ANC Learners Module 20 Dec

Antenatal Care Module
Learners Guide
Jakarta, Indonesia
December 2012
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Table of Contents
1. Introduction ..................................................................................................................... 4
Student Characteristics .............................................................................................................. 4
2. How to Use the Antenatal Care Module .................................................................. 5
3. Learning Objectives ....................................................................................................... 6

3.1 Develop knowledge base .................................................................................................... 6
3.2 Develop clinical skills .......................................................................................................... 8
3.3 Enhance professional development ............................................................................... 9
4. Core Topics and Clinical Conditions ........................................................................ 9
5. Physical Examination and Procedural Skills ..................................................... 10
6. Guide to Ethical Behaviour ...................................................................................... 10
7. Teaching and Learning Programme ..................................................................... 11

7.1 Overview.................................................................................................................................11
7.2 The Programme ...................................................................................................................12
7.2.1 Introduction ................................................................................................................................. 12
7.2.2 Clinical Skills Session ............................................................................................................... 12
7.2.3 Clinical Teaching ........................................................................................................................ 12
7.2.4 Problem-based Learning ........................................................................................................ 12
7.2.5 Topic Tutorials ............................................................................................................................ 12
7.3 Topics, Teaching and Learning Methodology and Assessment/Evaluation...13
8. Learning Resources .................................................................................................... 16

References................................................................................................................................................ 16
9. Assessment .................................................................................................................... 17
10. Procedural Skills Tutorial...................................................................................... 18

10.1 Taking an Obstetric History ..........................................................................................18
10.2 Performing an Obstetric Examination ......................................................................23
11. Teaching and Learning Materials ........................................................................ 27

11.1 Group Discussion ..............................................................................................................27
11.1.1 Group Exercise: Use of pregnancy calculator .............................................................. 27
11.1.2 Discussion: Birth and emergency preparedness plan ............................................. 28
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11.2 Case-based Learning Case Triggers............................................................................29
Case Study 1: Focused Antenatal Care ......................................................................................... 29
Case Study 2: Health education for women following the basic component of
Focused Antenatal Care...................................................................................................................... 30
11.3 Problem-based Learning Case Triggers ...................................................................30
Case Study 1: Counselling for HIV Testing During Antenatal Care................................... 30
Case Study 2: Antenatal Assessment and Care (Anaemia) .................................................. 31
11.4 Knowledge Assessment ..................................................................................................32
11.4.1 Knowledge Assessment on Focused Antenatal Care: ............................................... 32
11.4.2 Knowledge Assessment: ....................................................................................................... 33
Prevention and Management of Malaria and Other Causes of Fever In Pregnancy .. 33
Preventing Mother-To-Child Transmission of HIV ................................................................. 34
Postpartum family planning ............................................................................................................. 35
11.5 Checklists .............................................................................................................................37
11.5.1 Checklist for Focused Antenatal care.............................................................................. 37
11.5.2 Checklist for birth and emergency preparedness plan ........................................... 43
11.5.3 Checklist for demonstration of breast feeding............................................................ 44
11.6 Learners Guide: ................................................................................................................46
11.6.1 Learners Guide: Antenatal Assessment - Taking an Obstetric History ............ 46
11.6.2 Learners Guide: Antenatal Assessment - Physical Examination ........................ 51
11.7 Counseling Guide for Post-partum Family Planning Postpartum IUD .......56
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1. Introduction
The module on antenatal careis an inter-related learning experience between several basic
sciences and clinical disciplines. These modules include:
- Anatomy and Embryology Modules for anatomy of the female genital tract and fetal growth
and development (third year)
- Physiology Module for physiology of pregnancy (third year)
- Microbiology and Infectious Disease Modules for STI/RTI and HIV (third year)
- Pharmacology Module for prescribing medicines in pregnancy and the puerperium (third
year)
- Haematology and Clinical Pathology Modules for urine and blood investigations (third year)
- Womens Health Module for obstetric and gynaecological issues (fifth year)
- Medicine Module for medical disorders in pregnancy (fifth year)
- Nutrition Module for nutrition during pregnancy and breastfeeding (third year)
- Community Medicine Module (third year)that will cover public health topics closely related to
Obstetrics and safe motherhood. These are:
Maternal and Neonatal Mortality and Morbidity
Initiatives to improve maternal and newborn health
Services for maternal and neonatal health in Indonesia
The Empathy Module (first year), Basic Clinical Skills Module including counseling (second
and third year) and subjects such as Ethics and Professionalism and Cultural Competence
are critical elements of antenatal care provision.
The Antenatal Care module is based on the WHO Antenatal Care model which has been
used extensively in low and middle-income countries as the Focused Antenatal Care model.
The Antenatal Care module is primarily for the doctor practising as a general practitioner at
the health centre/puskesmas level; and can also be used by midwives working at this level.
Student Characteristics
Students who can take the Antenatal Care module are those who have completed Stage 1 of
their education and have acquired learning skills of Stage 1 General Education. These
students must have achieved basic skills and attitudes, such as life-long learning skills,
generic skills and concern for the environment and the community.
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2. How to Use the Antenatal Care Module
The Antenatal Care module is introduced in the third year and will be undertaken in the Basic
Clinical Skills Module (fourth year), Womens Health Module (fifth year) and in the Pre-
internship training.
This module contains the following information:

Learning Objectives
The Core Topics and Clinical Conditions you are to be able to address as a result of your
learning experience related to this module
Teaching/Learning materials:
- TheCase-Based and Problem-based Learning Case Triggers
- The worksheets for taking an obstetric history and conducting an obstetric examination as
part of procedural skills
- Checklists and Learners Guide
- A Counselling Guide for post-partum family planning
In the Fifth Year when going through the Womens Health rotation, you will complete a
Clinical Skills logbook which will reflect your tasks and observations related to antenatal care.
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3. Learning Objectives
Antenatal care (ANC) is the care provided throughout pregnancy to help ensure that women
go through pregnancy and childbirth in good health and that their newborns are healthy. The
emphasis in this module is on Focused ANC (FANC), which relies on evidence-based
interventions provided to women during pregnancy by skilled healthcare providers such as
midwives, doctors, and nurses with midwifery and life-saving skills. Focused ANC includes
assessment of maternal and fetal well-being, preventive measures, preparation of a birth and
emergency preparedness plans and health messages and counseling.
3.1 Develop knowledge base

During the third year, a knowledge base will have been developed of the
following in the respective Modules:
Normal Anatomy and Physiology

Obstetrics: anatomy of the female pelvis, fetal growth and development
Obstetrics: physiology of pregnancy
Gynaecology: menstrual cycle
Microbiology
Sexually transmitted infections/Reproductive tract infections (gonorrhea and chlamydia
infections, syphilis, HIV/AIDS, candidiasis, trichonomas vaginitis, bacterial vaginosis, Human
Papilloma Virus (HPV) infection, genital herpes)
Haematology and Clinical Pathology

Haematological, biochemical and other laboratory investigations
Pharmacology
Safe prescribing of medicines in pregnancy and puerperium
Population health issues

Sexually transmitted infections/Reproductive tract infections
Mental health in obstetrics
Public health interventions conducted for the mother and newborn in Indonesia and
internationally
Community Medicine
Maternal and Neonatal Mortality and Morbidity
Initiatives to improve maternal and newborn health
Services for maternal and neonatal health in Indonesia
Cultural competence
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In the Antenatal Module, the Learning Objectives are:
To explain management of the normal antenatal period:
Obstetrics:
Pre-pregnancy counseling
Evidence-based interventions and care during the antenatal period which can prevent and
treat complications of pregnancy
Focused antenatal care (FANC), basic elements of FANC assessment and care - first and
subsequent antenatal visits (assessment, interventions including referral, counseling and
advice) for the basic component of antenatal care
Common clinical problems in the antenatal period
Maternal nutrition and immunization
Birth and emergency preparedness plans and the relation to the Three Delays.
To explainmanagement of the normal post-partum period:

Obstetrics:
Postpartum care, breastfeeding, maternal complications
Gynaecology:
Contraception for women who breast feed and those who do not breast feed.
To explain early newborn care

Early newborn care, neonatal complications
To explain and interpret theinvestigations carried out routinely during the antenatal
period
Blood for Haemoglobin
Blood group and Rhesus
Blood sugar
Urine for protein, sugar, bacteriuria
Ultrasound scans
Perform, interpret and explain the following investigations: blood pressure, mid-upper arm
circumference.
interpret and explain the following investigations:haemoglobin estimation, blood
sugar,urinalysis, urinary pregnancy test, genital swabs (high vaginal swab, endocervical
swab) and cervical smear.
To provide informationon common issues in pregnancy

Obtain knowledge to be able to provide information on:
- Normal pregnancy
- Nutrition requirements and mineral and vitamin supplements
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- Minor disorders in pregnancy
- Investigations routinely carried out in antenatal period
- Prevention of maternal to child transmission of HIV and syphilis
- Immunization
- Skilled attendance at delivery
- Birth and emergency preparedness plans and the relation to the Three Delays
- Post-partum care and newborn care in the early puerperium, including breast feeding.
To communicatewith clients, their families and other health professionals

Communicate clearly and sensitively with clients, their families and with other health
professionals during process of antenatal care.
Communicate effectively with clients and their families on diagnosis, procedures and
management in a culturally appropriate manner.
Appreciate the diversity of traditions and cultures of different population sub-groups and adapt
provision of care.
Communicate clearly and sensitively with clients and their families to abandon practices that
are harmful or of no proven effect on the mother and newborn.
3.2 Develop clinical skills

Obstetrics:
Develop basic clinical skills (obstetric history taking, calculate estimated date of delivery
(EDD) and physical examination) to arrive at a provisional diagnosis and differential
diagnoses.
Elicit history from an Obstetric patient.
Measure mid-upper arm circumference (MUAC)
Perform breast examination, an abdominal examination in women during pregnancy (early
pregnancy and pregnancy over 20 weeks) and recognize normal findings and common
abnormalities.
Identify women with specific conditions and complications of pregnancy who require referral
to a district hospital.
Gynaecology:
Perform bivalve speculum examination and recognize normal findings, signs of vaginal and
cervical infection and common abnormalities.
Communication and Counselling

Develop skills in communicating and counseling with the woman and her husband and family
on issues such as care of a normal pregnancy, birth and emergency preparedness,
postpartum and early newborn care (including breast feeding and family planning).
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The skills developed during the Community Medicine rotation: the counseling process, the
guiding principles and the factors that can influence the counseling process will be reinforced
in this module.
3.3 Enhance professional development

Develop the following attitudes:
Inter-professional Relationship: Multi-disciplinary health care is an integral part of antenatal
care and this module offers an opportunity to develop inter-professional relationships.
Muilti-cultural Approach: Develop respect for the differing cultural positions in antenatal care.
Encourage traditional practices that are beneficial and be able to counsel on harmful
practices.Conceptualise the clinical problem in a clinical and social context.
Sense of Responsibility: By virtue of the unique and close relationship and involvement with
the client and her family in preventive and promotive activities and care throughout the
pregnancy, to develop a sense of responsibility.
Appreciate ethical issues

To develop an understanding of common ethical issues in provision of antenatal care related
to respect for the clients/patient, privacy and confidentiality; and an approach to issues where
the health providers stance is at variance with that of the client.
4. Core Topics and Clinical Conditions

The core topics and clinical conditions in the Antenatal Care Module will also be covered in
the related basic sciences, community medicine and clinical modules.
Normal pregnancy
- Pre-pregnancy counselling and the use folic acid preconception and nutritional
requirements and lifestyle changes in pregnancy.
- Consideration of past obstetric history, including mode of delivery
- Safe drug prescribing in pregnancy and the puerperium
- The risk of substance abuse in pregnancy
- Nutrition requirements and mineral and vitamin supplements in pregnancy
- Minor disorders in pregnancy
- Changing demographics of pregnancy.
Focused antenatal care

- Principles and concepts
- Basic component of focused antenatal care
- The booking visit (history and examination)
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- Routine investigations during antenatal period/visits
- Prevention of maternal to child transmission of HIV and syphilis
- Immunization
nd rd th
- Care during subsequent visits (2 , 3 and 4 ) for the Basic component of focused
antenatal care
- Skilled attendance at delivery
- Birth and emergency preparedness plans
- Sexual relations during pregnancy
- Immediate post-partum and early newborn care
5. Physical Examination and Procedural Skills

Take history in pregnancy (Obstetric history taking)
Perform breast and obstetric examination
Perform a speculum examination
Apply the Classifying Form to identify clients/woman for the basic component of antenatal
care
Identify women with complications for referral
Communicate and counsel the woman, her husband and family
Complete clinic medical records and Mother and Child Book (which is kept with the mother).
6. Guide to Ethical Behaviour

You are expected to apply the principles of ethical conduct that you learnt in The Empathy
Module (first year) and Basic Clinical Skills Module.
Respect for the patient

Respect for the patient includes deference to and acknowledgement of the patients right in
making decisions, treating the patient with compassion and dignity, maintaining confidentiality
and respect for patient privacy, avoiding misrepresentations, deception and nondisclosure,
and keeping promises.
Privacy
It is important to respect the client/patients privacy. Before starting a physical examination,
explain to the client/patient what you will be doing and obtain consent. Make sure you have
drawn the curtains. If you are a male student, you may want to ask a nurse or a fellow female
student to be present during the examination. Only the area to be examined should be
exposed at any time and do not leave the patient exposed longer than necessary. Speculum
or vaginal examination should be performed only with the client/patients consent and under
supervision of a doctor.
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Consent
Your clinical handbook will explain the process of obtaining agreement/consent from
out-patient/ward staff to interview a client/patient. You should proceed to the
client/patient only when you have obtained the agreement.
Once agreement/consent is obtained, you should introduce yourself to the
client/patient you wish to interview that you are a medical student and explain why
you are there.
You need to obtain consent from every client/patient you wish to interview.
The client/patient must be made aware that their agreement to be
interviewed/examined is voluntary, that they are free to agree or refuse and that their
medical care will not be affected in any way by their decision.
Confidentiality
You are expected to uphold the same standards of confidentiality as doctors.
You should not reveal the name of any patient to anyone who is not involved in the
care of the client/patient. Details other than names can lead to identification of a
client/patient, so caution needs to be exercised in sharing such details.
Discussing the client/patient that you have seen with your tutors and fellow students
is an important part of medical education. It is acceptable to share your experiences
with family and friends but make sure that you do not disclose any identifying
information.
Other Points in Clinical interactions

Help the patient sit up and to get dressed (as appropriate)
Thank her for agreeing to be interviewed or examined
Dress appropriately out of respect for the client/patient and doctors who are helping
you in your medical education
Wear your photo identity card
Turn off mobile phones during tutorials and interactions with clients/patients
7. Teaching and Learning Programme
7.1 Overview
It is important to participate in all activities related to this module. You will be introduced to the
principles of antenatal care and focused antenatal care in the third year. The opportunity to
put your skills on taking an obstetric history and performing an obstetric examination will be
given in the fourth year and consolidated during the fifth year in the Womens Health module.
This includes clerking of in-patients (pregnant women/patients), participation in out-patient
clinics. These skills will be reinforced in the pre-internship rotation.
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7.2 The Programme
7.2.1 Introduction
You will have an introductory lecture on antenatal care to develop some foundation in the
concepts of antenatal care, obstetric history taking and performing an obstetric examination.
7.2.2 Clinical Skills Session

You will have opportunities to take obstetric history during role play and perform an obstetric
examination on mannikins during the third year. In the fourth and fifth year, you will have the
experience of taking a history and performing an examination on women coming for antenatal
care or those admitted to the obstetric ward. You will encounter women with minor
disorders/ailments of pregnancy or those with complications during the antenatal period.
In the application of the Focused antenatal care model, basic antenatal care will be provided
to women who have an uncomplicated pregnancy. However, it is important to be able to
identify women who develop conditions or complications that require more specialized care.
Therefore, it is important for you to identify these women through performing a thorough
history and physical examination. You will also need to acquire the skills to communicate
effectively with women and their families (i) to adhere to the antenatal care visit schedule and
interventions, (ii) to plan for delivery and (iii) to convince them to seek care at the next referral
level/district hospital as required.
7.2.3 Clinical Teaching

You are expected to attend all the outpatient antenatal clinics which provides opportunities to
interact with pregnant women and their families. Problem-based learning (PBL) and clinical
tutorials will be scheduled to be at the outpatient clinic sessions.
7.2.4 Problem-based Learning

The problem-based learning (tutorials) will take place during the clinical weeks 2-6 and 8-9 of
the Womens Health rotation.
7.2.5 Topic Tutorials

There will be two topic tutorials scheduled each week: one in Obstetrics and Gynaecology
and another in Neonatal Paediatrics in the Womens Health rotation.
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7.3 Topics, Teaching and Learning Methodology and Assessment/Evaluation
Table 1: Topics, Teaching and Learning Methodology and Assessment/Evaluation
Topic Sub-topics to be covered Method Year Assessment &
Evaluation
Antenatal care (ANC) Elements of care in pregnancy Introduction Lectures 3rd Assessment
Purpose of antenatal care Self-assessment
Focused antenatal care Concepts and Principles of FANC Introduction Lectures 3rd Questions
(FANC) Goals of FANC Presentation/Discussion Group discussion
Comparions of traditional and focused Case-based discussion
antenatal care Directly observed
Application of Classifying Form practical skills
1
First antenatal Visit Obstetric History Role play 3rd,4th,5th OSCE
Interaction with Clients Mini CEX
Clinical Examination Practice on mannikins 3rd,4th,5th
Examination on Clients Evaluation
Essential/Supporting Investigations Introduction Lectures 3rd Clinical Log Book
Case-based discussion Directly observed
Interventions for Basic ANC Component Introduction Lectures 3rd practical skills
Assessment for Referral Problem/Case-based MCQ, MEQ,
1
In providing FANC, health service providers give emphasis to individualised assessment and the actions needed to make decisions about antenatal care by the provider
andthe pregnant woman together. Each visit comprises of eliciting history/information; conducting an examination and supporting investigations/tests; assessing the need for
referral; implementing interventions; counselling, responding to questions and scheduling the next visit; and maintaining complete records
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Evaluation
Advice, Questions and Scheduling discussion Long case based
Birth and emergency preparedness and Self-study 3rd examination
complication readiness Group Discussion Research by student
The Three Delays group
nd rd
Subsequent Visits (2 , 3 , History and Clinical Examination Presentation/Discussion 3rd,4th,5th
th
4 ) Interventions for Basic ANC Component Problem/Case-based
Assessment for Referral discussion
Advice, Questions and Scheduling
Common Minor Ailments Nausea, Vomiting Topic discussion 5th
Leucorrhoea, etc
Communication/Counselling Anaemia Problem/Case-based 3rd
Nutrition discussion
Counselling for Testing for HIV and syphilis Role play on different
(pre-test counseling, provider-initiated scenarios
counseling counseling and testing, post- test
counseling)
Postpartum family planning
Postpartum care and Early Mother Clinical morning discussion 3rd
Newborn Care Postpartum care and hygiene Topic discussion
Nutrition
Breast-feeding
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Evaluation
Family planning
Danger signs in post-partum period
Sexual relations in the puerperium
Baby
Thermal control
Cord care
Sleeping patterns
Hygiene (washing, bathing)
Danger Signs for newborn
Pre-pregnancy counselling Pre-pregnancy counselling Self study 3rd
Use of folic acid preconception
Lifestyle changes in pregnancy
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8. Learning Resources
Lecture notes will be available one day before the activity. There are useful references on the
website that will be sent out prior to the learning activity.
References
WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model
(2002) WHO
WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal
care (2001) Villar, J et al Lancet 357 1551- 64
Standards for Maternal and Newborn Care (2007) Department of Making Pregnancy Safer
WHO
Pregnancy, Childbirth, Postpartum and Newborn Care (2006), WHO
Managing Newborn Problems, (2003) WHO
Decision-making tool for family planning providers and clients (2007) WHO and JHPIEGO
WHO Reproductive Health Library
nd
Oxford Handbook of Obstetrics and Gynaecology (2008) 2 edition
Basic Maternal and Newborn Care: A Guide for Skilled Providers (2004)AuthorsBarbara
Kinzie and Patricia Gomez - ACCESS JHPIEGO/Maternal and Neonatal Health Program
Best Practices in Maternal and Newborn Care - A Learning Resource Package for Essential
and Basic Emergency Obstetric and Newborn Care(2008) JHPIEGO USAID- ACCESS
Postpartum Intrauterine Contraceptive Device Services Trainers Notebook (2010)

JHPIEGO USAID- ACCESS
Antenatal Care, Part 2 - Blended Learning Module for the Health Extension
ProgrammeEthiopian Federal Ministry of Health, the Ethiopian Office of UNICEF, The Open
University UK and AMREF (the African Medical and Research Foundation).
Pocket Book of Maternal Health Care Indonesia (2011 Draft)
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Thaddeus, S and Maine, D (1994) Too Far To Walk: Maternal Mortality in Context
9. Assessment
Self-assessment Questions (SAQ)
- Self-Assessment Questions after the introduction lectures.
Group discussion
- Calculating expected date of delivery
- Discussion on birth and emergency preparedness plans
Clinical Log Book
Case-based discussion
- Case Study 1: Focused Antenatal Care
- Case Study 2: Health education for women following the basic component of focused
antenatal care
Problem-based discussion
- Case Study 3: Counselling for HIV Testing During Antenatal Care
- Case Study 4: Antenatal Assessment and Care- anaemia
Directly observed Practical Skills

- Checklist for obstetric history taking
- Checklist for obstetric examination
- Checklist for birth and emergency preparedness plans
- Checklist for postpartum family planning (postpartum IUD insertion)
- Checklist for demonstrationof breastfeeding
MCQ, MEQ,
OSCE
Obstetric history taking
Obstetric examination
Interpretation of investigations from first and subsequent antenatal visits
Demonstration of breastfeeding
Mini Clinical Evaluation Exercise (Mini CEX)
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10. Procedural Skills Tutorial
10.1 Taking an Obstetric History

Identification
Name, Age
Husbands name, Husbands Age
Address, Phone Number
Religion
Current Pregnancy History

The first day of last menstrual period (LMP)
Expected date of delivery (EDD)
Maturity by Dates
Menstrual cycle, Regularity
Vaginal bleeding
Leucorrhea
Nausea and vomiting
Problems in current pregnancy
Use of medications and herbs (jamu)
Gynacological (including Contraceptive History)

Previous contraceptive history
Recent history of contraception before pregnancy
Any surgical procedures
Period(s) of infertility: when? duration? cause?
Previous Obstetric History

Number of pregnancy
Number of delivery, Number of labours at term/ Number of preterm labour
Date (month and year) of outcome of each event (live birth, still birth, miscarriage, abortion,
ectopic, hydatidiform, mole) specify (validate) preterm births and type of abortion if possible.
Number of living children, birth weight, and sex, Infant weight of <2.5 kg or> 4 kg
Presence of problems in previous pregnancy, labour and puerperium:

Mother: Bleeding in previous pregnancy, labour, and puerperium (placenta abruption,
placenta praevia); Presence of hypertension, pre-eclampsia, gestational diabetes in previous
pregnancies; breech or transverse presentation;labour: (spontaneous, induced,
LSCS);delivery: spontaneous, assisted with vacuum, forceps, LSCS;obstructed labour e.g.
shoulder dystocia;PPH, puerperal sepsis;exclusive breast feeding.
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Baby: Malformed or abnormal baby, macrosomic (4500g) newborn, IUGR, resuscitation or
other treatment of newborn;twins; anyperinatal, neonatal or fetal death.
The Obstetric History is usually summarized in a pre-formatted table (Table 2).
Medical History
Heart disease
Hypertension
Diabetes mellitus (DM)
Liver diseases (hepatitis)
Tuberculosis (TB)
Chronic Renal conditions
Thalassemia and other hematological disorders
Asthma
Psychiatric disorders
Epilepsy
Sexually transmitted infections
HIV status if known
History of surgery, operations other than cesarean section
Any regular medication - specify
Allergy to medicines/food
History of trauma/accident
Blood group (if Known)
History of blood transfusion, Rhesus (D) antibodies
Status of tetanus immunization
Use of medications and herbs (jamu).
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Table 2: Summary of Obstetric History
Index Age & Sex Pregnancy Duration of Delivery Postpartum Birth weight Status at Other issues of
of Child (Normal or pregnancy (Normal or (Normal or birth note
complicated) complicated) complicated)
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Family History
Hypertension
Diabetes mellitus
Twins
Congenital abnormalities
Socio-economic History
Marital status, number of times married and age of marriage(s)
Occupation and daily activities
Occupation of the spouse
Education
Income (if possible)
Ethnic group
Eating or drinking habits
Smoking habit, use of recreational drugs and alcohol
Options of place for delivery
Maternal and family responses to pregnancy and labour preparedness
Number of family members helping at home
Decision maker in the family
Sexual life, history of casual sex and sexual history of the spouse
Housing: type, size, number of occupants
Sanitary conditions: type of toilet, source of water
Electricity or source of heating and lighting
Cooking facilities
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Table 3: Summary of History to be Completed at First Visit
(based on table in draft pocket book of Maternal Health Care)
Identity Current Pregnancy History
Name, Age Leucorrhea
Husbands name Nausea and vomiting
Address Vaginal bleeding
Phone Number Other problems/abnormalities
Religion Use of medication, traditional medicine and
herbs
Menstrual History Family History

The first day of last menstrual period Diabetes mellitus
Menstrual cycle Hypertension
Expected date of delivery Multiple pregnancy
Maturity by dates Congenital abnormalities
Contraceptive History Other Medical History
Previous contraceptive history Heart disease
History of contraception before pregnancy Hypertension
Previous Obstetric History Diabetes mellitus (DM)
Number of pregnancies Liver diseases such as hepatitis
Number of deliveries Tuberculosis (TB)
Number of labour at term, preterm labor Chronic renal disease
Mode of delivery Malaria
Number of living children, birth weight, and Asthma
sex
Number of miscarriage(s), abortion(s) Epilepsy
Bleeding in previous pregnancy, labour, and Any regular medication
puerperium
Presence of hypertension, pre-eclampsiain Allergy to medication, food
previous pregnancies
Other problems in previous pregnancies, History of surgery (other than CS)
labours and puerperium
Breech or transverse presentation Sexually transmitted diseases
Duration of exclusive breast feeding HIV status if known
Infant weight of <2.5 kg or> 4 kg History of blood transfusion
IUGR Blood group
Twins History of trauma/accident
Perinatal, neonatal, fetal death Status of tetanus immunization
Socio-economic History
Marital status, number of times married and Number of family members helping at home
age of marriage(s)
Occupation and daily activities Decision maker in the family
Occupation of the spouse Maternal and family responses to pregnancy
and labor preparedness
Education Options of place for delivery
Income (if possible) Housing
Eating or drinking habits Sanitation conditions
Ethnic group Electricity
Smoking, use of recreational drugs and Cooking facilities
alcohol
Sexual life, history of casual sex
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10.2 Performing an Obstetric Examination
General physical examination at the first visit:
General status, appearance, co-operativeor not
Face: is there palpebral edema or pallor
Eyes, mouth and dental hygiene, caries, thyroid
Vital signs: (blood pressure, body temperature, pulse rate, respiratory rate)
Body weight
Height
Mid Upper arm circumference (MUAC)
Heart, lungs, breast (if there are lumps), nipples, abdomen (surgical scar), spine,
extremities (edema, varicose veins, patellar reflex), as well as cleanliness of the skin.
Measure mid-upper arm circumference (MUAC)

Measure the MUAC just before or just after checking the blood pressure
Use a soft tape-measure, as for symphysis-fundal height
Measure the MUAC at any gestation, or during or after labour
Measurethearmcircumferenceineithertherightorleftarm,midwaybetweenthetipoftheshoulder(ac
romion)and the tip of the elbow (olecranon)
Record the measurement to the nearest 1 mm
The arm should hang freely (elbow extended)
Record the MUAC on the antenatal card
An MUAC 33 cm:
Suggests obesity
Is associated with an increased risk of pre-eclampsia and maternal diabetes
Is associated with an increased risk of delivery of a larger than normal infant
Indicates that blood pressure measurement with a normal-sized adult cuff may be an
overestimation
An MUAC<23 cm:
Suggests undernutrition or a chronic wasting illness
Is associated with delivery of a smaller than normal infant
Breast Examination
Visual Inspection of the Breasts
- Help the woman prepare for examination
- Ask the woman to uncover her body from the waist up.
- Have her remain seated with her arms at her sides.
- Visually inspect the overall appearance of the womans breasts, such as contours,
skin, and nipples; note any abnormalities.
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Contours are regular with no dimpling or visible lumps.
Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no
lesions, sores, or rashes.
Normal variations:
- Breasts may be larger (and more tender) than usual.
- Veins may be larger and darker, more visible beneath the skin.
- Areolas may be larger and darker than usual, with tiny bumps on them.
Nipples - There is no abnormal nipple discharge.

Nipples are not inverted.
Normal variations:
- Nipples may be larger, darker, and more erectile than usual.
- Colostrum (a clear, yellowish, watery fluid) may leak spontaneously from nipples
after 6 weeks gestation.
- Place the thumb and fingers on either side of the areola and gently squeeze.
- If the nipple goes in when it is gently squeezed, then it is inverted.
Palpation
Palpation of both breasts with the flat of the hand and then with the fingers while the woman
in the sitting position, and thenwhen she is lying down/supine.
Palpate the axillary and supraclavicular nodeslymph nodes.
Obstetric physical examination at the first visit:

- Shape of abdomen (note any surgical scars)
- Fundal height
Vaginal Examination
- Vulva/perineum to check for presence of varicose veins, condylomata, edema,
hemorrhoids, or other abnormalities.
- Speculum examination to assess cervix, signs of infection, and fluid from the uterine os.
- Vaginal examination to assess: cervix*, uterus*, adnexa*, Bartholins, urethral, Skenes
glands (*when gestational age is <12 weeks). This is usually not carried out in Indonesia.
Obstetric physical examination at each subsequent visit:

- Monitor fetal growth and development by measuring uterine fundal height (Table 4).
Palpate abdomen using Leopolds maneuvers I-IV as shown below:

Leopold I: determining uterine fundal height and fetal parts located in the uterine fundus
24
(carried out since the early first trimester).
Leopold II: determining position of the fetal back (performed by the end of second trimester).
Leopold III: determining fetal parts located at the bottom ofthe uterus (carried out by the end
of second trimester).
Leopold IV: determining how far fetus enters the pelvis (doneat the end of the second
trimester).
Auscultate fetal heart rate using a fetoscope or Doppler (ifgestational age is > 16 weeks).
Assessment of fetal heart rate with a fetoscope can be started around 20week of gestation.
With the help of ultrasonic Doppler fetal heart beating can be detected between 14 and 20
weeks of gestation.
Assessment of fetal heart with fetoscope (Pinard stethoscope)

The best place to hear the fetal heart is through the fetal back. It is better to assess the fetal
heart beat after determining the fetal lie, position and presentation. If the position of the fetus
seems to be left occipital anterior the wide end of the Pinard stethoscope should be placed at
about half way between the umbilicus and the symphysis pubis and about 5 cm to the left. If
presentation of the fetus is breech, the stethoscope should be placed above the umbilicus.
Position the bell end of the stethoscope over the place on the maternal abdomen under which
the baby's back is felt.
Apply the ear to the flat end. Apply gentle pressure and indent the abdomen nearly a
centimeter, depending on the thickness of the abdominal wall.
Take your hand away from the stethoscope and listen. You are listening for a sound that feels
more like a vibration than a sound, or something similar to watch ticking under a pillow. If you
hear a slow shooching noise, feel the maternal pulse at the same time and if it coincides
with the shooching you are hearing the uterine vessels.
Normal fetal heart rate is regular, with a range is 120-160 beats per minute.
25
Table 4: Estimated uterine fundal height
Gestational age Uterine Fundal Height
By Palpation By Tape Measure

Palpable above the pubic
12 weeks
symphysis
In between the pubic
16 weeks -
symphysis and umbilicus
At the umbilicus (20 2) cm
20 weeks
(Gestational age in weeks

22-27 weeks
2) cm
in between the umbilicus and
28 weeks (28 2) cm
the xiphoid process
(Gestational age in weeks
29-35 weeks
2) cm
36 weeks At the xiphoid process (36 2) cm
Adapted from Pocket Book of Maternal Health Care Final Draft (Department of Obstetrics
and Gynaecology, Faculty of Medicine, University of Indonesia and WHO, Indonesia)
Figure 1: Uterine height values by weeks of gestation

Belizan, J et al American Journal of Obstetrics and Gynaecology (1978)
26
Leopold Maneuvres: I, II, III and iV
11. Teaching and Learning Materials
11.1 Group Discussion

11.1.1 Group Exercise: Use of pregnancy calculator
Divide students into groups.
Give groups examples: Exercises for Calculating Expected Date of Delivery
(EDD) of LMP dates.
Give instructions to participants to provide gestation and EDD.
Ask one representative of each group to write the answer on the board.
27
1. Mrs. A. comes to the antenatal clinic on 3 January. She tells you that her last normal
menstrual period started on 10 October. How many weeks pregnant is she? What is her
EDD?
2. Mrs. B. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?
3. Mrs. C. comes to the antenatal clinic on July 11. She tells you that her last normal
menstrual period started on 6 March. How many weeks pregnant is she? What is her EDD?
4. Mrs. D. comes to the antenatal clinic on 15 May. She tells you that her last normal
menstrual period started on 1 January. How many weeks pregnant is she? What is her EDD?
5. Mrs. E. comes to the antenatal clinic for first visit on 20 April. She tells you that her last
normal menstrual period started on 10 November. How many weeks pregnant is she? What is
her EDD?
6. Mrs. F. comes to the antenatal clinic for the first time today, 14 June. This is her first
pregnancy. She does not have regular menses and does not remember when she had her
last menses. She does remember that she felt some breast changes and nausea at the
beginning of March and the baby began moving yesterday. On examination you measure her
uterus at 1 cm below the umbilicus and you hear the fetal heart at 156 beats/min.
Approximately how many weeks pregnant is she and when will her date of delivery be?
(From Best Practices in Maternal and Newborn Care - A Learning Resource Package for
Essential and Basic Emergency Obstetric and Newborn Care - 2008 (JGPIEGO USAID-
ACCESS)
11.1.2 Discussion: Birth and emergency preparedness plan

Divide into groups of four to discuss birth and emergency preparedness plans displayed in
PowerPoint slide.
Reassemble and discuss answers in large group.
Discuss reasons for having a Birth and Emergency Readiness Plan. What do you
understand bythe Three Delays?
28
11.2Case-based Learning Case Triggers
Case Study 1: Focused Antenatal Care

Directions
Read and analyze this case study individually. When the others in your group have finished
reading it, answer the case study questions. The other groups in the room are working on the
same or a similar case study. When all groups have finished, we will discuss the case studies
and the answers each group developed.
Client Profile
A 29-year-old pregnant woman called Sara comes to see you. She tells you that this is her
third pregnancy and the last time she had her menstrual period was 25 weeks ago.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Sara?
Assessment (Information gathering through history, physical examination and

testing)
2. What history will you include in your assessment of Sara, and why?
3. What physical examination will you include in your assessment of Sara, and why?
4. What laboratory tests will you include in your assessment of Sara, and why?
Discuss the three questions with the tutor who will provide additional information
related to Sara.
5. Based on these findings, what is Sara's diagnosis, and why?
Care Provision (Implementing plan of care and interventions)
6. Based on your diagnosis (problem/need identification), what is your plan of care for Sara,
and why?
Discuss the issues with the tutor.
Evaluation
Sara comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is
120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 32-
week size. What do these signs suggest and what actions would you take?
Sara says that she would like to space her pregnancy and may consider not to have further
29
children after this delivery. Previously she has not used a modern method of contraception
but the pregnancies were spaced by breastfeeding.
7. Based on these findings, what is your continuing plan of care for Sara?
Discuss your plan of care with the tutor and how counseling will be provided on family
planning.
Discuss method options for the postpartum woman.
(Reference: Pregnancy, Childbirth, Postpartum and Newborn Care, WHO, 2006,

Decision-making tool for family planning providers and clients, WHO and JHPIEGO, 2007)
Case Study 2: Health education for women following the basic component of Focused
Antenatal Care
Trigger
Nina, a 20 year-old married woman in her first pregnancy comes for her first antenatal visit at
16 weeks. She is found to be eligible to follow the basic component of focused antenatal care
(FANC). What health education will you give her?
Discuss issues on health education with your tutor.
Trigger
Nina and her husband want to know more about diet in pregnancy. They belong to the
middle-income group and they do not have any food taboos. How will you advise them?
Discuss with your tutor the points on nutrition that you would discuss with Nina and
her husband.
11.3 Problem-based Learning Case Triggers
Case Study 1: Counselling for HIV Testing During Antenatal Care

Trigger
Marina, a 24 year-old married woman in her first pregnancy comes for her first antenatal visit
at 14 weeks. She has recently moved to this area.
Discuss with your tutor the points you will focus on when taking her history.
While obtaining an obstetric history, Marina mentions that she has lived in another part of
Indonesia and that her husband is a long-distance truck driver. You realize that Marina
30
resided in an area where STI and HIV prevalence is above the national prevalence and that
her husbands occupation could have exposed him to casual sex.
Based on her history, what will be included in your interventions/supporting tests?
Outcome:
Marina comes back with the test results which are both negative
The speculum examination is also normal.
Discuss with your tutor on post-test counseling for Marina.
How would you proceed if Marina had refused to be tested?
If Marina had tested positive for syphilis or HIV, how would you proceed with care
provision?
Discuss with your tutor on the plan of care for Marina.
Case Study 2: Antenatal Assessment and Care(Anaemia)

Directions
Read and analyze this case study individually. When the others in your group have finished
reading it, answer the case study questions. The other groups in the room are working on the
same or a similar case study. When all groups have finished, we will discuss the case studies
and the answers each group developed.
Client Profile
Mrs. B., a 26-year-old gravida 3/para 2, presents for her first antenatal clinic visit. Her children
are 18 months and 8 months of age. Both are well. She and her family live in a rural village
that is in a malaria-endemic area. You note that Mrs. B. looks pale and tired.
Pre-Assessment
1. Before beginning your assessment, what should you do for and ask Mrs. B.?
Assessment (Information gathering through history, physical examination and testing)

2. What history will you include in your assessment of Mrs. B., and why?
3. What physical examination will you include in your assessment of Mrs. B., and why?
4. What laboratory tests will you include in your assessment of Mrs. B., and why?
Discuss what you will focus on in your assessment of Mrs B.
31
Testing: Hemoglobin is 9 g/dL Other test results: RPR non-reactive; HIV negative;
blood type - O, Rh-positive.
5. Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?
Care Provision (Implementing plan of care and interventions)
6. Based on your diagnosis (problem/need identification), what is your plan of care for
Mrs. B., and why?
Evaluation
Mrs. B. comes back to the antenatal clinic on the appointed date, and on assessment your
findings are as follows:
She has taken her iron/folate tablets as directed, even though she has had mild
constipation.
She has been able to rest more because her mother-in-law has provided more help
than usual. She also reports that her appetite has improved.
She appears less tired and is not as pale, generally, as she was at her first antenatal
visit. She says that she feels much better.
On physical examination, you find that she still has mild conjunctival pallor.
She does not have a fever.
The fetal heart rate is normal, and Mrs. B. says that the fetus is active.
Mrs. B.s hemoglobin is now 10 g/dL. It was also measured at the last visit.
7. Based on these findings, what is your continuing plan of care for Mrs. B.?
(Reference: Best Practices in Maternal and Newborn Care: Learning Resource Package:
Prevention and Management of Malaria and Other Causes of Fever in Pregnancy)
11.4Knowledge Assessment
11.4.1Knowledge Assessment on Focused Antenatal Care:

Instructions: Which of the following statements is false? In each case, explain what is
incorrect.
1. Focused antenatal care focuses on the pregnant woman alone.
2. Women in the basic component receive only 4 FANC visits, unless warning signs or
symptoms are detected at any stage.
3. Pregnant women do not need to prepare any equipment for labour and delivery.
4. The birth plan in FANC is essentially the same for every woman and she is told about it at
the fourth visit.
32
5. Prophylaxis in FANC focuses on prevention of sexually transmitted infections, including
mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia and tetanus.
11.4.2 Knowledge Assessment:
Prevention and Management of Malaria and Other Causes of Fever In Pregnancy
Instructions: Write the letter of the single best answer to each question in the blank next to
the corresponding number on the attached answer sheet.
1. Malaria affects:
a. Nearly as many people as TB and HIV combined
b. Twice as many people as TB, HIV, leprosy and measles combined
c. Five times as many people as TB, HIV, leprosy and measles combined
2. In malaria-endemic areas, malaria during pregnancy may account for:

a. Up to 15% of maternal anemia
b. 514% of low birth weight
c. 30% of preventable low birth weight (LBW)
d. a) and b)
e. All of the above
3. Malaria prevention and control in pregnancy includes:

a. Focused antenatal care and health education
b. Intermittent preventive treatment (IPT)
c. Insecticide-treated nets (ITNs)
d. a) and c)
e. All of the above
incorrect.
4. Malaria is less severe in women during their first or second pregnancies than it is in
subsequent pregnancies.
5. In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.
6. Women who are HIV positive have increased resistance to malaria.
7. IPT should not be used during the first 16 weeks of pregnancy.
8. Quinine is the drug of choice for the treatment of complicated malaria.
Instructions:
Which of the following statements is false? In each case, explain what is incorrect.
33
4. Malaria is less severe in women during their first or second pregnancies than it is in
subsequent pregnancies.
5. In areas of unstable malaria transmission, malaria in pregnancy is often asymptomatic.
6. Women who are HIV + have increased resistance to malaria.
7. IPT should not be used during the first 16 weeks of pregnancy.
8. Quinine is the drug of choice for the treatment of complicated malaria.
11.4.3Knowledge Assessment:
Preventing Mother-To-Child Transmission of HIV

1. A key risk factor for mother-to-child transmission of HIV is:
a. High viral load of the mother
b. Advanced age of the mother
c. Parity of the mother
2. Some intrapartum interventions to reduce the risk of MTCT include:

a. Using good infection prevention measures
b. Avoiding artificial rupture of membranes and unnecessary trauma
c. Avoiding prolonged rupture of membranes
d. a) and b)
e. All of the above
incorrect.
3.Counseling to prevent acquiring HIV is important for HIV-negative women but not for HIV-
positive women.
4. ARVs should be provided during pregnancy for the health of the baby but not for the
mother.
5. There is no evidence of increased MTCT from vaginal rather than C-section delivery if
appropriate ARVs are used and the viral load is controlled.
6. MTCT is less likely if exclusive breastfeeding rather than mixed feeding is used.
7. For HIV survival, all women for whom replacement feeding is not acceptable, feasible,
affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed
their infant for 6 months.
34
11.4.4 Knowledge Assessment:
Postpartum family planning

1. Appropriate timing for postpartum family planning counseling includes:

a) 6 weeks postpartum
b) Immediate postpartum
c) Antenatal
a) and b)
All of the above
2. The criteria for LAM are:

a) Fully or nearly fully breastfeeding, less than 4 months postpartum, menses have not
returned, and baby still feeds at least once during the night
b) Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses have not
returned
c) Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses have not
returned
3. IUDs can be inserted:

a) Within 24 hours and after 6 weeks postpartum
b) Within 24 hours and after 4 weeks postpartum
c) Within 48 hours and after 4 weeks postpartum
d) Post-placental only (within 10 minutes of delivery) and after 6 weeks postpartum
4. IUD use:
a) Is associated with infertility
b) Increases risk of PID
c) is contraindicated in any woman who is HIV+
d) None of the above
e) All of the above
Instructions: In the space provided, print a capital T if the statement is true or a capital F if
the statement is false.
6. The breastfeeding woman can begin oral progestin-only pills at 6 weeks after delivery.___
7. Combined oral contraceptives can be used by non-breastfeeding women at 3 weeks
postpartum.______
8. IUDs and hormonal contraception may increase the risk of acquisition of HIV.
35
9. LAM provides 98% protection from pregnancy. _____
10. Fertility awareness methods (such as Standard Days Method) can be started at 6
weeks postpartum for both breastfeeding and non-breastfeeding women. _____
11. Vasectomy is not effective immediately, so the use of a backup contraceptive method
for 1 month after the procedure is recommended. _____
12. IUDs are the most cost-effective reversible method if used for 2 years or more.____
(Reference: Best Practices in Maternal and Newborn Care Learning Resource Package
JHPIEGO)
36
11.5 Checklists
11.5.1 Checklist for Focused Antenatal care
First Visit
Antenatal Assessment (History, Physical Examination, Testing) and Care
(To be used by the Facilitator/Teacher at the end of the module)
Rate the performance of each step or task observed using the following rating scale:
1 Needs Improvement: Step or task not performed correctly, performed out of sequence (if
sequence necessary), or omitted
2 Competently Performed: Step or task performed correctly and in proper sequence (if
sequence necessary), but learner does not progress from step to step efficiently
3 Proficiently Performed: Step or task performed correctly, in proper sequence (if sequence
necessary), and efficiently
Learner------------------------------------------------- Date Observed----------------

Antenatal Assessment First Visit
(History, Physical Examination, Testing) and Care.
Some of the following steps/tasks should be performed simultaneously
Step/Task Cases
Getting Ready
1. Prepare the necessary equipment.
2. Greet the woman respectfully and with kindness and introduce
yourself.
3. Offer the woman a seat.
4. Tell the woman what is going to be done, listen to her and
encourage her to ask questions.
5. Provide reassurance and emotional support as needed.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
History
1. Ask the woman how she is feeling and respond immediately to
any urgent problem(s).
2. Ask the woman her name and age
3. Ask the woman number of previous pregnancies and
37
breastfeeding (number of children, mode of delivery)
4. Ask the woman menstrual history including LMP and
contraceptive history.
5. Calculate the EDD and gestational age.
6. Ask the woman whether she has felt fetal movements within the
last day (if visit is after 16 weeks).
7. Ask the woman about medical conditions, medications and
hospitalizations, including HIV status if known.
8. Ask woman about daily habits, lifestyle, social support and
traditional beliefs and customs.
9. Ask the woman about tetanus immunization.
10. Ask the woman if she is using treated bed nets at all times (in
malarious areas).
11.
Askthewomanaboutotherproblemsorconcernsrelatedtoherpregnancy.
12. Record all pertinent information on the womans record/antenatal
card.

Physical Examination
1. Ask the woman to empty her bladder and save and test the urine.
2. Observe the womans general appearance.
3. Help the woman on to the examination table and place a pillow
under her head and upper shoulders.
4. Wash hands thoroughly with soap and water and dry them.
5. Explain each step of the physical examination to the woman.
6. Take the womans blood pressure, temperature and pulse.
7. Measure mid-upper arm circumference.
8. Check her heart and respiratory system
9. Examine the breasts.
10. Measure/estimate fundal height.
11. Examine abdomen and determine lie and presentation (after 36
weeks).
12. Listen to the fetal heart (second and third trimesters).
13. Wash hands thoroughly with soap and water and dry.
14. Inform the woman about the speculum examination
15. Put examination gloves on both hands.
16. Check external genitalia for sores and/or swelling.
17. Check the vaginal orifice for bleeding and/or abnormal
38
discharge.
18. Check cervix for signs of cervicitis.
19. Immerse both gloved hands in 0.5% chlorine solution and
remove gloves, wash hands.
20. Summarize findings and explain to the woman.
21. Record all relevant findings on the womans antenatal card.

Pre-test counseling
Conduct pre-test counseling for HIV and syphilis

Screening Procedures
2. Draw blood and do hemoglobin, blood group and Rh, RPR and
HIV tests (if opt-in), interpreting results accurately.
3. Perform urinalysis for protein, sugar and bacteriuria
4. Empty and soak the test tubes in 0.5% chlorine solution for 10
minutes.
5. Dispose off needle and syringe in puncture-proof container.
6. Immerse both gloved hands in 0.5% chlorine solution and remove
gloves.
8. Record results on the womans antenatal card.
9. Discuss the findings with her.

Identify problems/needs
Identify the womans individual problems/needs, based on the
findings of the antenatal history, physical examination and screening
procedures.

Provide Care/Take Action
1.Treat the woman for syphilis if the RPR test is positive, provide
post-test counseling on HIV and safer sex, and arrange for referral if
HIV positive.
2. Provide tetanus immunization based on need.
3. Provide counseling about necessary self-care topics.
39
4. Provide counseling about the use of insecticide-treated bed nets.
5. Dispense other necessary medications such as iron and folate.
6. Develop or review individualized birth plan with the woman;
develop or review her emergency preparedness plan, including
danger signs.
7. Record the relevant details of care on the womans
record/antenatal card.
8. Ask the woman if she has any further questions or concerns.
9. Ask her if she wants to bring her husband or family member on
her next antenatal visit.
10. Thank the woman for coming and tell her when she should come
for her next antenatal visit.
Adapted from Best Practices in Maternal and Newborn Care Learning Resource Package
JHPIEGO USAID ACCESS (2008)
Subsequent Visits
Antenatal Assessment (History, Physical Examination, Testing) and Care
Antenatal Assessment Subsequent Visits

(History, Physical Examination, Testing) and Care.
Some of the following steps/tasks should be performed simultaneously
Step/Task Cases
Getting Ready
2. Greet the woman respectfully and with kindness and introduce
yourself.
4. Tell the woman what is going to be done, listen to her and
encourage her to ask questions.
5. Provide reassurance and emotional support as needed.
History
1. Ask the woman how she is feeling and respond immediately to
any urgent problem(s).
40
2. Verify her name and age
3. Check the EDD and gestational age.
5. Ask the woman about any medical conditions and medications.
6. Ask the woman if she is taking iron and folate.
7. Ask the woman if she is using treated bed nets at all times (in
malarious areas).
8. Ask her if there has been any change in her social situation since
the last visit.
9. Record all pertinent information on the womans record/antenatal
card.
2. Observe the womans general appearance.
6. Take the womans blood pressure.
7. Measure/estimate fundal height.
weeks).
9. Listen to the fetal heart (second and third trimesters).
11. Inform the woman about the findings.

Screening Procedures
2. Draw blood and do hemoglobin if less than 7 g/l at first visit.
3. Perform urinalysis for protein, sugar and bacteriuria
4. Empty and soak the test tubes in 0.5% chlorine solution for 10
minutes.
5. Dispose off needle and syringe in puncture-proof container.
41
6. Immerse both gloved hands in 0.5% chlorine solution and remove
gloves.
8. Record results on the womans antenatal card and discuss them
with her.
Identify problems/needs
Identify the womans individual problems/needs, based on the
findings of the antenatal history, physical examination and
supportingtests/procedures.
Provide Care/Take Action

1. Provide counseling about necessary self-care topics.
2. Provide counseling about the use of insecticide-treated bed nets.
3. Dispense other necessary medications such as iron and folate.
4. Review individualized birth plan with the woman.
5. Review her emergency preparedness plan
6. Discuss signs of onset of labour
7. Discuss danger signs in pregnancy
8. Discuss postpartum family planning
9. Discuss self-care in post-partum period
10. Discuss breast feeding
11. Discuss care of the newborn
12. Record the relevant details of care on the womans
record/antenatal card.
13. Ask the woman if she has any further questions or concerns.
14. Thank the woman for coming and tell her when she should come
for her next antenatal visit.
42
11.5.2 Checklist for birth and emergency preparedness plan
To refer to 11.1.2 Birth and emergency readiness plan
Check List- Birth and emergency preparedness plan

Item Yes No
The discussion between the provider and the pregnant woman, her husband and
family includes: The provider
1. At the first visit, explains why abirthplan(including emergency/complication
readiness) is important
2. Advises her to have delivery in a health facility (puskesmas or district
hospital).
3. Advises that if she decides to deliver at home, the birth should be attended
by a skilled birth attendant
4. Assists the woman in choosing the appropriate healthcare facility (e.g.,
district hospital, health center)
5.Assists the woman in identifying a skilled birth attendant/provider
6. Ensures that the woman is familiar with local transportation systems
7. Checks that she has transportation to an appropriate place for the birth
based on her individual needs.
8. Assists the woman in planning to have funds available when needed to pay
for care during normal birth.
9. For emergency/complication preparedness, discuss emergency funds that
are available through the community and/or healthcare facility if danger signs
arise.
10. Discusses how decisions are made in the womans family. (who usually
makes decisions?)
11. Assists the woman in deciding the
companionofherchoicetostaywithherduringlaborandchildbirth,and accompany
her during transport if needed.
12. Assists the woman in making arrangements for
someonetocareforherhouseandchildrenduringher absence.
13. Ensures that the woman has identified an appropriate blood donor and that
this person will be available in case of emergency.
14. Ensures that the woman knows the danger signs which indicate a need to
enact the emergency/complication readiness plan.
15. Ensures that she knows the signs of labour
During Visits at 32 weeks and after thatthe discussion between the provider and the
pregnant woman, her husband and family includes: The provider
43
Item Yes No
16. Checks that the woman and family have finalized thebirthplan.
17. Checks what arrangements have been made since the last visit? (Has
anything changed? Have any obstacles or problems been encountered?)
18. Ensures that the woman knows the danger signs which indicate a need to
enact the emergency/complication readiness plan.
19. Makes sure the woman has gathered necessary items for a clean and safe
birth
20. Makes sure the woman has gathered necessary items for the newborn
11.5.3 Checklist for demonstration of breast feeding

The tutor can use the checklist to assess if the student/trainee can demonstrate the technique
of breastfeeding. The student/trainee can also use the checklist as a guide to demonstrate
the technique of breastfeeding.
Item Yes No
Positioning The mother is comfortable with back and arms supported.
Babys head and body are aligned; babys abdomen is

turned toward the mother.
Babys face is facing the breast with nose opposite nipple.
Babys body is held close to the mother.
Babys whole body is supported.
The baby is brought to the nipple height.
Holding The mother maysupporttheweightofher breast with her
hand and shape her breast by putting her thumb on the
upper part, so that the nipple and areola are pointing
toward the babys mouth; OR
Shemaysupportthebreastbyplacingher fingers flat against
the chest wall, while bringing the baby to her breast to
suckle.
Attachment Nippleandareolaaredrawnintothebabys mouth rather than

and Suckling only the nipple into the mouth.
Thebabysmouthiswideopen;lowerlipis curled back below
base of nipple.
Thebabys chin touches the mothers breast
Thebabytakesslow,deepsucks,oftenwith visible or audible
swallowing.
Thebabypausesfromtimeto time.
The baby may make smacking sounds.
44
Mother Mother does not complain of, or appear tohave,
comfort nipple/breast pain during the breastfeed.
Finishing the The newborn should release the breast her/himself rather
breast feed than being pulled from the breast.
Feeding may vary in length, anywhere from 4 to 40
minutes per breast.
Breasts are softer at the end of the feed compared to full
and firm at thebeginning.
Newborn looks sleepy and satisfied atthe end of a feed.
Burp the baby at the end of the feed
45
11.6 Learners Guide:
11.6.1 Learners Guide: Antenatal Assessment -Taking an Obstetric History

The Guide can be used by the student/trainee.
The Facilitator/Teacher can use the Guide at the end of the module and grade the
performance of the student/trainee.

Step/Task Case Case Case
Preamble
1. Prepare the necessary documents.
2. Greet and welcome the woman and introduce yourself
3. Ask her if someone is accompanying her, if so invite her
companion
5. Explain that you will proceed with a history taking and obtain
consent
6. If you are a male student, you may want to ask a nurse or a fellow
female student to be present during the history taking.
7. Make sure you have drawn the curtains to ensure privacy.
Introductions
1. Ask her name, age, address, phone number.
2. Ask her husbands name
3. Observe the womans general appearance and whether she is
cooperative or not.
Menstrual History
1. Ask her the first day of last menstrual period
2. Ask her if her menstrual cycle is regular and the length of each
cycle.
3. Calculate the expected date of delivery
4. Calculate thematurity by dates
46
Current Pregnancy History
1. Ask her if she noticed any leucorrhea
2. Ask her if she experienced nausea and vomiting
3. Ask her if she had any vaginal bleeding
4. Ask her if she experienced other problems/abnormalities
5. Ask her if she has usedmedication, traditional medicine and herbs
Previous Obstetric History
1. Ask her the number of pregnancy/pregnancies
2. Ask her the number of delivery/deliveries
3. Ask her the number of labours at term, preterm labours
4. Ask her the mode of delivery
5. Ask her the number of living children, birth weight, and sex
6. Ask her the number of miscarriage, abortion
Note: The obstetric history is usually entered in a tabular form,
see following section.
7. Ask her if she had bleeding in previous pregnancy, labour and
puerperium
8. Ask her if she had hypertension, pre-eclampsiain previous
pregnancies
9. Ask if she had abnormal presentations such as breech or
transverse presentation
10. Ask her if she had other problems in previous pregnancies,
labours and puerperium
11. Ask her if she breast fed her babies and if so, the duration of
exclusive breast feeding
Note: If she mentioned any of the above problems in 7,8,9 or if
she had a C.S., further details need to be elicited. See the
subsequent table.
12. Ask if any of the babies weighed<2.5 kg or> 4 kg
13. Ask her if any baby was small for gestational age (IUGR)
14. Ask if she has delivered twins or triplets, etc
15. Ask if any of her babies had a perinatal, neonatal or fetal death
Note: If she experienced a perinatal, neonatal or fetal death, further details need to be
elicited. See the subsequent table.
Gynaecological (including previous contraceptive) History
1. Ask for history of contraception before pregnancy
2. Ask if she had any surgical procedures
47
3. Ask if there were period(s) of infertility: If so, when? For how long?
and if she knew the reason cause?
Medical History (ask for the following conditions)
1.Known/diagnosed heart disease
2.Hypertension
3.Diabetes mellitus (DM)
4.Liver diseases such as hepatitis
5.Tuberculosis (TB)
6.Chronic renal disease
7.Malaria
8.Asthma
9.Epilepsy
10.Any regular medication prior to pregnancy and continuing during
pregnancy
11.Any allergy to medication, food
12.History of surgery (other than CS)
2
13.Sexually transmitted diseases
14.HIV status if known
15.History of blood transfusion
16.Blood group
17.History of trauma/accident
18.Status of tetanus immunization
Family History
1. Ask her if her parents had Diabetes mellitus
2. Ask her if her parents had Hypertension
3. Ask her if her mother, her sister or herself hadmultiple or higher
order pregnancy
4.Ask if there is a history of congenital abnormalities in her family
Socio-economic History Ask her
1.Marital status, number of times married and age of marriage(s)
2.Her occupation and daily activities
3.Education level
4.Income (if possible)
5.The husbands occupation and income
6.Eating or drinking habits
7.Ethnic group
8.Religion
2
The student could ask this point later after obtaining the social history and if the student feels
that the woman could be at increased risk of STI
48
9.Smoking, use of recreational drugs and alcohol
10.Sexual life, history of casual sex
11.Beliefs, perceptions or concerns regarding pregnancy or labour
12.Number of family members helping at home
13.Birth and emergency preparedness plans
14.Who is the decision maker in the family
15.Options of place for delivery
16.Housing
17. Sanitation conditions
18.Electricity
19.Cooking facilities
Thank her and explain that you will be examining her next
To ask in more detail if the following were mentioned in the obstetric history. Only the
more common conditions are covered.
Antepartum haemorrhage
At which month of pregnancy did she bleed?
Was it associated with pain?
Was it repeated and recurrent?
Did she need blood transfusion; if yes, how many units?
Did she need a surgical operation for the bleeding?
Did she have any complications afterwards?
What was the condition of the baby?
Post-partum Haemorrhage
When did she start to bleed?
Did she need blood transfusion; if yes, how many units?
Did she need a surgical procedure for the bleeding?
Pre-eclampsia
At which month of pregnancy did she have high blood pressure?
Was the urine tested for protein?
Did she have fits?
Did she have headache, blurred vision, abdominal pain?
Did she have a spontaneous delivery or was it induced?
Did she need a surgical procedure?
What was the condition of the baby?
History of caesarean section
49
Why was the operation done?
Where was the operation done?
Who performed the operation?
What was the outcome of the baby?
Did she have any complications after the operation?
History ofperinatal, neonatal or fetal death
What was the gestational age of the baby?
Was her antenatal period normal or were there complications?
Were the laboratory investigations normal?
Did she have medical conditions complicating pregnancy? What
treatment did she receive?
Did she have preterm labour or premature rupture of the
membranes?
Did she have spontaneous labour or was it induced?
Was the labour prolonged?
Did she have a normal delivery or assisted vaginal delivery or an
operation (LSCS)?
What is the birth weight of the baby?
Did the baby cry at birth?
Did the baby have any visible abnormalities?
Did the baby need resuscitation?
Was the baby admitted to a special care unit?
Did you breastfeed the baby?
At what age did the baby die?
Do you know what treatment was given to the baby?
What was the reason for the babys death?
History Taking at subsequent visits
After greeting her and asking her to sit down

How she is feeling since her last visit?
Are there are any concerns or complaints e.g. bleeding?
Are there any changes in her personal history since theprevious
visit?
Has she taken medication other than iron-folate, herbal medicines
Has she had other medical consultations, hospitalization?
Does she notice fetal movement? When did she first notice them?
Check on habits e.g. smoking
Has she decided where she will deliver?
50
If home delivery, has she identified the midwife who will assist her?
Check her birth and emergency preparedness plans.
Has she had any pain or bleeding?
11.6.2 Learners Guide: Antenatal Assessment - Physical Examination

The Guide can be used by the student/trainee.
The Facilitator/Teacher can use the Guide at the end of the module and grade the
performance of the student/trainee.

Following obstetric history taking, the student/trainee will proceed with an obstetric
examination: the general examination, examination of the cardiovascular and respiratory
system and breast examination. The student/trainee may also need to perform a speculum
examination.
(The general examination and examination of the cardiovascular and respiratory system will
not be elaborated here)
Because of the sensitive nature of these examinations, developing rapport with the patient is
extremely important.
Preamble
2. Explain that you will proceed with a physical examination and
obtain consent
3. If you are a male student, you may want to ask a nurse or a fellow
female student to be present during the examination.
4. Make sure you have drawn the curtains to ensure privacy.
51
2. Observe the womans general appearance and gait.

6. Conduct a general examination: check eyes for anaemia,
palpebral edema, tongue, thyroid
7. Take the womans blood pressure, temperature and pulse.
8. Measure the Mid-upper arm circumference (MUAC) just before
or just after checking the blood pressure
8.1 Use a soft tape-measure
8.2 Measure the arm circumference in either the right or left arm,
midway between the tip of the shoulder (acromion)and the tip of the
elbow (olecranon)
8.3 The arm should hang freely (elbow extended)
8.4 Record the measurement to the nearest 1 mm
8.5 Record the MUAC on the antenatal card or in the labour ward
admission notes
9. Expose her chest and check her heart and respiratory system.
10. Examine the breasts.
10.1 Inspection: skin, contour
10.2 Protraction or retraction of nipple
10.3 Expression of the nipple
10.4 Palpation of both breasts in the sitting and supine positions
10.5 Palpation of the breasts with the flat of the hand and then with
fingers
10.6 Palpation of the lymph nodes, including axillary and
supraclavicular nodes
10.7 Cover the chest and breasts
11. Abdominal examination
Tell the woman that you will proceed with an abdominal
examination. Expose the abdomen adequately (put a cover sheet to
the lower part of abdomen)
12. Inspection
- Note apparent size of abdominal distension
- Note any symmetry
- Note any fetal movements
52
- Note cutaneous signs of pregnancy linea nigra, straie gravidarum,

straie albicans, flattening/eversion of umbilicus
- Note any prominent superficial veins
- Note any surgical scars
(Note: Pfannenstiel scar may be obscured by pubic hair,
laparoscopy scars hidden within the umbilicus)
13. Measure/estimate symphisio-fundal height.
- palpated < 20 weeks
- measured in cm if more than 20 weeks put the end of the tape
measure to the symphiyis and bring it up to the fundus.
weeks).
14.1 Leopold I (Fundal grip) determining uterine fundal height and
fetal parts located in the uterine fundus (carried out since the early
first trimester).
14.2 Leopold II: determining position of the fetal back (performed by
the end of second trimester).
14.3 Leopold III: determining fetal parts located at the bottom of the
uterus (carried out by the end of second trimester).
14.4 Leopold IV: determining how far fetus enters the pelvis (done at
the end of the second trimester).
15. Assess amount of liquor (second and third trimesters)
Note: during the examination, maintain eye contact with the woman from time to time
16. Determine where the fetal back is and listen to the fetal heart
(second and third trimesters).
17. Check extremities for oedema.
18. Cover the womans abdomen and help her sit up
20. Explain/summarize the findings
If bivalve (Cuscos) speculum examination will be done: after

step 15 of obstetric examination
1. Cover the womans abdomen
2. Inform the woman about the speculum examination and the
purpose. Explain that shemight feel a little discomfort and that the
examination should be over fairly quickly. If they have any questions
or concerns then answer them.
53
3. Obtain consent
Note: Make sure that Point 2 and 3 of Preamble are in place
Make sure all equipment are ready: spot lamp, speculum, KY
jelly, swabs etc). Turn on the spot lamp to the examination site.
4. Ask her to raise her legs in the dorsal position
5. Cover her legs and lower abdomen with drapes
6. Wash hands
Note: Swab the external genitalia
Talk to the woman while you are examining her
8. Inspection: Check external genitalia
8.1 Check for any swelling, inflammation
8.2 Check for skin changes
8.3 Check for ulcers, lesions
8.4 Check the vaginal orifice for bleeding and/or abnormal
discharge.
9. Check if there are any haemorrhoids
10. Speculum introduction and examination
Note: Tell her you will be introducing the speculum
Insert an appropriate sized speculum, you may need to warm the
speculum. Swab the external genitalia.
10.1 The Labia minora are parted with left hand
10.2 Insert the closed speculum, upwards and backwards
10.3 Advance into vagina fully
10.4 Direct visualization as blades open to expose cervix
10.5 if cervix is not seen, close blades, withdraw slightly, change
direction and open again
10.6.Take swabs if there is vaginal discharge as required
10.7 Check for vaginal abnormalities, e.g. septum
10.8 Check cervix: normal or signs of cervical lesions, tumour
10.9 Speculum removal: ensure blades are open while sliding over
cervix
10.10 Partially close blades while withdrawing the speculum and
inspect vaginal walls
10.11 Blades should be closed at introitus, not trapping any vagina
11. Cover the womans thighs with drapes
12. Immerse both gloved hands in 0.5% chlorine solution and
54
remove gloves, wash hands.

13. Remove drapes, help her to get up and get dressed
14. Ask her to sit down
15. Summarize findings and explain findings to the woman.
Inform her if the findings are normal or if any conditions/
abnormalities were detected
55
11.7Counseling Guide for Post-partum Family Planning Postpartum IUD
Place a Yes in case box if task/activity is performed satisfactorily, an X if it is not performed satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the
standard procedure or guidelines Not Observed: Step, task or skill not performed by learner during evaluation by trainer
Learner Date Observed----------------------
COUNSELLING ON PPIUD SERVICES
ITEM STEP/TASK ASSESSMENT

GREETEstablish good rapport and initiate counseling on PPFP.
1. Establishes a supportive, Greets the woman, using her name and introducing self.
trusting relationship
Shows respect for the woman and helps her feel at ease.
2. Allows the woman to talk and Encourages the woman to explain her needs and concerns and ask questions.
listens to her. Listens carefully and supports the womans informed decisions.
3. Engages womans family Includes womans partner or important family member in the discussion, as the woman desires and
members. with her consent.
ASKDetermine reproductive intentions, knowledge of pregnancy risk and use of various contraceptives.
4. Determines any previous Explores womans knowledge and beliefs about the return of fertility and the benefits of pregnancy
56
experiences with family planning. spacing or limiting (as desired).
Asks whether she has had prior experience with family planning methods, any problems, reasons for
discontinuing, etc.
5. Assesses partner/family Explores partners/familys knowledge and beliefs about the return of fertility and the benefits of
attitudes about family planning. pregnancy spacing/limiting.
6. Assesses reproductive Asks about desired number of children, desire to space or limit births, desire for long-term family
intentions. planning, etc.
7. Assesses need for protection Explores womans need for protection from STIs, including HIV.
against sexually transmitted
infections (STIs). Explains and supports condom use, as a method of dual protection
8. Determines interest in a Asks whether she has a preference for a specific method based on prior knowledge.
particular family planning method.
TELLProvide the woman with information about PPFP methods.
9. Provides general information Advises that to ensure her health and the health of her baby (and family), she should wait at least 2
about benefits of healthy years after this birth before trying to get pregnant again.
pregnancy spacing (or limiting, if
desired). Advises about the return of fertility postpartum and the risk of pregnancy. Advises how LAM and
breastfeeding are different.
57
Advises about the health, social and economic benefits of healthy pregnancy spacing (or limiting, if
desired).
Note: For item 10, if the woman and husband already have a method in mind which is suitable to be used during the post-partum period, the provider may wish to
discuss on the method of choice and LAM and might not need to provide information on other methods that can be used during the post-partum period. The
explanations on the methods should be made in simple, easy-to-understand language.
10. Provides information about Based on availability and on womans prior knowledge and interest, briefly explains the advantages,
PPFP methods. limitations and use of the following methods:
LAM
Condoms
POPs
DMPA (injections)
- PPIUD
- No-scalpel vasectomy (male sterilization)
- Postpartum tubal ligation (female sterilization)
Shows the methods (using poster or wall chart or flip chart) and allows the woman to touch or feel the
items, including the IUD, using a contraceptive tray.
58
Corrects any misconceptions about family planning methods.
HELPAssist the woman in making a choice; give her additional information that she might need to make a decision.
11. Helps the woman to choose a Gives woman additional information that she may need and answer any questions.
method.
Assesses her knowledge about the selected method; provides additional information as needed.
12. Supports the woman's choice. Acknowledges the womans choice and advises her on the steps involved in providing her with her
chosen method.
EVALUATE and EXPLAINDetermine whether she can safely use the method; provide key information about how to use the method (focus on PPIUD,
per her choice)
13. Evaluates the womans health Asks the woman about her medical and reproductive history.
and determine if she can safely
use the method.
14. Provides key information Effectiveness: Prevents almost 100% of pregnancies

about the PPIUD with the woman: Mechanism for preventing pregnancy: Causes a chemical change that damages the sperm BEFORE
the sperm and egg meet
Duration of IUD efficacy: Can be used as long (or short) as woman desires, up to 12 years (for the
Copper T 380A)
Removal: Can be removed at any time by a trained provider with immediate return to fertility
15. Discusses advantages of the Simple and convenient IUD placement, especially immediately after delivery of the placenta
59
PPIUD: No action required by the woman after IUD placement (although one routine follow-up visit is
recommended)
Immediate return of fertility upon removal
Does not affect breastfeeding or breast milk
Long-acting and reversible (as described above)
16. Discusses limitations of the Heavier and more painful menses for some women, especially first few cycles after interval IUD (less
PPIUD: relevant or noticeable to postpartum women)
Does not protect against STIs, including HIV
Higher risk of expulsion when inserted postpartum (though less with immediate postpartum insertion)
17. Confirms that the woman Encourages the woman to ask questions.
understands the method.
Asks the woman to repeat key pieces of information.
RETURNPlan for next steps and for when she will arrive to hospital for delivery.
18. Plans for next steps. Makes notation in the womans medical record about her PPFP choice or which methods interest her.
If the woman cannot arrive at a decision at this visit, asks her to plan for a follow-up discussion at her
next visit; advises her to bring partner/family member with her.
Provides information about when the woman should come back for her next antenatal visit OR
continue with the next item on her management plan.
60
If the woman has PPIUD insertion, the following information should be provided prior to discharge from hospital (in addition to other information).
1. Discusses warning signs; Bleeding or foul-smelling vaginal discharge (different from the usual lochia)
explains that she should return to
the clinic as soon as possible if Lower abdominal pain, especially if the first 20 days after insertionaccompanied by not feeling well,
any arise. fever or chills
Concerns she might be pregnant
Concerns the IUD has fallen out
2. Confirms that the woman Encourages the woman to ask questions.

understands instructions.
Asks the woman to repeat key pieces of information.
3. Concludes the interaction Thanks her
61

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Antenatal Care Module

2. How to Use the Antenatal Care Module .................................................................. 5

3. Learning Objectives ....................................................................................................... 6

4. Core Topics and Clinical Conditions ........................................................................ 9

5. Physical Examination and Procedural Skills ..................................................... 10

6. Guide to Ethical Behaviour ...................................................................................... 10

7. Teaching and Learning Programme ..................................................................... 11

8. Learning Resources .................................................................................................... 16

10. Procedural Skills Tutorial...................................................................................... 18

11. Teaching and Learning Materials ........................................................................ 27

This module contains the following information:

3.1 Develop knowledge base

Normal Anatomy and Physiology

Haematology and Clinical Pathology

Population health issues

To explainmanagement of the normal post-partum period:

To explain early newborn care

To provide informationon common issues in pregnancy

To communicatewith clients, their families and other health professionals

3.2 Develop clinical skills

Communication and Counselling

3.3 Enhance professional development

Appreciate ethical issues

4. Core Topics and Clinical Conditions

Focused antenatal care

5. Physical Examination and Procedural Skills

6. Guide to Ethical Behaviour

Respect for the patient

Other Points in Clinical interactions

7. Teaching and Learning Programme

7.2.2 Clinical Skills Session

7.2.3 Clinical Teaching

7.2.4 Problem-based Learning

7.2.5 Topic Tutorials

Pregnancy, Childbirth, Postpartum and Newborn Care (2006), WHO

Managing Newborn Problems, (2003) WHO

WHO Reproductive Health Library

Postpartum Intrauterine Contraceptive Device Services Trainers Notebook (2010)

Pocket Book of Maternal Health Care Indonesia (2011 Draft)

Clinical Log Book

Directly observed Practical Skills

Mini Clinical Evaluation Exercise (Mini CEX)

10.1 Taking an Obstetric History

Current Pregnancy History

Gynacological (including Contraceptive History)

Previous Obstetric History

Presence of problems in previous pregnancy, labour and puerperium:

The Obstetric History is usually summarized in a pre-formatted table (Table 2).

Menstrual History Family History

Measure mid-upper arm circumference (MUAC)

Nipples - There is no abnormal nipple discharge.

Obstetric physical examination at the first visit:

Obstetric physical examination at each subsequent visit:

Palpate abdomen using Leopolds maneuvers I-IV as shown below:

Assessment of fetal heart with fetoscope (Pinard stethoscope)

Gestational age Uterine Fundal Height

By Palpation By Tape Measure

(Gestational age in weeks

36 weeks At the xiphoid process (36 2) cm

Figure 1: Uterine height values by weeks of gestation

11. Teaching and Learning Materials

11.1 Group Discussion

11.1.2 Discussion: Birth and emergency preparedness plan