienced person, because an ectopic pregnancy (in the fallopian tube) can easily be ruptured.

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Vaginal bleeding

ECTOPIC PREGNANCY (contd.) Differential diagnosis

aAbortion aAcute appendicitis aOvarian cyst (torsion or rupture) aAcute or chronic pelvic inflammatory disease aUreteral stones

Symptoms and signs aAbdominal pain aLight bleeding aTender adnexal mass aUterus slightly larger or softer than normal q

q

aAmenorrhoea aClosed cervix aFainting

Unruptured ectopic pregnancy • Symptoms of early pregnancy (irregular spotting or bleeding, nausea, swelling of breasts, bluish discolouration of vagina and cervix, softening of cervix, slight uterine enlargement, increased urinary frequency) • Abdominal and pelvic pain Ruptured ectopic pregnancy • Weakness, risk of prolapsus • Fast, weak pulse >110/min • Hypotension • Hypovolaemia • Acute abdominal and pelvic pain • Abdominal distension (distended abdomen with shifting dullness may indicate free blood) • Rebound tenderness • Pallor

Treatment Surgery

Management This is an emergency: refer the pregnant woman immediately for surgery. For more details, see "Vaginal bleeding in early pregnancy", page 117.

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Vaginal bleeding

MOLAR PREGNANCY Definition Molar pregnancy is characterized by an abnormal proliferation of chorionic villi.

Uterus with hydatidiform mole in situ.

Symptoms and signs

aHeavy bleeding aNausea/vomiting aDilated cervix aNo evidence of a foetus (except partial molar) aCramping/lower abdominal pain aEarly onset of pre-eclampsia (< 20 weeks) aUterus larger than dates and softer than normal aPartial expulsion of products of conception, which resemble grapes

Diagnosis Confirmation by laboratory test: strong elevation of ß-HCG (human chorionic gonadotrophin), but possible with normal values.

Treatment Surgical: evacuate the uterus by aspiration.

Management Refer the pregnant woman. Follow up with urine pregnancy tests every eight weeks for at least one year because of the risk of persistent trophoblastic disease or choriocarcinoma. If the urine pregnancy test is not negative after eight weeks or becomes positive again within the first year, refer the woman urgently to a tertiary care centre for further follow-up and management of choriocarcinoma. Depending on the national policy on family planning: - A hormonal family-planning method for at least one year is recommended to prevent further pregnancy. - Voluntary tubal ligation may be offered if the woman has completed her family (agreement of her partner is essential).

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Vaginal bleeding

PLACENTA PRAEVIA Definition Implantation of the placenta at or near the cervix in the lower uterine segment. TYPES OF PLACENTA PRAEVIA

TYPE 1

TYPE 2

TYPE 3

TYPE 4

RELATIONSHIP OF PLACENTA PRAEVIA TO CERVICAL OS

TYPE 1

TYPE 2

TYPE 3

Risk factors • History of placenta praevia, caesarean, curettage, endometritis • Pregnancy with twins • Uterine malformations • Multiple abortions • Addiction to smoking • Multiparity

Risks for the foetus • Anaemia, foeto-maternal haemorrhage • Foetal death • Prematurity • Foetal growth retardation • Cord prolapse • Malformations more frequent

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TYPE 4

Vaginal bleeding

PLACENTA PRAEVIA (contd.) Risks for the mother • Anaemia • Placenta accreta • Thrombo-embolic disease • Death

Symptoms and signs • Light bleeding (sometimes repetitive) or heavy bleeding, may be precipitated by intercourse or contractions • Relaxed uterus or contractions • Foetal presentation not in pelvis/lower uterine pole feels empty; more often breech or transverse lie

Diagnosis A careful speculum examination, if available, may be performed, but only by an experienced person because of the risk of sudden haemorrhage. Per vaginal examination is contraindicated but may be performed cautiously by an experienced person to confirm the diagnosis, once the woman is in hospital and ready for caesarean section.

Differential diagnosis • Bleeding after intercourse in woman with ectopia of the cervix due to pregnancy. • A careful speculum examination may be performed to diagnose other causes of bleeding such as cervicitis or trauma. The presence of these conditions, however, does not rule out placenta praevia.

Treatment Heavy and continuous bleeding: caesarean delivery irrespective of foetal maturity. Light or intermittent bleeding with foetus alive but premature: rest, transfer for careful management (see below) The pregnancy may continue and lead to delivery at term (type 1 and 2 may even allow vaginal delivery) or require emergency caesarean because of bleeding.

Management Refer the pregnant woman if she presents (see page119): - heavy or recurrent bleeding - lower abdominal pain or contractions Careful management (which means observation) if: - the haemorrhage is not heavy and persistent - the foetus is not showing signs of distress: normal heart rate, good movements - the pregnancy is less than 37 weeks - the pregnant woman is confined to strict bed rest for three days after the bleeding stops.

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Vaginal bleeding

ABRUPTIO PLACENTAE Definition Total or partial detachment of a normally situated placenta from the wall of the uterus before the foetus is delivered. See next page.

Risk factors • High blood pressure • History of abruptio placentae • Multiparity and advanced maternal age • Addiction to smoking or cocaine • Alcoholism • Traumatism • Short umbilical cord • Very distended uterus

Symptoms and signs • Bleeding, which may be retained in the uterus • Intermittent or constant abdominal pain • Tense/tender uterus • Decrease in/absence of foetal movements • Foetal distress or absence of foetal heart sounds

Diagnosis Difficult, especially if the haemorrhage is concealed.

Risks for the foetus Intrauterine or perinatal death

Risks for the mother Haemorrhagic shock Coagulopathy (clotting failure) Maternal death

Treatment Caesarean section as soon as possible, except if vaginal delivery is imminent with fully dilated cervix, ruptured membranes, engaged presentation.

Management Refer the pregnant woman (see page 119).

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Vaginal bleeding

ABRUPTIO PLACENTAE (contd.)

Non-externalized retroplacental haematoma

Externalized retroplacental haematoma

Retroplacental haematoma with partially externalized bleeding

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VAGINAL DISCHARGE Candida albicans: fungus The main source of infection is the gastrointestinal tract, but sexual transmission may occur. In the majority of women candidiasis is asymptomatic. The symptomatic disease is associated with an increase in the number of yeasts present in the vagina (predisposing factors: pregnancy, antimicrobial therapy, oral contraceptives, immunosuppression, AIDS, glycosuria). Vulvovaginal candidiasis: - Pruritus vulvae and vaginal discharge (whitish, odourless, curd-like plaques adhering to the vagina) - Possible erythema and/or oedema of the vulva and vagina Risks for the foetus: - Muco-cutaneous candidiasis, due to transmission during delivery - Rare but fatal disseminated pulmonary candidiasis, due to rising infection during pregnancy Treatment Nystatin 100 000 IU intravaginally, daily for 14 days or Fluconazole 150 mg orally as a single dose Trichomonas vaginalis: parasite Trichomoniasis is a sexually transmitted disease. In men: - mostly asymptomatic; occasionally urethritis In women: - yellow-green, frothy discharge, not malodorous - pruritus vulvae - dysuria - dyspareunia Treatment Metronidazole: 2 g orally as a single dose if treatment is imperative during the first trimester, but may also be given during the second and third trimesters of pregnancy or 400 or 500 mg orally, twice daily for 7 days, after first trimester.

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Vaginal discharge

Bacterial vaginosis Changes in the vaginal bacterial flora: lactobacilli are no longer predominant and Gardnerella vaginalis or Mycoplasma hominis increase. It is not clear whether this is a sexually transmitted disease. Women present a homogeneous white vaginal discharge with a fishy smell, but 50% of cases are asymptomatic. Risks for the foetus and the mother: - late abortion - premature rupture of membranes - prematurity - chorioamnionitis - postpartum endometritis Treatment Metronidazole: 200 or 250 mg orally, 3 times daily for 7 days, after the first trimester or 2 g orally as a single dose if treatment is imperative during the first trimester, but may also be given during the second and third trimesters of pregnancy.

p | 191

VITAMIN A DEFICIENCY Vitamin A is essential for maintaining normal health and physiology, and for growth and development. During pregnancy there is a greater need for vitamin A for both the mother and the foetus. Although the increase in requirement during pregnancy is relatively small, in countries where vitamin A deficiency (VAD) is endemic, women often experience deficiency symptoms such as night blindness, xerophthalmia and Bitot’s spots. Severe vitamin A deficiency and overload are both teratogenic in animals and associated with adverse reproductive outcomes. Although similar outcomes in human populations are not documented, the possibility of risk must be considered. WHO currently recommends that the relatively small additional need for vitamin A during pregnancy should be met through diet (see annex III.B) or a supplement not exceeding 10 000 IU daily throughout pregnancy.

Maternal supplementation during pregnancy (Either during the first 60 days following conception when there is a teratogenic risk or after the first 60 days following conception, for women whose habitual intakes are above the RDA20 or below the RDA)

For fertile women, independent of their vitamin A status, 10 000 IU (3 000 µg RE21 ) is the maximum daily supplement to be recommended at any time during pregnancy. Where VAD is endemic among children under school age and maternal diets are low in vitamin A, health benefits are expected for the mother and her developing foetus with little risk of detriment to either, from : • either a daily supplement not exceeding 10 000 IU vitamin A (3 000 µg RE) at any time during pregnancy; • or a weekly supplement not exceeding 25 000 IU vitamin A (8 500 µg RE). In this regard: - a single dose > 25 000 IU is not advisable, particularly between day 15 and day 60 following conception (day 0); - beyond 60 days after conception, the advisability of providing a single dose of > 25 000 IU is uncertain; any risk for non-teratogenic developmental toxicity is likely to diminish as pregnancy advances. In the case of a pregnant woman who may be reached only once during pregnancy, health workers should balance possible benefits from improved vitamin A status against potential risk of adverse consequences from receiving a supplement. Where habitual vitamin A intakes exceed at least three times the RDA (about 8000 IU or 2 400 µg RE), there is no demonstrated benefit from taking a supplement. On the contrary, the potential risk of adverse effects increases with higher intakes – above about 10 000 IU – if supplements are routinely ingested. WHO, UNICEF and the International Vitamin A Consultative Group (IVACG) recommend that, in areas of VAD endemicity, high doses of supplemental vitamin A (200 000 IU) be given to breastfeeding women during the infertile postpartum period lasting 4 to 6 weeks. 20 RDA: Recommended dietary allowance 21 RE: Retinol equivalents 1RE = 1µg all-transretinol = 0,0035 µmol = 3,33IU/1µmol = 286 µg retinol = 951 IU

p | 192

ANNEXES PART III Ante n at a l Pro b l e m s

ANNEX III.A.1

VACCINES

VACC I N AT I O N A N D P R E G N A N C Y

C ONTRAINDICATED DURING PREGNANCY

COMMENTS

- Viral vaccines * Live attenuated viruses Oral polio

Yes

Measles

Yes

Yellow fever

Yes

German measles

Yes

Chickenpox

Absolutely contraindicated

It is not necessary to interrupt the pregnancy of a woman who was vaccinated before she was known to be pregnant. It is not necessary to interrupt the pregnancy of a woman who was vaccinated before she was known to be pregnant. Contraindicated during the first three months of pregnancy, unless there is a major risk of infection with the virus. Vaccination is necessary in areas where the disease is endemic. Given the teratogenic potential of the vaccine (especially during the first three months of pregnancy), women must not be vaccinated until delivery. Vaccination of women of childbearing age who have not been vaccinated is essential, however, but must be accompanied by contraception one month before and two months after vaccination. Must not be administered to a pregnant woman at any stage of her pregnancy.

* Dead or inactivated viruses Injectable inactivated polio Influenza

No

Best polio vaccine for pregnant women.

No

Vaccination is recommended during the flu season for women who are past their 13th week of pregnancy and at any stage of their pregnancy for all women at high risk of developing the serious form of influenza.

Hepatitis A

Yes

As the innocuousness of the vaccine has not been definitively established, the risk that may be involved in vaccinating a pregnant woman must be weighed against the potential benefit.

Rabies

No

May be used at any stage of pregnancy regardless of whether infection is suspected or confirmed.

Hepatitis B

No

It is preferable to vaccinate only when there is a high risk of contracting this disease and in areas where the disease is endemic.

p | 194

ANNEX III.A.2

VACCINES

VACC I N AT I O N A N D P R E G N A N C Y

C ONTRAINDICATED DURING PREGNANCY

(contd.)

COMMENTS

- Bacterial vaccines * Live attenuated BCG

Yes

Not absolutely contraindicated during pregnancy, but not advised.

* Inactivated Pertussis (whooping cough)

Yes

The vaccine often triggers strong reactions and hyperthermia. It is not indicated for adults and there is no point in administering it to pregnant women since whooping cough is a childhood disease.

Cholera * Toxoids

No

Harmless for pregnant women.

Diphtheria

Yes

Given the reactogenic nature of the vaccine, which often has side-effects in adults, vaccination is not recommended.

Tetanus

No

Three doses of vaccine are recommended for women of childbearing age before or during pregnancy to prevent neonatal tetanus.

Pneumococcal Diseases

Yes

Not advisable during the first three months of pregnancy. Vaccinate only if necessary during the last three months.

HIB (Haemophilus Influenzae Type B)

Yes

The innocuousness of the vaccine has not been definitively established. Vaccinate only if there is a high risk of infection (meningitis or pneumonia).

Meningococcal meningitis groups A and C

No

The vaccine is innocuous at all stages of pregnancy and should be administered if there is any risk of infection.

Typhoid

Yes

May be administered at any stage of pregnancy, but only in risk areas.

* Polyosidic

This annex «Vaccination and pregnancy» comes from : ICRC, Expanded Programme of Immunization guidelines, to be published in 2005.

p | 195

ANNEX III.B

VITAMIN A, IRON AND FOLIC ACID FOOD SOURCES VITAMIN A

Excellent/more concentrated sources

Medium sources

Relatively poor sources

Remarks

p | 196

Liver (fowl and mediumto-large animals), fish liver oils, palm oil

IRON

FOLIC ACID

Meat (especially liver), fish, Liver, kidney, green leafy vegetables (spinach, eggs cassava leaves, amaranth, sweet potato leaves, beetroot leaves, rhubarb chard), yeast, broccoli

Almost all other Butter, eggs (egg yolk), Cereals (maize, rice and orange/yellow and wheat contain moderate vegetables (folic acid is crookneck squash, cheese, amounts, but consumed in present in all vegetable tissue), groundnuts yogurt, medium-fat fish, relatively large quantities carrots, green leafy are quite significant), vegetables (spinach, beans, peas, green leafy cassava leaves, amaranth, vegetables (spinach, sweet potato leaves, cassava leaves, amaranth, beetroot leaves, rhubarb sweet potato leaves, chard), broccoli, beetroot leaves, rhubarb red peppers, green chard), broccoli, nuts leguminous vegetables, pumpkin, yellow maize, apricots, mangoes, papaya, pineapple Milk, lean fish, red meat, fowl, bananas, tomatoes, germinated pulses, lentils, green peas

Eggs, milk

Dietetic fats enhance Absorption is increased absorption of liposoluble when combined with vitamins. Vitamin E vitamin C, so it is advisable enhances bioavailability of to add e.g. lemon to salads. vitamin A (preventing its Absorption is decreased by oxidation) tannins in e.g. tea and coffee, so it is recommended not to drink tea/coffee with meals

Normally, in a diet that meets energetic requirement, folic acid requirements are also met Ascorbic acid (vitamin C) also reduces destruction of folates during extraction. Folates are easily destroyed by heat, oxidation and UV. Some 50% nevertheless remain during storage, processing and cooking

BIBLIOGRAPHY Ante n at a l G u i d e l i n e s fo r Pr i m a r y H e a l t h Ca re i n C r i s i s Co n d i t i o n s

BIBLIOGRAPHY PART I ICRC, Assistance Policy, International Committee of the Red Cross, Geneva, April 2004. ICRC, Addressing the Needs of Women Affected by Armed Conflict, International Committee of the Red Cross, Geneva, 2004. ICRC, Planning, Monitoring, Evaluation database, International Committee of the Red Cross. Du Mortier S. et al., Boîte à outils pour l’analyse et la résolution des problèmes, International Committee of the Red Cross, Democratic Republic of the Congo, 2003. WHO, El Bindari-Hammad A, Smith D.L, Primary Health Care Reviews, Guidelines and Methods, World Health Organisation, Geneva, 1992. King J.A., Lyons Morris L., Taylor Fitz-Gibbon C., How to Assess Program Implementation, Sage Publications, California, 1987. UNHCR, Reproductive Health in Refugee Situations, United Nations High Commissioner for Refugees, Geneva, 1999. WHO, WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, World Health Organisation, Geneva, 2002. Aga Khan Foundation, Primary Health Care Management Advancement Programme, Assessing the Quality of Service, Module 6, User’s Guide, Aga Khan Foundation, Thailand, 1997. AEDES, Système d’information sanitaire, Association Européenne pour le Développement et la Santé, Brussels, 1996. UNFPA, Reproductive Health Kits for Crisis Situations, United Nations Fund for Population Activities, January 2003.

p | 198

BIBLIOGRAPHY PART II WHO, La fiche maternelle tenue à domicile. Comment la mettre au point, l’adapter et l’évaluer, World Health Organisation, Geneva, 1994. WHO, Integrated Management of Pregnancy and Childbirth – Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors, Department of Reproductive Health and Research, World Health Organisation, Geneva, 2003. Bennett V.R., Brown L.K., Myles Textbook for Midwives, 12th edition, Churchill Livingstone, United Kingdom, 1993. Columbia University, Averting Maternal Death and Disability (AMDD), New York http://www.amdd.hs.columbia.edu/ Hijab N., Carriere C., Program Orientation: A Tool for Self-Learning, February 2002. Paxton A., Maine D., Hijab N., Using the UN Process Indicators of Emergency Obstetric Service: Questions and Answers, January 2003. Hohlfeld P. et al., Le livre de l’interne, Obstétrique, 2nd edition, Médecine-Sciences/ Flammarion, Paris, 2000. JHPIEGO, Emergency Obstetric Care: Quick Reference Guide for Frontline Providers, Maternal Neonatal Health, JHPIEGO, Baltimore, USA, September 2003. nd

Lansac J., Berger C., Magnin G., Obstétrique pour le praticien, 2 edition, SIMEP, Paris, 1990. Lansac J. et al., Pratique de l’accouchement, 2nd edition, SIMEP, Paris, 1992. Liselele H.B. et al., “Maternal height and external pelvimetry to predict cephalopelvic disproportion in nulliparous African women: a cohort study”, British Journal of Obstetrics and Gynaecology, August 2000, Vol. 107, pp. 947-952.

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BIBLIOGRAPHY PART III WHO, Female Genital Mutilation: Integrating the Prevention and the Management of the Health Complications into the Curricula of Nursing and Midwifery – A Teacher’s Guide, World Health Organisation, Geneva, 2001. WHO, Management of Pregnancy, Childbirth and the Postpartum Period in the Presence of Female Genital Mutilation, World Health Organisation, Geneva, 2001. ICRC Malaria Guidelines, International Committee of the Red Cross, Geneva, February 2004. Philip R. Fischer, «Malaria and newborns», Journal of Tropical Pediatrics, Vol. 49, No. 3, June 2003. WHO, Clinical Management of Survivors of Rape: A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations, World Health Organisation, Geneva, 2002. ICRC Health in detention documentation, International Committee of the Red Cross, Geneva, 2004. Amone-P’Olak K., «The impact of civil strife on adolescent girls’reproductive health», Africa Health, March 2003, pp. 15 -18. WHO, Guidelines for the Management of Sexually Transmitted Infections, World Health Organisation, Geneva, 2003. ICRC’s operational framework in regard to HIV/AIDS for victims of armed conflict, International Committee of the Red Cross, Geneva, 2004. WHO, Prevention of Mother-to-Child Transmission of HIV: Selection and Use of Nevirapine, Department of Reproductive Health and Research, World Health Organisation, Geneva, 2001. ICRC Expanded Programme of Immunization Guidelines, International Committee of the Red Cross (to be published in 2005). WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, Department of Reproductive Health and Research, World Health Organisation, Geneva, 2003. WHO, Safe Vitamin A Dosage during Pregnancy and Lactation, World Health Organisation, Geneva, 1998. Burns A.A. et al., Where Women Have No Doctor, Hesperian Foundation, California, 2000.

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MISSION The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.

FOR FURTHER INFORMATION AND RESOURCES, PLEASE CONTACT: Your National Red Cross or Red Crescent Society or the nearest ICRC delegation

“ A mother is the truest friend we have, when trials, heavy and sudden, fall upon us; when adversity takes the place of prosperity; when friends who rejoice with us in our sunshine desert us, when troubles thicken around us, still will she cling to us, and endeavor by her kind precepts and counsels to dissipate the clouds of darkness, and cause peace to return to our hearts.” Washington IRVING International Committee of the Red Cross Health and Relief / Geneva 19 Avenue de la Paix 1202 Geneva, Switzerland T + 41 22 734 6001 F + 41 22 733 2057 E-mail: [email protected] or [email protected] www.icrc.org

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A N T E N ATA L G U I D E L I N E S F OR P R I M A RY H E A LT H C A R E I N C R I S I S CO N D I T I O N S Cristina Otero Garcia General nurse, paed...

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