The six pillars of Maternal and Newborn Health in Kenya include pre-conceptual care, family planning, focused antenatal care, essential obstetric care, essential newborn care, targeted post-partum care, and lastly post-abortion care. To promote the (MNH) pillars, it necessary to have skilled birth attendants and supportive functional health system.

The Kenya MNH model emphasizes the role communities play in promoting  their own health  the importance of strengthening the relationship between the community and health services, as well as promoting the human rights approach to health service delivery.

Objective 1: Explain the pillars of maternal and newborn health

Maternal and Newborn Health (MNH) Pillars 2009

1. Pillar 1:  Family planning and pre-pregnancy care– To ensure that individuals and couples have the information and services to plan the timing, number and spacing of pregnancies.

 Objectives of Pre conception Care:

1. To provide Health promotion and education to improve knowledge attitudes and behaviours of men and women with regard to pregnancy

2. To provide Evidence - based Screening for pregnancy risks

3. To provide Interventions to address identified risks and conditions

4. To Achieve universal coverage of Essential Obstetric Care

Age of the couple

Very young (16yrs and below); Elderly (35 yrs and above)

Parity

Primigravida; Grand multiparity (gravida five and above); Short pregnancy interval (less than 2 years)

Nutritional status

Under nutrition, obesity, malnutrition

Low Socio-economic status

Previous adverse pregnancy outcome

Recurrent spontaneous abortions, Stillbirths, Early neonatal deaths (first one week)

Previous baby with congenital abnormalities

Medical conditions such as

Anaemia, Malaria, HIV/AIDS, Tuberculosis, STIs/RTIs, cardiac disease, Diabetes

Sickle cell disease, Asthma, Hypertension (Pre and post conception)

ABO and Rhesus incompatibility, Breast cancer, cervical cancer, renal disease

Obstetric Complications such as

Previous obstetric Haemorrhage; previous C/S scars, previous preterm labour,

Previous PET / eclampsia

Substance abuse

Smoking; Alcohol or Drug abuse; Intake of prescription or over the counter drugs that are known to be teratogens.

Gender based violence

FGM, Early marriage, Physical / psychological abuse, Sexual violence

Negative cultural practices

Food restrictions, Health seeking behaviour

PRECONCEPTION CARE PROTOCOL

History taking should be comprehensive and include

1. Family history: hereditary conditions, Medical conditions, congenital abnormalities

2. Medical history: Diabetes, hypertension, HIV, TB, RT cancers e.g. Breast cancer, cervical cancer

3. Surgical history : Previous myomectomy, C/section, Obstetric fistula repair

4. Obstetric/gynaecological history: Pregnancy wastage, previous preterm deliveries, STI/RTI, menstrual disorders, prolonged sub fertility

5. Environmental history: exposure to radiation, Chemical

6. Occupational history: type of work and length of working hours as in long distance drivers, athletes, bicycle riders

7. Nutritional history: diet

8. Male partner history: mumps, STIs/HIV, substance abuse, tight clothing (around scrotum)

Physical examination

This should encompass a general examination (head to toe) to include vital signs, weight; e.t.c.

The systemic examination of the thyroid, heart, breasts, abdomen, pelvis and other relevant systems will be based on the history obtained from the woman.

 Investigations

Minimum investigations should include: Full blood count, random blood sugar, Syphilis test, HIV test, Blood group and rhesus, Urinalysis

Additional investigations are based on the history and examination

Interventions:

Health education and counseling

1. Psychosocial counselling

2. Family planning: Each woman, man, and couple should be encouraged to have a reproductive life plan including healthy timing and spacing of pregnancy

3. Life styles issues

·         Nutrition: Assess dietary status and advice on healthy nutrition.

·         Weight: Check BMI, Advise on weight gain or loss where BMI in <20 or >30

·         Substance abuse such as alcohol, hard drugs, tobacco, traditional medications, herbs  Timing of intercourse: Check that the couple understands the ovulatory cycle and can determine the most fertile days relative to the woman’s cycle. Advice that for conception to occur, intercourse should occur regularly (two to three times a week and should cover the most fertile time.)

·         Regular exercises

·         Adequate rest

·         Spiritual nourishment

4. Prenatal diagnosis: Educate women about options for prenatal diagnosis including genetic counselling (Down’s syndrome, sickle cell disease, thalasaemia, medical conditions); and virologic screening (TORCHES)

5. Discourage over the counter drugs and use of teratogenic medications

Other Specific interventions

Prophylaxis

·         Folic Acid Women who are trying to conceive should take folic acid supplements (400mcg) daily to reduce the risk of neural tube defects. This should begin 3months before pregnancy. Women with a history of neural tube defects or epilepsy should take 5mg daily.

·         Iron, Zinc, Vitamin A 10,000 IU, Iodine and Calcium may be taken during the preconception period depending on the health status of the patient and any underlying medical conditions or risks.

Management of Pre-existing medical problems

1. Stabilize medical conditions and ensure that medical control is optimal
2. Check that any drugs or treatments used are safe for use in pregnancy and do not affect sperm function( cytotoxic and radiation, smoking and alcohol etc.)
3. Where appropriate, refer women for specialised care.

2. Pillar 2: Focused Antenatal Care – To prevent complications where possible and ensure that complications of pregnancy are detected early and treated appropriately.  

Definition of antenatal care

Antenatal care (ANC) is health care given to a pregnant woman from conception to the onset of labour.

Aim of antenatal care

To achieve a good outcome for the mother and baby and prevent any complications that may occur in pregnancy, labour, delivery and the postpartum period

The approach

The risk approach to antenatal care has not resulted in significant improvement in maternal survival. Life threatening complications of pregnancy are difficult to predict with any degree of certainty. Health care providers must, therefore, consider the possibility of complications in every pregnancy and prepare clients accordingly.

While risk assessment can help direct counseling and treatment for individuals, it is important to understand that most women who experience complications have no 'risk factors' at all.

Every pregnant, delivering or postpartum woman is at risk of serious life threatening complications!

FANC: Focused antenatal care

Focused or targeted ANC refers to a minimum number of four comprehensive personalised antenatal visits, each of which has specific items of client assessment, education and care to ensure prevention or early detection and prompt management of complications. The focus is on birth preparedness and on individuals  readiness to handle complications. Always view each visit as if it were the only visit the woman may make. Many women cannot come for 4 visits

Antenatal care should be simpler, safer, friendly and more accessible. Women are more likely to seek and return for services if they feel cared for and respected by their providers. This personalized approach requires health care providers to use excellent interpersonal skills since listening to client's concerns is just as important as giving advice. It respects clients’ right to dignity, privacy, confidentiality, full and accurate information.

The objectives of focused antenatal care are:

1.      Early detection and treatment of problems

2.      Prevention of complications using safe, simple and cost-effective interventions

3.      Birth preparedness and complication readiness

4.      Health promotion using health messages and counseling

5.      Provision of care by a skilled attendant

Schedule of Visits

It is recommended that the pregnant woman should attend a minimum of four comprehensive personalized antenatal visits spread out during the entire pregnancy during which specific focused activities are carried out to guide the woman along the path of survival, as follows:

1.      First visit less than 16 weeks

2.      Second visit   16 - 28 weeks

3.      Third visit      28-32 weeks

4.      Fourth visit    32 – 40 weeks

N.B Depending on individual need, some women will require additional visits.

1. The first visit:

Content of the first visit

a) Obtain information on:

Personal history

1. Name
2. Age (date of birth)
3. Physical address and telephone number
4. Marital status
5. Educational level: primary, secondary, university
6. Economic resources: employed? Type of work, position of patient and husband/guardian
7. Tobacco use (smoking or chewing habit) or use of other harmful substances?

History of present pregnancy

·         Date of last menstrual period (LMP); certainty of dates (by regularity, accuracy of recall and other relevant information including contraceptive history). Determine the expected date of delivery based on LMP and all other relevant information. Use 280-day rule (LMP + 280 days). Some women will refer to the date of the first missed period when asked about LMP, which may lead to miscalculation of term by four weeks

·         Quickening if applicable

·         Any unexpected event (pain, vaginal bleeding, other: specify)

·         Malaria attacks

·         Habits: smoking/chewing tobacco, alcohol, drugs (frequency and quantity)

 

Obstetric history

·         Number of previous pregnancies (Gravida and Parity)

·         Date (month, year) and outcome of each event (live birth, stillbirth, neonatal death, abortion, ectopic, hydatidiform mole)

·         Specify (validate) preterm births

·         Specify type and gestation of any abortion, and management if possible (MVA, D&C)

·         Birth weight of previous pregnancies (if known)

·         Sex of the baby / babies

·         Puerperium (eventful or uneventful)

·         Periods of exclusive breast-feeding: when? For how long?

·         Special maternal complications and events in previous pregnancies;

 

Specify which pregnancy, validate by records (if possible):

·         recurrent early abortion

·         induced abortion and any associated complications

·         thrombosis, embolus

·         hypertension, pre-eclampsia or eclampsia

·         placental abruption

·         placenta praevia

·         breech or transverse presentation

·         obstructed labour, including dystocia

·         third-degree tears

·         third stage excessive bleeding

·         puerperal sepsis

·         Gestational diabetes.

Obstetrical operations:

·         caesarean section (indication, if known)

·         forceps or vacuum extraction

·         manual removal of the placenta

·         destructive procedures (craniotomy, decapitation)

Special perinatal (foetal, newborn) complications and events in previous

·         Pregnancies; specify which pregnancy, validate by records (if possible):

·         twins or higher order multiples

·         low birth weight: <2500 g

·         intrauterine growth restriction (if validated)

·         rhesus-antibody affection (hydrops)

·         malformed or chromosomally abnormal child

·         macrosomic (>4500g) newborn

·         resuscitation or other treatment of newborn

·         perinatal, neonatal or infant death (also: later death)

Medical history

Specific diseases and conditions:

·         tuberculosis, heart disease, chronic renal disease, epilepsy, diabetes mellitus

·         oRTIs

·         HIV status, if known

·         other specific conditions depending on prevalence in the region, e.g. hepatitis, malaria, sickle cell trait

·         operations other than caesarean section

·         blood transfusions

·         Rhesus D negative antibodies

·         current use of medicines: specify

·         Period of infertility: when? duration, cause(s)

·         Any other diseases, past or chronic; allergy

b) Perform physical examination

·         General appearance

·         Head to toe examination

·         Measure blood pressure, pulse, temperature

·         Record weight (kilograms) and height (metres) to assess the mother's nutritional status

·         Check for signs of anaemia: pale complexion, fingernails, conjunctiva, oral mucosa, tip of tongue and shortness of breath

·         Examine the chest, including breast exam and heart auscultation

·         Measure uterine size (fundal height)

·         Signs of previous caesarean section (scar)

·         Foetal presentation and heart sounds if applicable

·         Inspection of the external genitalia to assess for abnormalities:

·         -FGM status: - If type III discuss the possibility of de-infibulation (opening up either antenataly or during labour)

·         -Varicosities, warts, discharge

c) Perform the following tests:

·         Urine: multiple dipstick test for proteinuria, acetone and sugar for all women and urinalysis for bacteriuria

·         Blood: syphilis (VDRL or RPR)

·         Blood-group typing (ABO and rhesus)

·         Haemoglobin (Hb)

·         Counseling and testing for HIV

·         Sputum for AFB if indicated.

 

d) Implement the following interventions:

·         Iron and folic acid supplements to all women

·         If test for syphilis is positive: treat

·         Tetanus toxoid ( See the 5 TT schedule as per the Kenya guidelines)

·         Refer woman when complications arise that cannot be managed at that facility, e.g.:

·         Severe anaemia, Hb <7.0 g/ml

·         Antepartum Haemorrhage

·         High blood pressure (>140/90 mm Hg)

·         Intra-uterine growth restriction / IUCD

·         Underweight, use mid upper arm circumference(MUAC)

·         Polyhydramnios

·         Tuberculosis

·         Opportunistic infections / AIDS

·         If the first visit is after 16 weeks, give:

·         In malaria endemic areas: sufadoxine/pyrimethamine (IPT), three tablets once to be taken at the facility under supervision(DOT)

·         Mebendazole 500mg stat

e) Assess the need for specialized care

Determine whether the woman is in need of special care and/or referral to a specialized clinic or hospital. The following conditions might require specialised care:

Diabetes

Heart disease

Renal disease

Epilepsy

Drug abuse

Family history of genetic disease

Objective 2: Outline the components of an individual birth plan

f) Development of an individual birth plan

Assist the pregnant woman to develop an Individual Birth Plan (IBP). Encourage the male partner to be involved in the health care of the mother-to-be and his baby and they should know:

·         The Expected Date of Delivery (EDD)

·         The danger signs in pregnancy, childbirth and the postpartum period.

·         The danger signs for the newborn.

·         She should decide on who will be the skilled attendant at her delivery and where

·         She should be advised to identify a birth companion

·         What transport she will use before, during labour and after delivery if complications arise

·         How she will raise funds for transport, delivery charges and for essential items/supplies

·         Identification of possible blood donors in case of haemorrhage

·         Her postpartum contraception plans and subsequent reproductive goals

·         A decision maker is identified in case of emergency

·         Where women have a bad obstetric history like previous caesarean section, stillbirth, retained placenta / PPH, the woman should be advised to deliver at a facility that can provide Comprehensive Emergency Obstetric and Newborn Care (CEONC)

·         Where multiple pregnancies have been diagnosed, the woman should be referred immediately to a CEONC facility for confirmation of the multiple pregnancies and planning for the delivery.

Objective 3.Identify the danger signs in pregnancy, labour and puerperium

Advice on complications and danger signs

Counsel on possible complications during pregnancy, labour and postpartum period

 Danger signs in pregnancy

·         Bleeding per vagina

·         Bleeding

·         Drainage of liquor

·         Severe abdominal pains

·         Severe headaches

·         Generalized body swelling

·         Reduced foetal movements

·         Convulsions

Danger signs in labour

·         Labour pains for more than 12 hours (sun rise to sunset)

·         Excessive bleeding

·         Ruptured membranes without labour for more than 12 hours

·         Convulsions during labour

·         Loss of consciousness

·         Cord, arm or leg prolapse

Danger signs in postpartum period (mother) - Excessive bleeding

·         Fever

·         Foul smelling discharge

·         Abdominal cramps or pains

·         Painful breasts or cracked nipples

·         Mental disturbances

·         Extreme fatigue

·         Facial or hand swelling

·         Headaches

·         Convulsions

·         Painful calf muscles

Danger signs in postpartum period (newborn)

·         Fast breathing(more than 60 breaths/minute)

·         Slow breathing less than 30 breaths per minute

·         Severe chest in-drawing - Grunting

·         Umbilicus draining pus /redness extending to skin

·         Floppy or stiff

·         Fever(temp 38 degree c and above

·         Convulsions

·         More than 10 skin pustules

·         Bleeding from stump/cut

·         Give advice on whom to call or where to go in case of any of the above complications / emergencies

h) Health promotion, questions and answers, and scheduling the next appointment

·         Advice on personal hygiene, rest, nutrition, family planning, malaria, worm infestations, HIV/AIDS and PMTCT.

·         Give advice on safer sex. Emphasize the risk of acquiring or transmitting HIV or STIs without the use of condoms

·         Advise women to stop the use of tobacco (both smoking and chewing), alcohol and other harmful substances

·         Counsel on breast-feeding of the last born child; when to stop breast-feeding, generally until seven months gestation (but avoid breastfeeding if there is history of habitual abortion)

·         Counsel on exclusive and early initiation of breast-feeding (alternative options will be discussed in other chapters)

·         Counsel on the signs of labour (contractions, vaginal discharge, lower abdominal pains)

·         In case of an emergency home delivery the mother should be encouraged to visit the health facility within 48 hrs for a postnatal check-up

·         Request the woman to record when she notes the first foetal movement

·         Advise the woman to bring her partner (or a family member or friend) to later ANC visits so that they can be involved in the activities and can learn how to support the woman throughout her pregnancy, childbirth and postnatal period

·         Schedule appointment as per recommendations (state date, and hour). This should be written in the woman’s antenatal card and in the clinic’s appointment book.

I) Maintain complete records

·         Complete clinic record. Give the ANC card/ mother child booklet to the patient and advise her to bring it with her to all appointments she may have with any health services.

2. The second visit:

Contents of the second visit

a) Obtain information on:

Personal history

·         Note any changes since first visit

·         Check-up on habits: smoking, alcohol, other

Present pregnancy

·         Note abnormal changes in body features or physical capacity (e.g. peripheral swelling, shortness of breath), observed by the woman herself, by her partner, or other family members

·         Record symptoms and events since first visit: e.g. pain, bleeding, vaginal discharge (amniotic fluid or any other), and manage appropriately

·         Check for signs and symptoms of anaemia.

·         Note foetal movements; record time of first recognition

·         Review the individualised birth plan

·         Obstetric history

·         Review relevant issues of obstetric history as recorded at first visit.

·         Medical history

·         Review relevant issues of medical history as recorded at first visit

·         Note any inter-current diseases, injuries, or other conditions since first visit

·         Note intake of medicines, e.g. anti-TB, ARTs and check on compliance

·         Iron and folate intake: check on compliance

·         Note other medical consultations, hospitalization or sick-leave since last visit

b) Perform physical examination

·         Measure blood pressure and pulse

·         Fundal height

·         Oedema

·         Other signs of disease: shortness of breath, coughing, others.

·         Vaginal examination: do only if indicated. If patient is bleeding or spotting, do not perform vaginal examination but refer for further management.

c) Perform the following tests:

·         Urine: repeat multiple dipstick test to detect urinary-tract infection, proteinuria, and sugar

·         Blood: repeat Hb if Hb at first visit was below 7.0 g/m1 or signs of anaemia are detected on examination.

d) Implement the following interventions:

·         Iron: continue; if Hb is <7.0 g/ml, consider further investigations

·         If bacteriuria was treated at first visit and test is still positive, consider culture, change treatment and/or refer

·         Tetanus toxoid in line with national guidelines

·         In malaria endemic areas: administer sufadoxine/pyrimethamine as per national guidelines

·         Administer mebendazole 500mg stat after 1st trimester

·         68 National Guidelines for Quality Obstetrics and Perinatal Care

e) Re-assess for complications and possible referral

·         Reassess whether the woman has developed any new complications since first visit, and refer/manage appropriately

·         Hb <7.0 g/ml at first and present (second) visit

·         APH / spotting

·         high blood pressure (>140/90 mm Hg):

·         foetal growth restriction

·         gestation diabetes

·         reduced foetal movement

·         polyhydramnios

·         malnutrition

·         opportunistic infections

f) Advice, questions and answers, and scheduling the next appointment

·         Repeat all the advice given at the first visit

·         Questions & answers: time for free communication

·         Schedule the next appointment

g) Maintain complete records

Complete clinic record. Give the ANC card /mother child booklet to the patient and advise her to bring it with her to all appointments she may have with any health services.

3. The third visit:

Contents of the third visit

a) Obtain information on:

Personal history

·         Note any changes since second visit

·         Check-up on habits: smoking, alcohol, other

·         Present pregnancy

·         Note abnormal changes in body features or physical capacity (e.g. peripheral swelling, shortness of breath), observed by the woman herself, by her partner, or other family members

·         Record symptoms and events since second visit: e.g. pain, bleeding, vaginal discharge (amniotic fluid or any other), and manage appropriately

·         Check for signs and symptoms of anaemia.

·         Note foetal movements

·         Review the individualised birth plan

·         Obstetric history

·         Review relevant issues of obstetric history as recorded at first visit.

·         Medical history

·         Review relevant issues of medical history as recorded at first and second visit

·         Note any inter-current diseases, injuries, or other conditions since second visit

·         Note intake of medicines, e.g. anti-TB, ARTs and check on compliance

·         Iron and folate intake: check on compliance

·         Note other medical consultations, hospitalization or sick-leave since last visit

b) Perform physical examination

·         Measure blood pressure and pulse

·         Fundal height

·         Palpate abdomen for multiple pregnancy

·         Oedema

·         Other signs of disease: shortness of breath, coughing, others.

·         Vaginal examination: do only if indicated. If patient is bleeding or spotting, do not perform vaginal examination but refer for further management.

c) Perform the following tests:

·         Urine: repeat multiple dipstick test to detect urinary-tract infection, proteinuria, and sugar

·         Blood: repeat Hb if Hb at previous visit was below 7.0 g/m1 or signs of anaemia are detected on examination.

d) Implement the following interventions:

·         Iron: continue; if Hb is <7.0 g/ml, consider further investigations

·         If bacteriuria was treated at previous visit and test is still positive, consider culture, change treatment and/or refer

·         Tetanus toxoid in line with national guidelines

·         In malaria endemic areas: administer sufadoxine/pyrimethamine as per national guidelines

e) Re-assess for complications and possible referral

Follow up on previous observations and assess for new complications, and refer/manage appropriately

·         Hb <7.0 g/ml at first and present (second) visit

·         APH / spotting

·         high blood pressure (>140/90 mm Hg):

·         foetal growth restriction

·         multiple pregnancy

·         gestation diabetes

·         reduced foetal movement

·         polyhydramnios

·         malnutrition

·         opportunistic infections

·         any other alarming symptoms or signs

f) Advice, questions and answers, and scheduling the next appointment

·         Repeat all the advice given at the first and second visit

·         Give advice on measures to be taken in case of (preterm) labour

·         In case of suspected twins, advice mother to visit a facility that can provide Comprehensive Emergency Obstetric and Newborn Care to prepare for delivery

·         Reconfirm in writing on whom to call and where to go in case of emergency or any other need

·         Plans to ensure transport is available in case of need during labour

·         Questions & answers: time for free communication

·         70 National Guidelines for Quality Obstetrics and Perinatal Care

·         Provide recommendations on lactation, contraception and the importance of the postpartum visits.

·         Schedule appointment: fourth visit

g) Maintain complete records

Complete clinic record. Give the ANC card /mother child booklet to the patient and advise her to bring it with her to all appointments she may have with any health services.

1.      The fourth visit:

Content of the fourth visit

a) Obtain information on:

Personal history

·         Note any changes since second visit

·         Check-up on habits: smoking, alcohol, other

·         Present pregnancy

·         Note abnormal changes in body features or physical capacity (e.g. peripheral swelling, shortness of breath), observed by the woman herself, by her partner, or other family members

·         Record symptoms and events since second visit: e.g. pain, bleeding, vaginal discharge (amniotic fluid or any other), and manage appropriately

·         Check for signs and symptoms of anaemia.

·         Note foetal movements

·         Review the individualised birth plan

·         Obstetric history

·         Review relevant issues of obstetric history as recorded at first visit.

·         Medical history

·         Review relevant issues of medical history as recorded at first and second visit

·         Note any inter-current diseases, injuries, or other conditions since second visit

·         Note intake of medicines, e.g. anti-TB, ARTs and check on compliance

·         Iron and folate intake: check on compliance

·         Note other medical consultations, hospitalization or sick-leave since last visit

b) Perform physical examination

·         Measure blood pressure and pulse

·         Fundal height

·         Palpate abdomen for multiple pregnancy

·         Oedema

·         Other signs of disease: shortness of breath, coughing, others.

·         Vaginal examination: do only if indicated. If patient is bleeding or spotting, do not perform vaginal examination but refer for further management.

c) Perform the following tests:

·         Urine: repeat multiple dipstick test to detect urinary-tract infection, proteinuria, and sugar

·         Blood: repeat Hb if Hb at previous visit was below 7.0 g/m1 or signs of anaemia are detected on examination.

d) Implement the following interventions:

·         Iron: continue; if Hb is <7.0 g/ml, consider further investigations

·         If bacteriuria was treated at previous visit and test is still positive, consider culture, change treatment and/or refer

·         Tetanus toxoid in line with national guidelines

·         In malaria endemic areas: administer sufadoxine/pyrimethamine as per national guidelines

e) Re-assess for complications and possible referral

Follow up on previous observations and assess for new complications, and refer/manage appropriately

·         Hb <7.0 g/ml at first and present (second) visit

·         APH / spotting

·         high blood pressure (>140/90 mm Hg):

·         foetal growth restriction

·         multiple pregnancy

·         gestation diabetes

·         reduced foetal movement

·         polyhydramnios

·         malnutrition

·         opportunistic infections

·         any other alarming symptoms or signs

f) Advice, questions and answers, and scheduling the next appointment

·         Repeat all the advice given at the first and second visit

·         Give advice on measures to be taken in case of (preterm) labour

·         In case of suspected twins, advice mother to visit a facility that can provide Comprehensive Emergency Obstetric and Newborn Care to prepare for delivery

·         Reconfirm in writing on whom to call and where to go in case of emergency or any other need

·         Plans to ensure transport is available in case of need during labour

·         Questions & answers: time for free communication

·         70 National Guidelines for Quality Obstetrics and Perinatal Care

·         Provide recommendations on lactation, contraception and the importance of the postpartum visits.

·         Schedule appointment: fourth visit

g) Maintain complete records

Complete clinic record. Give the ANC card /mother child booklet to the patient and advise her to bring it with her to all appointments she may have with any health services.

1.      The fourth visit:

Content of the fourth visit

a) Obtain information on:

Personal history

·         Note any changes since third visit

·         Check-up on habits: smoking, alcohol, other

·         Present pregnancy

·         Note abnormal changes in body features or physical capacity (e.g. peripheral swelling, shortness of breath), observed by the woman herself, by her partner, or other family members

·         Record symptoms and events since third visit: e.g. contractions (pre-term labour?), pain, bleeding, vaginal discharge (amniotic fluid or any other), and manage appropriately

·         Check for signs and symptoms of anaemia.

·         Note foetal movements

·         Review the individualised birth plan

·         Obstetric history

·         Review relevant issues of obstetric history as recorded at first visit.

·         Medical history

·         Review relevant issues of medical history as recorded at previous visits

·         Note any inter-current diseases, injuries, or other conditions since third visit

·         Note intake of medicines, e.g. anti-TB, ARTs and check on compliance

·         Iron and folate intake: check on compliance

·         Note other medical consultations, hospitalization or sick-leave since last visit

b) Perform physical examination

·         Measure blood pressure and pulse

·         Fundal height

·         Palpate abdomen for multiple pregnancy and presentation

·         Oedema

·         Other signs of disease: shortness of breath, coughing, others.

Vaginal examination: do only if indicated. If patient is bleeding or spotting, do not perform vaginal examination but refer for further management.

c) Perform the following tests:

·         Urine: repeat multiple dipstick test to detect urinary-tract infection, proteinuria, and sugar

·         Blood: repeat Hb if Hb at previous visit was below 7.0 g/m1 or signs of anaemia are detected on examination.

·         71 National Guidelines for Quality Obstetrics and Perinatal Care

d) Implement the following interventions:

·         Iron: continue; if Hb is <7.0 g/ml, consider further investigations

·         If bacteriuria was treated at previous visit and test is still positive, consider culture, change treatment and/or refer

·         In malaria endemic areas: administer sufadoxine/pyrimethamine as per national guidelines

e) Re-assess for complications and possible referral

Follow up on previous observations and assess for new complications, and refer/manage appropriately

·         Hb <7.0 g/ml at first and present (second) visit

·         APH / spotting

·         high blood pressure (>140/90 mm Hg):

·         foetal growth restriction

·         abnormal presentation / twin pregnancy

·         gestation diabetes

·         reduced foetal movement

·         polyhydramnios

·         malnutrition

·         opportunistic infections

·         any other alarming symptoms or signs

f) Advice, questions and answers, and scheduling the next appointment

·         Repeat all the advice given at the first and second visit

·         Give advice on measures to be taken in case of the initiation of labour or leakage of amniotic fluid.

·         In case of suspected twins and/or malpresentation, advice mother to deliver at facility that can provide Comprehensive Emergency Obstetric and Newborn Care

·         Reconfirm in writing on whom to call and where to go in case of emergency or any other need

·         Plans to ensure transport is available in case of need during labour

·         Questions & answers: time for free communication

·         Provide recommendations on lactation, contraception and the importance of the postpartum visits.

·         Schedule appointment: if not delivered by end of week 41 (state date and write it in the ANC card), go to hospital for check-up.

g) Maintain complete records

Complete clinic record. Give the ANC card to the patient and advise her to bring it with her to all appointments she may have with any health services.

The Mother and Child Health Booklet

·         On the new Ministry of Health MCH Health Booklet, you will see a place to record:

·         Personal information

·         Medical and surgical history; information on previous pregnancies, gravida and parity.

·         Findings of the general physical examination

·         A checklist to record additional data: urine, Hb, pallor, maturity, fundal height, presentation, lie, foetal heart rate and oedema

·         Intermittent Preventive Treatment for Malaria

·         Complications and/or referral information

·         Laboratory data

·         Delivery

·         Immunization and maternal medication information.

·         Post natal information and a place to record general "notes"

·         Family Planning usage

National guidelines for IPT

 Intermittent Preventive Treatment (IPT) an effective approach to preventing malaria in pregnant women by giving antimalarial drugs in treatment doses at defined intervals after quickening to clear a presumed burden of parasites

·          The Ministry of Health Guidelines on Malaria directs us to give SP to pregnant women in endemic malaria areas, at least twice during each pregnancy, even if she has no physical signs and her haemoglobin is within normal range.

·          Administer IPT with each scheduled visit after quickening (16 weeks) to ensure women receive at least 2 doses at an interval of at least 4 weeks.

·          IPT should be given under Directly Observed Therapy (DOT) in the ANC clinic and can be given on an empty stomach

 

DOSE OF TT	When to give
1	At first contact or as early as possible in pregnancy
2	At least 4 weeks after TT1
3	At least 6 months after TT2 or during subsequent pregnancy
4	At least 1 year after TT3 or during subsequent pregnancy
5	At least 1 year after TT4 or during subsequent pregnancy

3. Pillar 3. Essential Obstetric Care – To ensure that essential care for the high-risk pregnancies and complications is made available to all women who need it.

4. Pillar 4. Essential Newborn Care – To ensure that essential care is given to newborns from the time they are born up to 28 days in order to prevent complications that may arise after birth.

5. Piilar5. Targeted Postpartum Care– To prevent any complication occurring after childbirth and ensure that both mother and baby are healthy and there is no transmission of infection from mother to child.

6. Pillar 6; Post Abortion Care – to provide clinical treatment to all women and girls seeking care, for complications of incomplete abortion and miscarriage as well as counseling and contraceptives.

(Note that HIV PMTCT services are now integrated into ALL the pillars of MNH and clean and safe delivery is part of Essential Obstetric Care)

Skilled Attendance

Skilled attendance at birth (skills, numbers, enabling environment) and availability of Emergency Obstetric Care, will reduce maternal and neonatal deaths.

Skilled attendant

The emphasis for improving maternal health must be on training and deploying an adequate number of skilled health workers to provide antenatal, intrapartum and postnatal care. The term "skilled attendant" refers exclusively to people with midwifery skills (e.g. doctors, midwives, nurses, clinical officers) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications. Health centers and dispensaries that provide delivery services to expectant women should be adequately staffed with a skilled birth attendant and midwives that can assist women during birth.

Enabling Environment

The skilled attendant requires an enabling environment with appropriate infrastructure as well as ensuring that there is effective referral system that is supported by adequate supplies, equipment, drugs, good management and supportive supervision.

Coordination of MNH services

The coordination of MNH services nationally is part of the core mandate of the Division of Reproductive Health Ministry of Public Health and Sanitation. Within the Ministry of Medical services, the Division of Obstetrics and Gynaecology oversees these services with support from the Division of Paediatrics. This is in line with the National Health policy framework, Vision 2030, the National Health Sector Strategic Plan, and the Reproductive Health Policy.

Quality of MNH care

The quality of MNH care is achieved and maintained by adhering to Quality Assurance standards. Through Quality Improvement approaches such as: the Service Charter, Client Oriented Provider Efficiency (COPE), Performance Improvement Approach (PIA), Kenya Quality Model (KQM), Standard Based Management and Recognition (SBM-R); etc. The above quality improvement approaches and tools complement support supervision.

Referral Systems

A key aspect in ensuring a good maternal health service is a functional referral system. Access to a telephone and/or vehicle, with emergency funds or fuel to transfer urgent cases day or night is extremely important. Good record keeping and use of detailed referral letters will assist in reducing delay in the care for women with obstetric emergencies and severely ill newborns.

Effective communication between health care providers at both the community level and at the point of referral is essential for management of obstetric emergencies and for ensuring continuity of care.

The referral system can be strengthened through active supportive supervision, regular feedback on cases, continuing education and formal in-service update sessions.

Consultations between Dispensaries, Health Centres and the hospitals including the use of telemedicine and other modern technologies facilitates patient management, and reduces unnecessary referrals and delays. For further reading, please refer to the National Referral Guidelines 2009.

Community Action, Partnerships

Involving community members (particularly women and their families, health care providers, and local leaders) in efforts to improve maternal health helps to ensure programme success; Community education about obstetric complications and when and where to seek medical care is important to ensure birth planning/ use of birth preparedness cards, early recognition of complications and prompt care-taking behaviour

Male involvement and participation

Previously MNH issues have been considered to be women issues; however it is evident that for successful programme implementation, male participation is imperative. However, studies have shown that male involvement in MNH results in good outcomes for both mother and baby. Male involvement and participation is critical in addressing the first and second delay. In the Kenyan context, men have the resources and are the main decision makers in the families and communities on issues relating to MNH.

Equity for All

Rights based perspective helps legitimize prioritization of women’s health. It focuses attention on social, economic and geographic inequities. Strong political support and national ownership are essential to create enabling policies to attract resources for maternal and newborn health and to ensure those resources reach groups with the highest maternal mortality and morbidity.

Reproductive Rights

Health care providers should appreciate that most maternal and neonatal deaths are avoidable, and therefore maternal and newborn health must be given its due prominence. Safe Motherhood is a basic human right as women are entitled to enjoy a safe pregnancy and childbirth.

THE SAFE MOTHERHOOD INITIATIVE

Maternal and newborn morbidity and mortality have been recognized internationally as public health priorities. The Global Safe Motherhood Initiative launched in Nairobi in 1987 aimed at reducing the burden of maternal deaths and ill health in developing countries.

The Safe Motherhood Initiative differed from other health initiatives in that it focused on the wellbeing of women as an end in itself while MNH focused on the mother and the unborn baby. It underscored the fact that Safe motherhood is a basic human right.

CLIENT AND PROVIDERS SERVICE RIGHTS

Clients Rights include:

1. Right to Information

All members of the community have a right to information on the benefits of reproductive health including Maternal and Newborn health for themselves and their families. They also have a right to information on how to access the services.

2. Right to Access

All members of the community have a right to receive services from reproductive health / MNH programs, regardless of their socio-economic status, political affiliations, religious beliefs, ethnic origin, marital status or geographical location. Access includes freedom from barriers such as policies, standards and practices, which are not scientifically justifiable.

3. Right of choice

Individuals and couples have the right to decide freely where to obtain RH /MNH services. 22 National Guidelines for Quality Obstetrics and Perinatal Care

4. Right to safety

Clients have a right to safety in the practice of MNH

5. Right to Privacy

Clients have a right to privacy while holding conversation with service providers and while undergoing physical examination.

6. Right to Confidentiality

The client should be assured that any information she/he provides or any details of the service received will not be communicated to other parties without her/his consent.

7. Right to Dignity

Reproductive Health /MNH clients have a right to be treated with courtesy, consideration, and attentiveness and with full respect of their dignity regardless of their level of education, social status or any other characteristics, which would single them out or make them vulnerable to abuse.

8. Right to Comfort

Clients have a right to comfort when receiving services. This can be ensured by providing quality services in hygienically safe and conveniently located service delivery sites.

9. Right to Continuity of Care

Clients have a right to receive services and reliable supply of RH /MNH commodities and drugs for as long as they need them.

10. Right of Opinion

Clients have a right to express their views freely on the services they receive.

PROVIDERS’ RIGHTS

Outlined below are some needs of Providers, which if met will contribute to facilitating the provision of quality services that in turn address the rights of their clients.

1. Training

To continuously have access to the knowledge and skills needed to perform all the tasks required of them.

2. Information

To be kept informed on issues related to their duties

3. Infrastructure

To have appropriate physical facilities and organization to provide services at an acceptable level of quality.

4. Supplies

To receive continuous and reliable supplies and materials required for providing reproductive health services at acceptable standards of quality.

5. Guidance

To receive clear, relevant and objective guidance.

6. Back up

To be reassured that whatever the level of care at which they are working they will receive support from other individuals or units.

7. Respect

To receive recognition of their competence and potential, and respect for their human needs.

8. Encouragement

To be given stimulus in the development of their potential, initiative and creativity.

9. Feedback

To receive feedback concerning their competence and attitudes as judged by others.

10. Self–expression

To express their views freely, concerning the quality and efficiency of the reproductive health program.