1 Care of the mother
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- Maternal care
- Antenatal care
- Common problems during pregnancy
- Keeping healthy during pregnancy
- Important danger signs in pregnancy
- HIV during pregnancy
- Labour and delivery
- Postnatal care
- Case studies
When you have completed this chapter you should be able to:
- Give the duration of a normal pregnancy
- Advise a woman on how to confirm that she is pregnant
- Understand why it is important to book early for antenatal care
- Explain to a woman what to expect at an antenatal clinic
- Conduct home visits to support and advise a woman during her pregnancy
- List the danger signs during pregnancy
- Tell when a woman is in labour
- Conduct home visits after the baby is born
1-1 What is maternal care?
Maternal care is the care of women from the time that they fall pregnant until six weeks after their baby has been born. Maternal care can be divided into three periods:
- The puerperium (the six weeks after the baby is born)
1-2 How long is a normal pregnancy?
The duration of a pregnancy is usually measured from the first day of the woman’s last normal period to the day that her baby is born. The first day of the last period is used as most women will remember this date while many will not know the date when they fell pregnant.
Using this method the average duration of a normal pregnancy is 40 weeks (280 days). It is much better to measure the duration of pregnancy in weeks than in months as this is more accurate.
The duration of most pregnancies is about 40 weeks.
1-3 What is a term pregnancy?
While the average length of a normal pregnancy is 40 weeks not all normal pregnancies end at exactly 40 weeks. The length of a normal pregnancy may vary from 37 weeks to 42 weeks. A pregnancy that ends between 37 and 42 weeks is called a term pregnancy and the baby is called a term baby.
1-4 Are some pregnancies too short or too long?
Yes. A pregnancy that ends before 37 weeks is called a preterm pregnancy and these babies are called preterm babies. About 15% of all pregnancies end before 37 weeks. Less commonly a pregnancy can last too long when the woman gives birth at or after 42 weeks. The risk of the baby dying or having problems is much greater if the pregnancy ends too soon or too late.
1-5 How is the duration of pregnancy determined?
There are three common ways of assessing the duration of the pregnancy:
- The date of the last normal menstrual period: this is used to calculate the expected date of delivery 40 weeks later
- The size of the uterus: usually measured from 16 weeks of pregnancy
- An ultrasound scan of the abdomen: this is most accurate when done before 20 weeks of pregnancy
1-6 How does a woman know that she is pregnant?
Any woman of childbearing age (from the start of menstrual periods to menopause when periods stop) who has unprotected sexual intercourse may fall pregnant. Usually the first signs of pregnancy are:
- A woman misses a normal menstrual period (this is usually the first sign that a woman may be pregnant)
- Her breasts become swollen and tender
- She feels nauseous, especially in the morning (“morning sickness”)
- She feels tired and has little energy, especially towards the end of the day
- She may go to the toilet to pass urine more often than usual.
A missed period, tender breasts and nausea are common signs of pregnancy.
1-7 How can a pregnancy be confirmed?
A pregnancy test can be done on a sample of urine. The pregnancy test becomes positive by the time a woman misses her period. Usually a woman will go to her local clinic or a family doctor for a pregnancy test. Some women choose to buy a pregnancy test at a pharmacy and test their own urine. If the pregnancy test is positive, many women will go to the nearest antenatal clinic to have their pregnancy confirmed.
1-8 When should a woman first go to book at an antenatal clinic?
It is best for a woman to book for antenatal care as soon as pregnancy is confirmed with a pregnancy test. This is usually done at about 8 weeks of pregnancy when the second period is missed. The earlier a woman books for antenatal care the better. It is very important that all women book early for antenatal care. If possible pregnant women should book for antenatal care before 12 weeks of pregnancy (before the third period is missed).
Women should book for antenatal care as soon as pregnancy is confirmed.
1-9 Why should women book early for antenatal care?
Women who book early for antenatal care are more likely to have a safe and healthy pregnancy and deliver a normal, healthy baby. It is important for community health workers to encourage all women who think they may be pregnant to attend an antenatal care clinic.
1-10 Why is antenatal care important for all pregnant women?
Antenatal care provides many important advantages for pregnant women:
- She receives advice about a healthy lifestyle during pregnancy
- She is screened for important problems that can be treated better if they are detected early
- The baby’s growth is monitored
- She is supported, given advice and learns about her pregnancy as it progresses
- She is helped to prepare for labour
- She is educated about breastfeeding and caring for her baby after birth
- If she is HIV positive she receives the correct management to keep her and her baby healthy
- She is advised about family planning after her pregnancy.
Antenatal care is important to keep the mother and baby healthy during pregnancy.
1-11 What happens at the first antenatal visit?
Routine care at the first visit to an antenatal clinic includes:
- Confirming that the woman is pregnant
- Finding out how far the pregnancy is
- Taking a careful medical and social history
- A general physical examination which should include:
- a breast examination
- measuring blood pressure
- measuring upper arm circumference
- testing urine for sugar and protein
- checking for a history of coughing which may suggest TB
- An abdominal examination of the uterus
- A number of screening blood tests for:
- Rhesus blood group
- A cervical smear (PAP test) to screen for cervical cancer
- A tetanus toxoid injection to protect her baby from tetanus if the umbilical cord becomes infected
- Deciding whether or not the woman is healthy and her pregnancy is normal
- Deciding what level of care the woman needs during her pregnancy and where she should go for further antenatal care.
1-12 What is a maternity case record?
Every woman who books for antenatal care will be given a maternity case record (antenatal card) which she will keep with her and take to every antenatal care visit. The maternity case record includes all the information, clinical findings and test results relating to the woman’s pregnancy. The maternity case record is very important as it is a communication document between all the health workers who the woman will see during her pregnancy.
The maternity case record contains all important information about a woman’s pregnancy.
1-13 Where should women go for antenatal care?
Women who are healthy and have a normal pregnancy can attend their closest primary care clinic for antenatal care. If a woman has a health problem, such as diabetes or hypertension, or if she has a high-risk pregnancy, such as twins or a previous stillbirth, she will probably be referred to an antenatal care clinic at a hospital. At each visit the woman will be assessed to decide where she should go for her further antenatal care.
About 80% of pregnant woman are assessed as having a low risk of problems during pregnancy. These women can receive antenatal care at a local clinic. About 20% of pregnant women will have a risk factor or a clinical problem that could cause complications during pregnancy or delivery. These women will be referred to a level 2 or level 3 hospital for further antenatal care.
1-14 Should all pregnant women have an ultrasound scan?
If possible all women should have an ultrasound scan at about 12 weeks of pregnancy. The scan is often repeated at about 20 weeks. Ultrasound scans:
- Confirm the duration of pregnancy (this is important if the woman is not sure of the date of her last normal menstrual period)
- Check whether there are twins
- Identify the site of the placenta
- Look for any serious fetal abnormalities such as Down syndrome.
Women at increased risk of fetal problems, such as poor growth or a physical abnormality, may have additional scans later in pregnancy.
1-15 How many antenatal visits are needed during pregnancy?
If the woman is at low risk of problems she will usually need eights visits after the first booking visit. Antenatal visits are usually at:
- 20 weeks
- 26 weeks
- 28 weeks
- 30 weeks
- 34 weeks
- 36 weeks
- 38 weeks
- 40 weeks
If the woman has not delivered by 41 weeks she should go back to the antenatal clinic. Women must take their maternity case record to every antenatal visit.
Women must be encouraged to attend all antenatal visits.
1-16 What happens at follow up antenatal visits?
After the first antenatal visit, women must attend all their scheduled antenatal visits to make sure that both mother and fetus are healthy and to look for any complications. At each of these visits:
- A history is taken for problems or danger signs
- Blood pressure is measured
- The size of the uterus is determined by measuring the symphysis-pubic height (the distance from the woman’s pubic bone to the top of her uterus) to assess the growth of the fetus
- Urine is tested for sugar and protein
- The woman is assessed whether she is still at low risk of problems or whether she needs referral to a higher level of care
- The woman is given advice and support, information about her pregnancy, what to expect during labour, the importance of breastfeeding and immunisation of her baby
- HIV positive women are encouraged to continue taking ARVs
- The woman is given a date for her next antenatal care visit.
1-17 Are home visits by a community health worker helpful during pregnancy?
Yes. If possible a community health worker should visit the mother at least four times during her pregnancy. The aim of these visits is to:
- Support and advise the woman on a healthy lifestyle
- Make sure that she attends all antenatal clinic visits
- Make sure that she carries out the instructions given at the clinic
- Make sure that she is takes her supplements and any other prescribed medicines such as ARVs
- Ask about danger signs
- Help with common problems such as morning sickness, constipation or heartburn.
It is important that community health workers ensure that all pregnant women attend a clinic for antenatal care.
Common problems during pregnancy
1-18 How can you help a woman with morning sickness?
Nausea especially in the mornings (“morning sickness”) is a common problem in the first three months of pregnancy but can continue later on in pregnancy. There are a few simple things that help:
- Eat a dry biscuit or piece of dry bread before getting up in the morning
- Only drink between meals and not with meals
- Avoid fatty foods
- Have a number of snacks throughout the day rather than three big meals a day.
1-19 What advice can be given for constipation and heartburn?
Constipation and heartburn are common in pregnancy.
Constipation is difficulty passing hard stools. Women can be advised to drink more water and eat more fruit and vegetables and wholewheat bread instead of white or brown bread. Exercise may help. It is best to avoid laxatives or herbal medicines as some of these may be harmful to the mother and her fetus.
Heartburn is a painful, burning feeling in the throat and chest especially when a woman lies down. It is caused by stomach acid leaking up into the throat. It is more common towards the end of pregnancy. Women can be advised to eat frequent small meals, wait for two hours after eating before lying down, have a glass of milk before going to bed and to raise the head of the bed.
1-20 What is anaemia in pregnancy?
Anaemia means having a low level of haemoglobin. In pregnancy this is usually due to a lack of iron (iron deficiency). It can be prevented if all pregnant women take daily iron supplements.
Iron deficiency anaemia presents with:
- Pallor (paleness especially of the tongue and nails)
- Shortness of breath with mild exercise.
If you think a woman has anaemia she must be referred to the clinic where she can be examined and the haemoglobin level in her blood can be checked.
Keeping healthy during pregnancy
1-21 How can a woman keep healthy during pregnancy?
There are number of things that all women can do to keep healthy during pregnancy:
- Eat a healthy diet
- Get some exercise every day
- Pay attention to personal hygiene
- Avoid unprotected sex
- Take routine supplements correctly
- Do not take any medicines that are not given by the clinic or hospital
- Do not smoke cigarettes
- Do not drink alcohol
- Do not take recreational (illegal) drugs.
Community health workers should educate pregnant women on how to keep healthy.
Pregnant women should not smoke or drink alcohol.
1-22 What is a healthy diet during pregnancy?
Healthy eating during pregnancy is important so that the fetus can grow and develop normally.
- Pregnant women should have three meals a day with healthy snacks between meals. Smaller meals and frequent snacks are helpful if nausea, heartburn and indigestion are a problem.
- Fish, meat and beans are a good source of protein.
- Fruit and green vegetables are rich in essential vitamins and minerals.
- Salt should be used sparingly.
- Fatty or fried foods, fast foods and fizzy drinks should be avoided.
A good diet is very important for women who are undernourished (they do not get enough food or the right foods for good health).
A healthy diet during pregnancy is especially important for undernourished women.
1-23 Why is the woman’s upper arm circumference measured?
Measuring the upper arm circumference helps to identify women who are undernourished at booking. A thin mother needs nutritional advice and possibly food parcels to ensure that she gains weight adequately during pregnancy so that her fetus can grow normally. An upper arm circumference less than 23 cm suggests that the woman is undernourished while a measurement of 33 cm or more suggests obesity (severely overweight).
While it is important that pregnant women are not underweight, it is also important that they do not become obese as this extra weight may be difficult to lose after delivery.
If the arm circumference is abnormally high or low, the woman’s weight will be monitored at each antenatal visit. It is important that undernourished women gain weight during pregnancy. Obese women often do not need to gain weight while pregnant.
1-24 What supplements are routine given to pregnant women?
- Iron tablets (ferrous sulphate): one 200 mg tablet daily to treat or prevent anaemia
- Folic acid: one 5 mg tablet daily to help the fetus develop normally.
- Calcium tablets: 1000 mg daily to prevent complications of pre-eclampsia
These supplement tablets should be taken every day throughout pregnancy. It is best if supplements are taken at the same time every day as this helps women to remember them. Women may have dark stools when taking iron tablets. This is not a problem.
It is important to take all prescribed supplements during pregnancy.
1-25 How much exercise should a woman have during pregnancy?
It is important that pregnant women keep fit. Walking each day is the best exercise. Heavy work and too much exercise should be avoided especially during the second half of pregnancy. Some women go to antenatal exercise classes.
Important danger signs in pregnancy
1-26 What are the important danger signs in pregnancy?
All pregnant women should be told to be aware of the important danger signs in pregnancy. Important danger signs are:
- Severe headache
- Abdominal pain
- Fits (seizures or convulsions)
- A decrease in the amount that the mother feels the baby move
- Any vaginal bleeding
- Draining amniotic fluid from the vagina before 37 weeks of pregnancy.
If a pregnant woman has any of these danger signs she must immediately go to the antenatal clinic or to a hospital. The community health worker should remind pregnant women of these danger signs at every home visit.
It is important that all community health workers and pregnant women know the danger signs during pregnancy.
1-27 What is pre-eclampsia?
Pre-eclampsia is an important and dangerous condition that may present during pregnancy. The signs of pre-eclampsia are:
- High blood pressure
- Swelling of the face
- Protein in the urine
- Abdominal pain
- Severe headaches.
If pre-eclampsia is not detected early and treated correctly, eclampsia may develop. Eclampsia presents with the symptoms of pre-eclampsia as well as fits (seizures or convulsions). Both the mother and the fetus can die if eclampsia develops.
It is important to measure a pregnant woman’s blood pressure and check for protein in her urine at every antenatal visit.
HIV during pregnancy
1-28 How are HIV positive women managed during pregnancy?
All women should be screen for HIV at booking with a blood test. If positive they will be started on ARVs and managed according to the national protocol for HIV positive women. All pregnant women must be encouraged to practice safe sex. It is important that HIV negative women do not become infected.
When making home visits community health workers must always encourage women on ARVs to take their medication correctly every day so that they and their baby are kept healthy.
Labour and delivery
1-29 What is a birth plan?
All pregnant women should have a birth plan (delivery plan). This is a plan for what needs to happen when the woman goes into labour and her baby is delivered and what support she needs. There are important things that pregnant women and their families should think about:
- What date are they expecting to deliver?
- Where are they going to deliver?
- How will they get there, especially if it is at night?
- Do they have money for transport?
- What will they need to take with them?
- Who will look after their children?
Every pregnant woman must have a birth plan.
1-30 Is it safe for a woman to deliver at home?
It is important that every woman should be delivered by a skilled birth attendant. Usually delivery will take place at a clinic near to her home. Only under special circumstances should a low-risk woman be delivered by a skilled birth attendant at home.
All high-risk women must be delivered in hospital. It is extremely dangerous for both the mother and baby if a high-risk woman gives birth at home.
If a home delivery is unavoidable the mother and baby must be taken to a clinic or hospital as soon as the delivery is completed.
1-31 What is a birth companion?
A birth companion is someone, often a friend or family member, who can support the woman during labour. Labour is quicker and less stressful with a birth companion. Clinics should be encouraged to accept birth companions.
1-32 When should a mother go to the clinic or hospital to deliver?
A pregnant woman should go to the clinic or hospital when she is in established labour or when her waters have broken. The signs of established labour are:
- Regular contractions
- The contractions are usually painful
- The contractions become longer and more frequent with time
- There may be backache
- There may be a blood stained, mucus vaginal discharge (a “show”) a few days before the onset of labour.
It is helpful to time the length of each contraction and also how frequently they occur. When you think the woman is in established labour she should be taken to the delivery facility.
It is important to know the signs of labour.
1-33 What are the different ways that a baby can be born?
There are three ways that a baby can be born:
Most babies can be born vaginally. This is the normal way to deliver and about 80% of all babies are born this way.
Due to complications in either the mother or the baby it may be necessary for the baby to be born by Caesarean section. This is an abdominal operation which is done in hospital.
If the baby will not deliver normally it may be necessary to do an assisted delivery using a vacuum extractor or forceps. This is usually done by a doctor in hospital.
When the baby is not delivered normally both mother and baby will usually stay a few days in hospital before being discharged home.
1-34 What are the three stages of normal labour?
Labour is divided into three stages:
This the time that it takes for contractions to open up the mother’s cervix until it is wide enough for the baby to be born. Stage one begins when contractions start and usually lasts less than 12 hours.
This is the time it takes for the mother to push her baby out. Stage two lasts less than two hours.
This is the time taken to deliver the placenta. After delivery of the baby the mother will be given an injection to speed up the third stage.
1-35 When can a mother come home after delivery?
If she is a low-risk mother and the delivery is normal and the baby is healthy, she can usually be discharged home after six hours. The time to discharge may be longer in order to arrange transport or until a convenient time for her family to fetch her.
If there are problems with the mother or the baby the discharge may be delayed. It is important to keep the mother and baby together. If possible the mother should not be discharged home if the baby is small or ill and needs to stay in hospital. This is important so that the mother can bond with her baby and provide breast milk.
1-36 What is postnatal care?
Postnatal care is the care given to the mother from the time of delivery until six weeks after delivery. This period is called the puerperium. Care during the puerperium is an important part of maternal care and must not be forgotten.
1-37 When should the mother be seen again after delivery?
Usually both the mother and the baby are seen on day 3 after a normal delivery to make sure that they are well. This may take place in the clinic or at home.
There a number of important items that must be assessed in the mother:
- Is she feeling generally well and managing her baby?
- Is she breastfeeding well or does she have any problems with her breasts?
- Does she have a temperature? A temperature above 37.5 degrees suggests an infection.
- Is she having any heavy vaginal bleeding?
- Does the lochia (vaginal fluid) smell offensive (bad)?
- Does she have abdominal pain or tenderness?
If any of these observations are abnormal the mother must be referred urgently to a nurse or doctor for assessment. The most important complications after delivery are infection and vaginal bleeding.
Community health workers should provide home visits after delivery.
1-38 When is the postnatal visit?
Both the mother and the baby are usually seen at a clinic for the postnatal visit at six weeks after delivery. By this time she should be healthy and breastfeeding well. There should be no lochia or vaginal bleeding and her abdomen and breasts should be normal.
This is a good time to speak to the mother about family planning and contraception. The further management of HIV mothers and their babies must also be planned.
Case study 1
A community health worker visits a home to check that a granny is taking her TB medication correctly. She says her granddaughter aged 16 years has missed two periods and she wonders whether she might be pregnant. The granny tells her granddaughter to go to the clinic only when she is 6 months pregnant.
1. What signs of pregnancy could the CHW ask about?
She could ask about breast tenderness and swelling, nausea, tiredness and the need to pass urine frequently. These are all common signs of early pregnancy.
2. How can the pregnancy be confirmed?
The pregnancy can be confirmed with a urine pregnancy test. This can be done at a local clinic.
3. When should a woman go to a clinic to start antenatal care?
Antenatal care should start as soon as the pregnancy is confirmed. If possible this should be before 14 weeks. The sooner antenatal care starts the better.
4. Why is antenatal care important?
Antenatal care is important because it helps to keep mother and baby healthy during pregnancy.
5. How can a CHW help with antenatal care?
A CHW can help with antenatal care by making sure that all pregnant women have booked for antenatal care and are attending antenatal clinics on time. They can support women by advising on a healthy lifestyle, reminding them of danger signs and encouraging them to take their daily supplements and any prescribed medication.
Case study 2
A pregnant woman complains of constipation and dark stools. She also says she has had abdominal pain and some vaginal bleeding for the past two days. When the CHW asker her she reports that her baby has not moved much that day.
1. How can the mother manage her constipation?
She should be advised to drink more water, eat more fruit and vegetables and eat whole wheat bread instead of white or brown bread.
2. What is a common cause of dark stools in pregnancy?
Taking iron supplements often causes dark stools. The woman should be reassured that this is not a problem.
3. Are you worried about her abdominal pain and vaginal bleeding?
Yes. These are two danger signs. This woman should be taken to the clinic urgently for assessment and management.
4. Why are fetal movements important?
Because frequent fetal movements suggest that the baby is healthy. It is very worrying that this baby is not moving much. This is another danger sign that indicates that the mother must go to the clinic as soon as possible.
5. What are the danger signs of pre-eclampsia?
The important signs are:
- Abdominal pain
- Severe headache
Case study 3
A young woman with her first pregnancy is very frightened about labour and delivery. She wants her mother to stay with her when she is in labour but the midwife at the antenatal clinic says this is not possible.
1. What is a birth companion?
Someone that the woman knows well who can support her while she is in labour. Her mother could be her birth companion. All delivery centres should allow a woman in labour to have a birth companion.
2. What are the advantages of a birth companion?
Labour is usually quicker and less stressful to the woman if a birth companion is present.
3. What is a birth plan?
This is a clear idea of what is needed when a woman goes into labour, such as:
- Where is she going to deliver
- What are the arrangements to get there
- What will she need to take with her
- Every pregnant woman must have a birth plan.
4. Would it be safe for her mother to deliver her at home?
No. Every delivery must be conducted by a skilled birth attendant. This is best done at a clinic or hospital.
5. Can all women deliver safely at a clinic?
Most low-risk women can deliver safely at a clinic but all high-risk women should deliver in a hospital where complications can be managed. Some high-risk women may need a Caesarean section.