The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation

1. AN T E N ATA L R I S K AS S E S S M E N T TO O L S
B Y H AJ . S H AFA’ AT U U M AR
FOCUS ANTENATAL
CARE:

2. INTRODUCTION
• All pregnancies and deliveries are potentially at
risk. However, there are certain categories of
pregnancies where the mother, the fetus or the
neonate is in a state of increased jeopardy.
• Early identification and management of the risks
associated with pregnancy is essential to
providing optimal treatment to pregnant women.

3. FOCUS ANTENATAL CARE
• This model developed in 2002 was a goal-oriented
approach to delivering evidence-based interventions at
four critical times during pregnancy.
• This approach achieved an increase in ANC in low-and
middle-income countries (LMICs).
• This traditional approach was replaced by focused
antenatal care (FANC) — a goal-oriented antenatal care
approach, which was recommended by researchers in
2001 and adopted by the World Health Organization
(WHO) in 2002 and was reviewed in 2016

4. FOCUS ANTENATAL CARE…,
• It emphasizes contact rather than visit and
recommends a total of 8-contacts instead of
current 4-visits and the provision of quality care
at each contact.

5. FOCUS ANTENATAL CARE
FANC (4 visits)
• 1st visit around 12 weeks or anytime feels she is pregnant
• 2nd visit between 24-28 weeks
• 3rd visit at 32 weeks
• 4th visit at 36 weeks
W.H.O.2016 ANC MODEL (8visits)
• 1 visit in the 1st trimester (up to 12 weeks of gestation),
• 2 visits in the second trimester (at 20 and 26 weeks of
gestation)
• 5 visits in the third trimester (at 30, 34, 36, 38 and 40 weeks)

6. ANTENATAL RISK ASSESSMENT
• is an assessment carried out on all pregnant
women at each antenatal visit using
• It is done to know the general status of a
pregnant woman at present.
• Risk assessment is done to identify the risks and
manage it.

8. IDENTIFICATION AND
MANAGEMENT

9. ANAEMIA
• Commonest medical disorder in pregnancy.
• 18-20 pregnant women are anaemic in
developed countries as compared to 40-75% in
developing countries.
• It is responsible for significant high maternal
and fetal mortality rate worldwide

10. DEFINITION
ANAEMIA: generally refers to as reduction in the number of circulating blood
cells and haemoglobin level resulting in to reduction of oxygen carrying
capacity of the blood.
ANAEMIA IN PREGNANCY: The WHO and American college of Obstetricians
and Gynecologist define anaemia in pregnancy as follows:
 1st trimester: Hb <11g/dl
 2nd trimester: Hb <10.5g/dl
 3rd trimester: Hb <11g/dl
However, most of the physician begin a work up of anaemia in pregnancy until
Hb is less than 10g/gl.

11. CAUSES
Decrease erythropoiesis
Excessive destruction of red blood cell
Haemorrhage
Severe hookworm infestation
Deficiency of iron, vitamin B12, folic acid necessary for
production

12. RISK FACTORS FOR ANAEMIA IN
PREGNANCY
 Multiple pregnancy
 Excessive vomiting during pregnancy
 Teenage pregnancy
 Previous anaemia in pregnancy
 No child spacing
 Lack of iron in diet
NOTE: the most common cause of anaemia in pregnancy is as a result of
 Iron deficiency
 Folate deficient
Which is occur in one third of pregnant woman during the 3rd trimester.

13. CLASSIFICATION
• Physiological Anemia
• Pathological Anemia
• Iron deficiency
• Folic acid deficiency
• Vitamin B12 deficiency
• Hemorrhagic Anemia
• Acute—following bleeding in early months of pregnancy or APH
• Chronic—hookworm infestation, bleeding piles, etc.
• Hemolytic anemia
• Familial—congenital jaundice, sickel cell anemia, etc.
• Acquired—malaria, severe infection, etc
• Bone marrow insufficiency
• hypoplasia or aplasia due to radiation, drugs or severe infection.
• Hemoglobinopathies
• Abnormal structure of one of the globin chains of the hemoglobin molecule of
globin chains of the hemoglobin molecule ex- sickle cell disease

14. SIGNS AND SYPTOMS
• Weakness/tiredness
• Dizziness
• Breathlessness and mild exertion
• Pedal oedema ( swelling of legs)
• Prominent neck vein in severe anaemia
• Pallor of conjunctiva, gum, tongue, nail beds,
and or palms and soles of the feet
• Hepatomegaly
• Splenomegaly

15. DIAGNOSIS
• Screening of patient for anaemia
• Ask and listen: ask if she eats non nutritive foods
and not pica
• If her pregnancy has been closely spaced
• If she bruises easily
• If she had haemorrhage with any pregnancy
• Social and dietary history taking including date
of last menstrual period

16. DIAGNOSIS CON’T
• Physical examination- examine the conjunctiva,
tongue, lips, palms of the hand nail beds and
sole of the feet for pallor
• Blood specimen is obtained for sickling cells,
malaria parasites, haemoglobin if 8gms or
below.
• Estimation of the packed cell volume of blood
(PCV).
• Stool examination for ova of worms and
parasites especially for hook worm.

17. EFFECTS OF ANEMIA ON THE MOTHER
• Reduced resistance to infection caused by
impaired cell-mediated immunity
• Increase risk of post partum haemorrhage
• Predisposition to PIH and preterm labor due to
associated malnutrition
• Worsen existing maternal condition

18. EFFECTS TO FETUS
• Intrauterine hypoxia and growth retardation
• Prematurity
• Low Birth Weight
• Increased risk of perinatal morbidity and
mortality

19. DEGREES OF ANAEMIA
• Mild
• Moderate and
• Severe.

20. MANAGEMENT
• Avoidance of frequent childbirths
• Supplementary iron therapy
• Dietary advice
• Adequate treatments to eradicate illnesses likely
to cause anemia
• Early detection of falling hemoglobin level

21. MILD ANAEMIA
The haemoglobin level is below 10.4 -11.9gm/dl i.e. above 8.1g/dl
MANAGEMENT:
She is better manage as outpatient
Dietary advice is given on source of iron e.g increased consumption
of dark green vegetables e.g ugu vegetable, intake of food rich in
protein, and vitamin
Iron supplement e.g ferrous sulphate tablet 200mg tds plus folic
acid tablet 5mg daily.
Treatment of malaria and worm infestation if identified during
investigation of blood and stool.

22. MODERATE ANAEMIA
This is when the haemoglobin estimate is or below 8.1gm/dl (i.e.
between 7g/dl to 8.1g/dl)
MANAGEMENT
Double doses of iron supplement of ferrous sulphate 400mg t.d.s.
, folic acid 5mg daily throughout pregnancy is given.
Advice on food rich in iron, protein and vitamin c (use of locally
and affordable foods).
Treat malaria and worm infestation (if present after investigation).
Check haemoglobin at every visit for the rest of the pregnancy.

23. SEVERE ANAEMIA
This is when the haemoglobin level is 6g/dl or below
Haematocrit 20% or less
There is : increased incidence of preterm labour, fetal
distress, low birth weight and increased risk of
perinatal mortality

24. NURSING MANAGEMENT OF SEVERE
ANAEMIA
Admit for rest if HB is less than 6g/dl
Start an iv infusion using a large bore canular or
needle
Infuse normal saline or Ringers lactate at the rate of
1L over 8hours
Avoid given sedative
Refer urgently for transfusion (if not in the hospital).

25. NURSING MANAGEMENT OF SEVERE
ANAEMIA
Prop patient up in bed to allow for easy breathing and
prevent congestion of the lungs
Monitor maternal and fetal heart closely
Check temperature 4hourly pulse and fetal heart rate
half hourly
Monitor intake and output charts
Record any abnormal variation

26. NURSING MANAGEMENT CON’T
Give high protein diet rich in green vegetables and
vitamin c.
Give fresh fruits and nourishing drinks to augument the
diet.
Treat for hookworm, if in endemic area give
mebendazole.
Provide iron (120mg) and folate (400mcg) by mouth daily
for 6month.

27. PREVENTION OF ANAEMIA IN
PREGNANCY
• Identification of risk factors for heamorrhage and
managing them appropriate.
• Use of iron supplement for all pregnant woman
throughout pregnancy
• Identification and treatment of malaria and worm
infestation
• Prophylactic treatment and worm infestation

28. PREVENTION OF ANAEMIA IN
PREGNANCY…,
• Check for other signs of infection or diseases
• Check haemoglobin
• Emphasize on sleeping under treated net to
prevent malaria
• Advice on child spacing after delivery
• Educate on nutrition i.e diet rich in iron, folate
and vitamin c and to avoid food that decrease
iron absorption e.g coffee

29. MANAGEMENT DURING LABOR
• 1st stage
• Special precautions
• Comfortable position on bed
• Light analgesia
• Oxygenation to increase oxygenation of maternal
blood and prevent fetal hypoxia
• Strict asepsis
• 2nd stage Usually no problem.
• 10iu of oxytocin IM given
• Give 20 iu oxytocin in D/S 500ml .

30. MANAGEMENT DURING LABOR…,
• 3rd stage
• Intensive observation.
• blood loss must be replaced by fresh pack cell and amount must
not exceed loss amount to avoid overloading
Puerperium
• Bed rest
• Sign of infection detected and treated.
• Pre delivery iron therapy must be continued until patient
restores.
• Diet
• Patient and family members must be counseled for help
at home regarding baby care and household chores

31. FOLLOW UP
Recheck haemoglobin 48hours after transfusion.
Advice on nutrition.
Continue iron therapy if still pale.
Explain the important of keeping ante natal appointment.
ADVICE ON DISCHARGE
Advise on diet rich in iron, protein and vitamins.
Advice on use of iron supplements to augument diet.
Educate on taking iron drugs after meals with fruit juices or
vitamin c to enhance absorption.
Remind her on family planning.
Advice her on keeping aseptic techniques in order to avoid
infection.

32. CONCLUSION
• Anemia in pregnancy is the most commonly occurring
disorder during pregnancy, so every mother who are
pregnant must screen for anemia and must take
treatment as soon as possible along with diets rich in
iron and also must have family support and care
throughout pregnancy.

33. MALARIA
• Malaria infection during pregnancy is a
significant public health problem with substantial
risks for the pregnant woman, her fetus, and the
newborn child. Malaria-associated maternal
illness and low birth weight is mostly the result of
Plasmodium falciparum infection and occurs
predominantly in Africa.
• Malaria infection in pregnant women is
associated with high risks of both maternal and
perinatal morbidity and mortality.

34. DEFINITION
• Malaria is a febrile illness caused by
plasmodium- a parasite transmitted through the
bite of an infected female Anopheles mosquito.
• Malaria is more frequent and complicated during
pregnancy.

35. SIGN AND SYMPTOMS
• Headache
• High-grade fever (temperature 38ºc)
• Muscle pain
• Nausea and Vomiting
• Shivering, chills and rigors
• Sweats
• Diarrhoea
• Loss of appetite
• Weakness

36. CLINICAL DIAGNOSIS
• Laboratory examination
• Blood smear test
• Rapid diagnostic tests (RDTs)
• Haemoglobin estimation may show anaemia

37. MANAGEMENT OF MALARIA IN
PREGNANCY
• The World Health Organization (WHO) recommends a
three-pronged strategy for control of malaria in
pregnancy, (prompt treatment with highly effective drug)
• use of insecticide-treated nets (ITNs)
• intermittent preventive treatment (IPTp), using
sulphadoxine-pyrimethamine (SP)
• the administration of a full treatment course of an
effective antimalarial at regular antenatal visits, usually a
month apart.

38. SECOND AND THIRD TRIMESTER
The following drugs are use in the treatment of
uncomplicated malaria in the 2nd and 3rd
trimesters of pregnancy:
• ACTs, namely artemether-lumefantrine
• amodiaquine-artesunate
• mefloquine-artesunate
• dihydroartemisinin piperaquine (DHA-PQ),

39. CONCLUSION
• Pregnant women are uniquely susceptible to malaria. Optimal
malaria prevention varies with the transmission; in higher
transmission areas ITNs have demonstrated benefits.
• In lower transmission settings, women may lack malaria immunity
and are at risk of developing severe, potentially fatal disease or
losing their babies to miscarriage or stillbirth; they require
immediate diagnosis and treatment.
• ACTs are recommended in most circumstances, although quinine
remains the first choice in the first trimester of pregnancy.
• The approach to treatment should be tailored according to
pregnancy trimester and clinical severity of malaria.