FOCUSED AN

NTENATAL CARE
MALARIA IN PREGNAN
NCY

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION

TUBERCULOSIS

Orientation Package
for Service Providers

4th Edition 2007

© M O H -D R H /D O M C /D LTLD /JH PIEG O
 A C K N O W LED G EM EN T

The revision ofthis edition has been m ade possible through funding from U SA ID and W H O .
W e w ould like to take this opportunity to thank D FID for availing funds for the tw o earlier
versions of this package and Population Councilfor their substantialinput. W e w ould also
like to take this opportunity to thank allthose w ho have participated in the in developm entof
this orientation package and im plem enting FA N C/M IP/PM TCT in different districts in the
country.

W e appreciate the trem endous supportthatthe follow ing institutions have provided tow ards
the developm entofthis orientation package.These include:M inistry ofH ealth H eadquarters,
D ivision of Reproductive H ealth (D RH ), D ivision of M alaria Control (D O M C), N ational
A ID S & STI Control Program (N A SCO P), D ivision of Leprosy, Tuberculosis and Lung
D isease (D LTLD ), D ivision of N ursing, D ivision of Clinical O fficers, D ivision of Public
H ealth,The N ursing Councilof K enya,U niversity of N airobidepartm entof O bstetrics and
G ynaecology, departm ent of Paediatrics, Provincial G ynaecologists, D istrict H ealth
M anagem entTeam s and JH PIEG O /John H opkins U niversity.

G ratitude is also extended to allthose people w ho have contributed in one w ay oranother

tow ards the finalization ofthis orientation package

© M O H -D RH /D O M C/D LTLD /JH PIEG O

 Tabl
ab e ofcont
o co te
ent
ts
ƒ Forew ord … ...… … … … … … … … .… ...… … … .… … … … … … … … … … … … … … .1
ƒ A cknow ledgem ent
ent… ...… … … … … … … … … .… … … … … … … … … … … … … … .2 2
ƒ Table ofC ontents … ...… … … … … … … … ....… … … … … ..… … … … … … … … … . 3
ƒ A cronym s … ...… … … … … … … … … … … … … … … … … … … .… … … … … … … … . 4
ƒ O rientation Package … ...… … … … … … … … … … … … … … … … … ...… … … … .5- 56
ƒ O verview ofM aternalM ortality … ...… … … … … … … … … … … … … … … … ..7-10
ƒ Focused A ntenatalC are… ...… … … … … … … … … … … … … … … … … … ..… 11-55
ƒ Tuberculosis in Pregnancy… … … … … … … … … … … … … … ..… … … … .… 56-92
ƒ M alaria in Pregnancy...........… … … … … … … … … … … … .........… … … … ..93-116
ƒ M alaria C ase M anagem
g ent.....................................................................117-137
ƒ A naem ia in Pregnancy........… … … … … … … … … … ........… … … ...… … ..138-147
ƒ Vitam in A … .… … … … … … … … … … … … … … … … … … … .… … … … ...… ..148-150
ƒ Preventing M other-too-C hild Transm ission (PM TC T)ofH IV… … … .....151 .151-174
ƒ Q uality A ntenatalC are… … .… … … … … … … … … … … … … … .… … … … .175-177
ƒ Infection Prevention… … … ..… … … … … … … … … … … … … ..… … … .… ..178-179
ƒ G roup W ork…k … … … … … … … … … … … … … … … … … … … … ..… … … … .180- 180 185
ƒ ListofA nnexes… … … … … … … … … … … … … … … … … … … … ..… … … … … ..186

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 ACRONYMS
ƒ AIDs - Acquired Immunodeficiency syndrome ƒ INH - Isoniazid

ƒ AL - Artemether –Lumefantrine ƒ IPT - Intermittent Preventive Treatment

ƒ ANC - Ante Natal Clinic ƒ ITNs - Insecticide Treated Nets

ƒ APH - Ante partum Hemorrhage ƒ IV - Intravenous

ƒ CCC - Comprehensive care Clinic ƒ LAB - Laboratory

ƒ DOT - Directly Observed Therapy ƒ LAM - Lactational Amenorrhea

ƒ FANC - Focused Antenatal Care ƒ LLINs - Long Lasting Insecticidal net

ƒ FP -Family Planning ƒ MCH - Maternal Child Health

ƒ GIT - Gastrointestinal Tract ƒ PMTCT - Prevention Mother to Child Transmission

ƒ HIV - Human Immune deficiency Virus ƒ PTB - Pulmonary Tuberculosis

ƒ IBP - Individual Birth Plan ƒ SP - Sulfadoxine Pyrimethamine

ƒ IC - Intravascular coagulation ƒ STI - Sexually Transmitted Infections

ƒ IUCD - Intra Uterine Contraceptive Device ƒ TBA - Traditional Birth Attendant

ƒ IM - Intramuscular
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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 What iss an orientation
or ntat on pac
package?
ag ?
ƒ A collection of materials and activities that aims to
hi hli h KEY useful,
highlight f l practicali l points
i f providers.
for id
ƒ The orientation is done centrally (provincial) and then
“ h ” (repeat)
“echo” ( t) sessions
i are done
d att di
district
t i t andd
facility levels.
ƒ O i t ti package
Orientation k ttraining
i i sessions
i are short-
h t
generally lasting for approximately 3 days
ƒ M t i l usually
Materials ll iinclude
l d national
ti l guidelines/strategies.
id li / t t i
ƒ Critical information that providers need to remember in
d t d p
day-to-day practice
ti is compiled
mpil d onto
nt J Jobb aids.
ids
ƒ Orientation packages include exercises that help health
care workers look at their values and attitudes in
relation to the particular component being addressed.

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5
This orientation package focuses on
the content of quality:
ƒ Focused Antenatal Care
ƒ Intermittent Preventive Treatment
ƒ Malaria Case Management
ƒ PMTCT
ƒ TB screeningg in pregnancy
p g y
ƒ TB case management and referral
ƒ Enhancing linkages within the existing
structures in provision of comprehensive FANC
ƒ Community
C it role
l in
i promotion
ti off care seeking
ki
behavior.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Overview of maternal mortality in Kenya
ƒ Maternal mortalityy is the number off women who
die as a result of childbearing, during the
pregnancy or within 42 days of delivery or
termination of pregnancy in one year, per 100 000
live births during that year
year.
ƒ Estimates of deaths related to p pregnancy
g y and
childbirth have increased from 260/100,000 in
1994 to 590/100,000
, in 1998. In 2003 there was
a slight decline which was 414/100,000 *, which is
still unacceptably
p y high.
g
*(Kenya DHS)
© M O H -D R H /D O M C /N LTP/JH PIEG O
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The Direct causes of maternal
mortality
y are:
ƒ Hemorrhage:
g APH and PPH
ƒ Sepsis
ƒ Pre-eclampsia
l and eclampsia
l
ƒ Ruptured uterus
ƒ Complications
p of induced
abortion

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Indirect causes of maternal deaths
in Kenya
y are...

ƒ Malaria
ƒ Anaemia
A i
ƒ HIV/AIDS
ƒ TB

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9
 Actions that improve
p women’s and newborns’
chances of survival during pregnancy and
childbirth are:
ƒ Skilled attendance at birth (a skilled birth attendant
is a trained doctor, clinical officer, nurse or midwife.)
ƒ A trained TBA is NOT a skilled birth attendant
ƒ Prepared clients- who understand danger signs and are
ready for complications.
complications
ƒ Functional referral systems, which include
communication, transportation and financial issues.
ƒ Support supervision and logistics management

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The Safe Motherhood Pillars are…

SAFE M O TH ER H O O D
+

CAR E
TAR G ETED

PO ST ABO
FO CU SED

CLEAN AN D SAF

CH ILD TR AN SM ISSIO N
PR EVE

N EO N ATAL
PR E – CO N CEP TIO N CA
FAM IL

ESSEN TIAL O BS
E
EN TIO N O F M O TH ER
S
LY PLAN N IN G &

A
A

R TIO N CAR E
AN TE

PO ST
CAR
RE
EN ATAL C AR E

TPAR TU M

STETR IC CAR E
FE D ELIV ER Y
AR E

SKILLED ATTEN D AN TS AN D EN ABLIN G EN VIR O N M EN T TO PR O VID E Q U ALITY CAR E E TO

SU PPO R TIVE H EALTH SYSTEM S

EFFECTIVE SYSTEM S O F R EFER R AL,M AN AG EM EN T,PR O CU R EM EN T,TR AIN IN G ,
SU PER VISIO N ,AN D H EALTH M AN AG EM EN T IN FO R M ATIO N SYSTEM

CO M M U N ITY ACTIO N ,PAR TN ER SH IPS,M ALE IN VO LVEM EN T

EQ
Q U ITY FO R ALL /
/R EPR O D U CTIVE R IG H TS

© M O H -D R H /D O M C /D LTLD /JH PIEG O

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 Focused Antenatal care (FANC)

What is FANC?
ƒ It is personalised care provided to a pregnant
woman which emphasises
p on the woman’s overall
health, her preparation for childbirth and readiness
for complications (emergency preparedness).

ƒ It iis timely,
I i l f friendly,
i dl simple
i l and
d safe
f service
i to a
pregnant woman.

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 AIM OF FANC

ƒ To achieve a good outcome for the mother

and baby and prevent any complications
that may occur in pregnancy, labour,
d li
delivery and
d postt partum
t

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13
 World Health Organisation
recommends that:
ƒ Women can benefit from just a few antenatal visits, as
long as those visits are thorough.

ƒ Ideally women should receive at least 4 thorough,

comprehensive personalised antenatal visits,
comprehensive, visits spread out
during the entire pregnancy.

ƒ Always view each visit as if it were the only visit the

woman may make. Many women cannot come for 4 visits.

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 F u comprehensive,
Four mp n ,
personalised antenatal visits:
1st visit: <16 weeks

2nd visit: 16-28 weeks

3rd visit:
visit 28
28-32
32 weeks

4th visit:32-40 weeks

© M O H -D R H /D O M C /N LTP/JH PIEG O
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 Objectives of Focused Antenatall Care
ƒ Early
E l detection
d andd treatment off problems
bl
ƒ Prevention of complications using safe, simple
and cost-effective interventions
ƒ Birth preparedness and complication readiness
ƒ Health promotion using health messages and
counseling
ƒ Provision of care by a skilled attendant

© M O H -D R H /D O M C /D LTLD /JH PIEG O

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 Objective one: Early detection and
treatment off PProblems
bl
ƒ Service
S i providers
id should
h ld id
identify
tif existing
i ti medical,
di l
surgical or obstetric conditions during pregnancy. Such
as:
– Severe anaemia (Hb <7gm/dl)
– Vaginal bleeding
– Pre-eclampsia
p ((increased BP,, severe oedema))
– STI’s, HIV/AIDS, TB and Malaria
– Chronic diseases (diabetes
(diabetes, heart or kidney problems)
– Decreased/absent foetal movement;
– foetal malpresentation after 36 weeks

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 Why disease detection and not risk
assessment?
ƒ Risk approach is not an efficient or effective
strategy for maternal mortality reduction
reduction.

ƒ E
Every pregnancy is at risk!
k!
– Risk factors cannot ppredict complications:
p (e.g.
g
young age does not predict eclampsia).
– Research showed that the majority
j y of women who
experienced complications were considered low
risk (90% of women considered to be high risk,
gave birth
bi h without
i h experiencing
i i a complication).
li i )

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 Why disease detection and not risk
assessment cont…..
ƒ Risk factors do not predict problems. Most high
risk women deliver without problems and most
women who develop llife-threatening
fe threaten ng compl
complications
cat ons
belong to the low risk group.

ƒ Everyy pregnant
p g delivering
g or postpartum
p p woman is
at risk of serious life-threatening complications.

Every pregnant woman should be prepared for

the possibility of complications.
complications
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19
 Objective two: Prevention of
complications
The service provider
Th d should
h ld ensure
prevention/protection of complications by providing:
ƒ Tetanus
T t t
toxoid
id to
t preventt maternal
t l and
d neonatal
t l
tetanus
ƒ Iron/folate supplementation to prevent anaemia
ƒ Use of IPT and ITNS to prevent malaria/ anaemia
ƒ Ensure
E environmental
i t lh
hygiene
i to
t preventt iintestinal
t ti l
worms
™ Presumptive treatment of hookworm infection with
Mebendazole 500mg STAT anytime after the first
trimester
trimester*
*Basic Maternal and Newborn Care: A Guide to Skilled
Providers, Page 3-58
3 58
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Objective
j three: Birth p
preparedness
p and
complication readiness
Service providers should discuss components
of birth plan which include:
ƒ Place of birth
ƒ Skilled attendant
ƒ Transportation
ƒ Funds
ƒ Birth companion
ƒ Items for clean and safe birth and for
newborn © M O H -D R H /D O M C /D LTLD /JH PIEG O
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 Objective three cont
cont…Complication
Complication
Readiness
ƒ Knowledge of danger signs; what to do if
they arise
ƒ Choose decision maker
ƒ Emergency funds
ƒ Emergency transport
ƒ Blood
Bl d ddonor

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 Discuss birth partners/companions
with your clients
ƒ A birth partner/companion may be the father of
the baby
baby, a sister,
sister a mother-in-law,
mother in law mother or an
auntie.
ƒ A birth partner/companion should be involved in
makingg the individual birth plan
p (IBP).
( )
ƒ A birth partner/companion can provide support to
the woman during pregnancy at the antenatal clinic
and during delivery.
Make sure clients at your clinic know that you welcome
birth partners/ companions
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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 Individual birth p
plan ensures
that the client:
ƒ Knows when her baby is due
ƒ Identifies a skilled birth attendant
ƒ Identifies a health facility for
delivery/emergency
ƒ Can list danger signs in pregnancy and delivery
and knows what to do if they occur
ƒ Id
Identifies
ifi a ddecision-maker
i i k iin case of
f
emergency
ƒ K
Knowss how
h to
t gett money iin case
s of
f emergency
ƒ Has a transport plan in case of emergency
ƒ Has a birth partner/companion for the birth
ƒ Has collected the basic supplies for the birth

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 15% of all pregnant women develop life-
threatening
h i complications
li i requiring
i i
obstetric care*
care
These women could die if:
ƒ Nobody is there to make timely decisions at home and
in the health facility.
facility

ƒ No plans for referral or transport have been made

made.

ƒ No plans on how to meet new financial demands are

made.

* Yuster 1995, Fortney 1995 Antenatal Care:

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 Specific transport
questions
ti f
for th
the client
li t

ƒ Where will you deliver?

ƒ Where will you go in case of an emergency?
ƒ Where is it located?
ƒ How will you get there?
ƒ H
How f
far is
i it f
from your hhome? ?
ƒ How long will it take to get there?
ƒ H
Have you maded this
h journey before?
b f
ƒ How much will it cost to arrange for transport?
ƒ How will you raise the funds for this transport?

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 Brainstorm
Financial planning in the community
In your community what
h are the
h systems you have
h put in
place to assist a pregnant woman in case of an emergency?
Some suggestions include:
ƒ Developing
D l pin a revolving
l in fund from
f m which
hi h f
families
mili s can
nbborrow
money.
(T pay f
(To for ttransportt tto a referral
f lffacility,
ilit ththe ffamily
il would
ld h
have
to pay back the debt after the birth).
ƒ Pl
Planning
i before
b f the
h bi
birth h to meet any eventualities.
li i
Health facilities setting aside part of their facility improvement
fund to meet emergency transport costs.

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 Mother-Baby Package
ƒ One pair
O i of
f sterile
st il rubber
bb gloves
l s (or
( clean
l plastic
l sti
bags that can be worn over the hands where
gloves
loves are not available)
ƒ Soap
ƒ Cotton wool
ƒ Clean, unused razor blades
ƒ Thread or string
ƒ Clothing for the baby and mother
ƒ Money to pay for transport, hospital fees, etc.
ƒ Sanitary towels, napkins

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Mother-baby package cont…

New unused
razor blade g
Thread or string Money/funds
y

Family members can help purchase the items in

the mother-baby package and can help pay for
tr nsp rt orr the deliver
transport, delivery c
costs.
sts

Cotton wool Soap

Gloves
© M O H -D R H /D O M C /N LTP/JH PIEG O
29
 Individual Birth Plan (IBP) !!

Making
k it safe
f ffor BABY
AND ME!
Make y your individual
birth plan now!

Chantt IBP to
Ch t yourselves,
l your colleagues
ll and
d clients
li t iin order
d tto iincrease
awareness of this important addition to ANTENATAL care!

© M O H -D R H /D O M C /D LTLD /JH PIEG O

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 Danger g in p
g signs pregnancy
g y
ƒ Any vaginal bleeding in pregnancy( APH,
Abortion)
ƒ Severe headache or blurred vision (high blood
pressure eclampsia)
pressure,
ƒ Swelling on the face and hands (high blood
pressure,, eclampsia)
p mp )
ƒ Convulsions or fits (high blood pressure,
eclampsia)
p
ƒ High fever ( infection)
ƒ Laboured breathing g(ppneumonia,, heart problems,
p ,
severe anemia)
ƒ Premature
m labour p
pains
ƒ Noticed that the baby is moving less or not
moving at all (fetal distress, IUD ).
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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 Other danger signs in pregnancy

ƒ Feeling very weak or tired (anemia, severe disease,

multiple pregnancy)
ƒ Vaginal discharge (STI)
ƒ Abdominal pain (STI, early labor)
ƒ Genital ulcers (STI)
( )
ƒ Painful urination (STI)
ƒ Persistent vomiting( severe malaria etc)

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Da
angersi
ge s gns
g s du
during
g labou
abourand
a d de
deliver
ey
ƒ Severe headache/visual disturbances
ƒ Severe abdominal pain
ƒ Convulsions
C l i or fits
fi d during
i llabour
b
ƒ High fever with or without chills
ƒ Foul vaginal discharge
ƒ Labour
L b pains
p i s for
f m more th
than 12 h
hourss
ƒ Ruptured
p membranes without labour
for more than 12 hours
ƒ Excessive bleeding during delivery
ƒ Cord, arm or leg prolapse
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Danger signs after
f d
delivery
l

ƒ Placenta not delivered within 30 minutes

of baby’s birth
ƒ Excessive bleeding after delivery
ƒ Severe abdominal pain
ƒ Convulsions or fits
ƒ High fever with or without chills
ƒ Foul vaginal discharge due to infections
ƒ Mood swings (depression)

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Family members and skilled birth attendants should
know the danger signs of life-threatening
life threatening
complications and what to do:
ƒ Many families of women who die in pregnancy, delivery or
postpartum
p p often don’t recognise
g that a serious p
problem
is occurring!
ƒ Sometimes the husband/mother-in-law/mother makes all
the decisions.
ƒ Often th
Oft the d
decision
isi tto sseek
k care and
d arrange f
for ttransport
s t
is delayed as much as 1-3 days after recognition of a
life -threatening
threatening complication.
complication
What can we do?
– Make
M k sure clients,
li t ffriends
i d and
d ffamily
il members
b can recognise
i
danger signs and are involved in antenatal care and delivery! The
birth p
partner is a decision maker.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Recognise
g danger
g signs
g and get
g
prompt medical attention!
Acting quickly is important because a
woman
m could ld di
die iin a sh
shortt p
period
i d of
f tim
time::
ƒ in antepartum hemorrhage she can die
in just 12 hours.
ƒ in postpartum hemorrhage she can die in
just 2 hours.
ƒ with complications of eclampsia in as few
as 12 hours and
ƒ withh sepsis in about 3 days!
d !

© M O H -D R H /D O M C /D LTLD /JH PIEG O

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 Immediate Attention!

Don’t lose precious time...

Seek help in time!!

© M O H -D R H /D O M C /D LTLD /JH PIEG O

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 Objective four: Health promotion
using health messages and counseling

Encourage dialogue on the following:

ƒ Nutrition ƒ Drug compliance
ƒ Rest and hygiene ƒ Family planning/ health
timing and spacing of
ƒ Safer sex pregnancy
ƒ Care for common ƒ E l and
Early d exclusive
l i
discomforts Breastfeeding
ƒ U of
Use f IPT and
d ƒ Newborn care
ITNs/LLINs
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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 Maintain the woman
woman’ss health and
survival through:
Health education and counselling on:
ƒ Danger signs in pregnancy
ƒ Adequate nutrition and hydration
ƒ Early and exclusive breastfeeding
ƒ Prevention and treatment of sexually transmitted
infections (STIs) and worm infestation
ƒ Avoidance
d off alcohol
l h l andd tobacco
b
ƒ Individual
Ind v dual B
Birth
rth Plan
lan (IB
(IBP))
ƒ Complication readiness plan

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 Don’tt forg
Don forgett to couns
counsel th
the
mother on…
ƒ To come to postpartum clinic :Immediately,48hours,
2 weeks, at 6 weeks,6months and one year.

ƒ To visit well baby clinic (MCH/FP Clinic) for

immunizations
ƒ Follow up for exposed babies to TB and HIV.
ƒ To chose a postpartum family planning method:
– LAM (exclusive breastfeeding)
– Progesterone only pills
– Condoms
– Post p
partum IUCD
ƒ Feeding options

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 Teach mothers about the
importance of immunizations:

ƒ Inform
I f h
her about
b t ththe fi
first-year
t i
immunization
i ti schedule
h d l
to protect children from TB, polio, tetanus, diphtheria,
pertussis, hepatitis B and measles.
ƒ Immunise baby with BCG
BCG, HBV
HBV, OPV birth dose before
the mother leaves the health facility.
ƒ Ensure all babies delivered at home are taken to the
health facility
y for immunization.

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 Objective
j 5: Provision of Skilled
Care at Birth
ƒ Currently only 41% of pregnant women receive
skilled care at birth
ƒ By 2015, it is expected that three quarters of
pregnant women should receive skilled care at birth
ƒ A skilled attendant offers services either at the
h lth facility
health f ilit or within
ithi th
the community
mm it (d
(domiciliary
mi ili
practice)
ƒ F NC provides
FANC d an opportunity to increase skilled
k ll d
care
ƒ Brainstorm strategies in your catchment area in
support
pp of increased skilled care
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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During FANC visits, ensure that the following
have been accomplished
History taking: Provide:
ƒ Current complaints/identify
l /d f ƒ Iron, folate , IPT*(SP is the
danger signs currently recommended) tetanus
toxoid and Nevirapine if
ƒ Dietary
y historyy recommended
ƒ Tetanus vaccination status Counselling on:
ƒ Reproductive history ƒ Danger signs
ƒ History of medical illness e
e.g.
g ƒ Individual birth plan (IBP)
TB ƒ Complication readiness
ƒ Nutrition, breastfeeding, family
Physical
y exam: planning,
p g, safer sex,, hygiene,
yg , etc.
ƒ Physical assessment of general ƒ PMTCT
health ƒ Return date
ƒ Swollen glands ANC Profile
Most of the lab work should be done
ƒ Genital inspection, including during the first visit
sexually transmitted infections ƒ Sputum for AFB
ƒ Check
Ch k for
f blood
bl d pressure,
ss ƒ Urinalysis
U i l i
edema and proteinuria to rule ƒ Hb, grouping and Rh factor
out pre-eclampsia ƒ VDRL/RPR
ƒ Check
Ch k for
f anaemia i ƒ Sickle
Si kl cell, ll St
Stooll and
dHHepatitis
titis B
ƒ Check baby’s growth (if indicated)
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Are we together?
g
ƒ Mention the purpose of
focused antenatal care?

ƒ YES! We are together!

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44
Are we together?
Mention:
ƒ 5 iimportant
t t questions
ti tto ask
k about
b t
an Individual Birth Plan (IBP)
ƒ Danger signs in pregnancy
ƒ Danger signs in labour and delivery
ƒ Danger signs after delivery

YES! We are together!

© M O H -D R H /D O M C /D LTLD /JH PIEG O

45
 The role of fathers in antenatal
care

Many
y men are uncertain about how theyy can
contribute to a woman’s healthy pregnancy

© M O H -D R H /D O M C /N LTP/JH PIEG O
46
The role of men/fathers should be to:

ƒ Support and encourage women throughout

pregnancy
ƒ Ensure that mothers do not g get STIs (or
( HIV))
ƒ Ensure that they remain faithful (or use condoms
consistently and correctly)
ƒ Encourage mothers to attend antenatal clinic
ƒ Acc mp n their
Accompany th i wives/partners
i s/p tn s to t th
the h
health
lth
facility and during childbirth

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47
 Service providers should educate
f h
fathers about antenatall care
ƒ Fathers should make sure that the woman:
– has enough
ug nutritious
u u ffood to eat and that she
has taken iron and folate tablets.
– is sleeping under a treated net and is able to
get plenty of rest.
– has had 2 doses of SP and tetanus toxoid.
toxoid
ƒ Make sure that the couple has an individual birth
plan.
ƒ Make
M k sure that
th t the
th couplel know
k th
the d
danger signs
i
in pregnancy and labour.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
48
 Adolescents and pregnancy
p g y
ƒ In Kenya, 17-18% of all births are to women under the
age off 20 years*
s*
ƒ Pregnant youth are entitled to the same quality of care
that
h older
ld women are.
ƒ Research has shown that adolescents tend to delay y
seeking care due to social and cultural practices and as
such more attention should be directed to them.
ƒ Services should be provided in an acceptable, non-
jjudgmental
g manner,, convenient and offer
confidentiality to the adolescents.
Note:
N t : This will
ill encourage
n th
the young
n women
m n tto return
t n ffor
continued antenatal services.
* K D H S 1998/2003
© M O H -D R H /D O M C /D LTLD /JH PIEG O
49
Reinforce
f counseling
u g to the
adolescents /youth on..

ƒ Peer influence
ƒ Early ANC attendance
ƒ Safer sex (ABCD)
ƒ Drug abuse
ƒ STI, HIV/AIDS/TB
ƒ Family Planning
ƒ Dangers of abortion

© M O H -D R H /D O M C /D LTLD /JH PIEG O

50
 Antenatal care and adolescents

Brainstorm
ƒ What are the attitudes of service providers
about providing antenatal care to adolescents in
your clinic?
li i ?
ƒ Why do providers treat adolescents
differently?
ƒ D
Does your clinic
li i provide
id antenatal
t t l services
i tto
adolescents?
ƒ Are the services in your clinic youth-friendly?
© M O H -D R H /D O M C /N LTP/JH PIEG O
51
Brainstorm
How can
H n we change
h n
our attitudes about
providing care for
adolescents?
d l ?

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52
 Role play

Using a role play explain show how you can change your
attitude towards giving care to a young single
pregnantt woman who
h walks
lk into
i t your clinic
li i
g antenatal services..
seeking
Treat her with respect, give her adequate information and
t
treatment
t tbbecause you ((counselor)
l )b believe
li and
d understand
d t d it iis
your duty to treat her as any other pregnant woman.

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53
Before the woman leaves y
your clinic,,
STOP and ask her if she:
ƒ Has a supply of iron and folate tablets.
ƒ Has
H taken
k h her SP and dhhas h
had
dhher tetanus
toxoid injection.
ƒ K
Knows the
h danger
d signs in pregnancy and
d child
h ld
birth.
ƒ Knows her
h appointment for the h next ANC visit
and SP dose.
ƒ Has an individual birth plan.
ƒ Has been screened for TB
ƒ Knows the importance of using postpartum
family
y planning.
p g
© M O H -D R H /D O M C /D LTLD /JH PIEG O
54
 Integrated
g FANC Services

FANC TB

STIs PMTCT

LAB CCC
MALARIA
© M O H -D R H /D O M C /D LTLD /JH PIEG O
55
Tuberculosis in Pregnancy

© M O H -D R H /D O M C /N LTP/JH PIEG O
56
 What is Tuberculosis (TB)?
ƒ Tuberculosis is a chronic infectious disease caused
by an organism called mycobacterium tuberculosis
– Over 90%% of
f new TB cases and deaths h occur in
developing
p g countries

ƒ TB is one of the leading infectious causes of death

among women of reproductive age

ƒ TB has increased by 10 fold over the last 15 years in

Kenya

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57
 N LTP K enya - TB C ase Finding:1987 - 2006

140,000
Sm earPositive Pulm onary TB
Sm ear N egative Pulm onary TB
120 000
120, Extra Pulm onary TB
R etreatm entC ases
AllTB

100,000
orted cases

80,000
m bers ofrepo

60,000
N um

40,000

20,000

0
'87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Year

© M O H -D R H /D O M C /D LTLD /JH PIEG O

58
Factors leading to the increase in TB

ƒ HIV epidemic
ƒ Poverty
P t
ƒ Overcrowding
ƒ Poor nutrition
ƒ Limited access to health services

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59
 Types
yp s of Tuberculosis
u rcu os s
ƒ Pulmonaryy Tuberculosis ((PTB)) is the most common
and infectious type of TB.
– It affects the lungs
g and causes 81% of all TB cases in
Kenya

– Extra Pulmonary Tuberculosis (outside of the

g ) any
lungs) y organ
g of the body y such as the kidney,
y,
bladder, ovaries, testes, eyes, bones or joints,
intestines,, skin or glands,
g , and meninges
g

– The most common extra pulmonary TB is TB of the glands

also called TB lymphadenitis

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60
 Signs
g and Symptoms
y p of Pulmonary
y
Tuberculosis (PTB)

ƒ Persistent cough
g lasting
g for two or more weeks
with
h or without
h blood
bl d stainedd sputum
ƒ Loss of bodyy weight
g
ƒ Intermittent fever
ƒ Excessive night
g sweats
ƒ Shortness of breath
ƒ Loss of appetite
ƒ Chest pain
ƒ Excessive tiredness and generally feeling unwell

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61
 Signs
g and symptoms
y p of TB of the
glands (TB lymphadenitis*)
ƒ Slow and painless enlargement of the lymph nodes
which then become matted and eventually
discharge pus
ƒ The most common lymph nodes: cervical (neck)
lymph
ymp nodes
n
ƒ Generalised lymph
y p node enlargement
g is becoming
g
common in HIV related TB

*Confirmed during head-to-toe examination

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62
 When does TB p
pass from the
mother to the baby?
Pregnant women who are infected with TB can pass
TB to the baby:
ƒ Duringg pregnancy
p g y through
g the placenta
p barrier
causing fetal death or infection (congenital TB is
rare)
ƒ At birth when the baby inhales or ingests
i f t d amniotic
infected i ti fl
fluid
id or secretions
ti
ƒ After deliveryy when the babyy inhales droplet
p
secretions if the mother is coughing-commonest

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63
TB affects the health of a pregnant
p g
woman and her baby

TB in a p
pregnant
g woman can lead to:
ƒ Premature birth of the baby
ƒ Low birth weight or small baby for dates
ƒ Death of baby in the uterus
ƒ Infecting the baby with TB
ƒ Increased newborn deaths

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64
 Investigations

ƒ Smear positive TB cases are the most infectious

both to the new born and other children in the
household
ƒ Th
These are diagnosed
di d th
throughh sputum
t examination
i ti
ƒ Smear negative cases and Extra-pulmonary
Extra pulmonary are
diagnosed through history, physical examination,
radiography and histology

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65
 Why
y integration…TB/FANC
g
ƒ Since the onset of the HIV epidemic
p in the early
y
eighties in Kenya, the prevalence of TB has risen
sharply
ƒ HIV increases the likelihood of developing
tuberculosis
ƒ Pregnancy also increases the risk of developing TB
ƒ TB is the major
j opportunistic
pp infection in HIV and the
leading killer of PLWHA
ƒ More than 50% of TB clients in Kenyay are also HIV
positive
ƒ At least one out off eight
g off HIV+ ppregnant
g women
could also have TB*
*USAID Bureau for Africa, 2000

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66
 Integration
g of HIV,, TB and malaria
interventions into MCH services:

ƒ Ensures that women receive targeted care

according
di to their
h i needs
d with
i h appropriate
i li
linkages
k
and referral structures are in place
ƒ Involves the reorganization and re-orientation of
y
health systems to ensure the delivery
y of a set of
interventions or targeted package as part of the
continuum of care
ƒ Involves integrated procurement of commodities

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67
 Integration addresses structural ,
managerial and operational issues at all levels
of
f th
the hhealth
lth system
t iin order
d tto:
ƒ Create effective
ff coordination
d mechanisms
h
between departments,
p programs
p g and other
stakeholders
ƒ Support integrated training and capacity planning
planning,
management and joint supervision
ƒ H
Harmonize
i efforts
ff t tto supportt ttargeted
t d service
i
delivery

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68
Intensified TB case finding in FANC

ƒ All pregnant women should be screened for TB

ƒ Pregnant women suspected to have TB should
h
have their
h i sputum collected
ll d and
d tested
dffor TB
ƒ Pregnant women found to have TB should be
referred to the TB clinic for treatment
– Negative
N ti S Sputum
t d
doess nott exclude
l d TB!

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69
Key steps to integrating TB
case finding into FANC
ƒ Assess client: document results
ƒ Refer to lab: document results
ƒ Refer to TB clinic: document results
ƒ Follow-up visits: document progress in TB
mana ement
management

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70
 Assess client
Ask the the pregnant woman the
following questions:
ƒ Have you had persistent cough for
two weeks or more with or without
blood
l d stained d sputum?
ƒ Have yyou lost weight?
g
ƒ Fevers that come and go?
ƒHHave yyou
u experienced
p excessive
sweating at night?
ƒ Do yyou have swollen gglands?
(response can be confirmed during
head to toe examination)
© M O H -D R H /D O M C /D LTLD /JH PIEG O
71
 Symptoms
y p of TB ?

ƒ C (Coughing)
ƒ W (Weight loss)
ƒ F (Fever)
( )
ƒ N (Night sweats)
ƒ G (enlarged Glands)
© M O H -D R H /D O M C /D LTLD /JH PIEG O
72
 Refer to Lab:
ƒ If the pregnant woman has a cough for two
weeks
k or more, explain
l i th
thatt three
th specimens
i
of her sputum must be collected to help
c nfi m th
confirm the p
presence
s nc or absence
bs nc of f TB

ƒ Explain that testing and treatment for TB is

free

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73
Collection of sputum specimen
specimen:
laboratory
ƒ Ask the pregnant woman to cough deeply to
produce sputum in an open place
ƒ Ensure that nobody is standing nearby during
the cough
ƒ A id contaminating
Avoid t i ti th the outside
t id of
f th
the
container with sputum
ƒ Ensure that an adequate amount of sputum is
collected in the specimen pot

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74
 PTB confirmation is based on 3
sputum specimens collected
within a 24
24-hour
hour period
ƒ 3 specimens
p c m n are
ar collected
c ct ƒ #1 specimen
p c m n at the
th lab,
a , orr “on
n
and examined by direct the spot”
smear for acid fast bacilli – Provide container for next
(AFB) day home collection
ƒ “Spot”
p refers
f to a ƒ #2 early morning the
specimen obtained right following day client brings to
there in the clinic Lab
ƒ The process goes: SMS ƒ #3 specimen “spot” at the Lab
– Spot right after she drops off the
– Morning plus one from home
– Spot
© M O H -D R H /D O M C /D LTLD /JH PIEG O
75
 Refer to TB clinic:
ƒ Explain that TB can be treated over a 6-8 month
period and the drugs are safe to use during
pregnancy and breastfeeding
ƒ If the sputum is positive
– Send the woman to the TB clinic directly
– Document the positive results in the register
ƒ If the sputum is negative, but the woman is
symptomatic, send her to the TB clinic anyway
– Note: Negative smear test for TB does NOT exclude TB
– Explain that after delivery, barrier methods of
family planning are necessary as some TB drugs
interfere with the absorption
p of hormonal
contraceptives.

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76
 TB treatment
ƒ If a pregnant woman is confirmed to have TB the
treatment will last 6-8 months :
ƒ Intensive phase (2 months):
– Ethambutol ((E)) , Rifampicin
p ( R )), Isoniazid ((H)) and
Pyrazinamide (Z)
Continuation p
phase (4-6 months)*
– Rifampicin (R) and Isoniazid (H) (4 months)
– Ethambutol
m ((E)) and Isoniazid ((H)) ((6 Months))
ƒ For pregnant women who are HIV+ and also have TB, the
TB treatment should be continued and client referred to
the CCC
ƒ All co-infected ppatients HIV and TB should be started on
cotrimoxazole prophylaxis as it reduces mortality
*W
Which regimen
r g m n are
r yyouu uusing
ng inn yyour
ur district
r
© M O H -D R H /D O M C /D LTLD /JH PIEG O
77
 What is DOT
ƒ DOT: Directly
DOT Di tl Obs
Observed dT
Treatment
t t
ƒ Initial Phase: the first two months of TB
treatment should be administered under direct
observation
observat on of either
e ther a health worker in
n the
facility or a member of the household or
community
ƒ If client is too sick or observed treatment not
possible
ibl th
the client
li t should
h ld bbe admitted
d itt d tto h
hospital
it l
ƒ Continuation p phase: the client collects a supply
pp y
four weekly for daily self administration at home.

© M O H -D R H /D O M C /D LTLD /JH PIEG O

78
 What can be done to support
pp
TB control
ƒ Adhere to the national TB control program guidelines
g
for case detection, definition and management.
ƒ Provide health education for the community.
ƒ Encourage symptomatic women to come for TB testing
and treatment.
ƒ Provide counseling support so that they will complete
their treatment.
ƒ D
Develop
l a system for
f supervising
i i community
i h health
l h
workers assisting health care providers to track and
monitor
i treatment compliance.
li
ƒ Keepp accurate records.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
79
 Follow-up visits:

ƒ At each subsequent FANC visit nurse inquires

about
u TB treatment
m progress,
p g , looks for
f TB clinic
information and documents updates in the register
ƒ Continue follow-up into the post natal period

© M O H -D R H /D O M C /D LTLD /JH PIEG O

80
 At the post partum visit

ƒ Ask the ppostpartum

p mother if contact invitation
has been initiated
ƒ Ask if newborn and others have been assessed
and treated for TB
ƒ I she
Is h still
till ttaking
ki medications?
di ti ?
ƒ Document information in record
ƒ Explain that barrier methods of family planning
are necessary as some TB drugs interfere with
the absorption of hormonal contraceptives

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81
 TB and the newborn
ƒ Iffam mother has TB and has started treatment
m 2
months or more before the due date, she should
have 2 sputum
p smear tests done before the birth.
ƒ If she is sputum smear negative just before
deliveryy then she is non-infectious and the infant
does not need prophylaxis and BCG is given at birth
ƒ Iff she is sputum
p m smear
m positive
p then the newborn
must receive daily isoniazid (5mg/kg) for 3 months
and if the mothers sputum
p is negative
g and mantoux
test is non reactive (<5mm) then isoniazid should be
stopped and BCG given (3 days after prophylaxis
t
treatment
t thhas stopped)
t d)

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82
 TB and newborn/child care
ƒ If the Mantoux test is reactive (>5mm) after 3 months on
Isoniazid, then Isoniazid should be continued for another 3
months
ƒ Breast
r ast f
feeding
ng wom
women
n on INH
NH shou
should a
also
so include
nc u diett rich
r ch
in Vitamin B6
ƒ Any other child under five years old living in the same
household must also be given isoniazid prophylaxis if
mother is smear positive and child does not have active TB
INH given for 6 months

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83
 Don’t forget to DOCUMENT
at every step of the process!
ƒ FANC nurse documents her assessment
ƒ Laboratory documents results and sends
copy to ANC nurse
ƒ FANC nurse llooks
k for
f and d documents
d t lab
l b
results in register and ANC card
ƒ FANC nurse refers to TB clinic as
indicated and documents referral
ƒ At each subsequent FANC/PNC visit nurse
inquires
q about TB treatment progress,
p g
looks for TB clinic information and
documents updates in the register
© M O H -D R H /D O M C /D LTLD /JH PIEG O
84
 Screen! Refer! Follow-up!
D
Document-
t Document-
D t Document!
D t!

A N C nurse
screens for sym ptom s R efers to lab
A N C nurse
ofTB or to TB clinic,
follow s up,
lab results/ depending
TB clinic m anagem
g ent on sym ptom s
so far

Lab provides
results in w ritten
form to the clientto give Lab collects
to A N C nurse and spotsputum #1
TB clinic ifindicated C lientreturns in the m orning
L b col
Lab llect
ts
#2 and #3 ifindicated

© M O H -D R H /D O M C /D LTLD /JH PIEG O

85
 Referral forms assist in
communication and documentation
ƒ Referral, documentation and follow-up are
essential in stopping
pp the spread
p of TB.
ƒ Review referral form in the annex
Ch kl
Checklist for
f symptoms of
f TB?
TB
ƒC
ƒW
ƒF
ƒN
ƒG
© M O H -D R H /D O M C /D LTLD /JH PIEG O
86
Players are communicating
Pl mm i ti b between
t
themselves and with the client!

ƒ FANC Nurse
ƒ Laboratory Technician
ƒ TB Clinic staff
ƒ Client

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87
 Integrated
g care model for
pregnant woman

Integrated FA N C C linic
PM TC T/other interventions e.g.M IP

R eferral2
Laboratory TB C linic

© M O H -D R H /D O M C /D LTLD /JH PIEG O

88
 Integrating FANC and TB
(
(Brainstorm)
)

ƒ How will this work in your clinic?

ƒ How do you communicate with your laboratory?
ƒ What are the challenges?
ƒ If you cannot provide TB lab services, where do
you
y u send your
y u clients for
f TB confirmation
f m and
treatment?

© M O H -D R H /D O M C /D LTLD /JH PIEG O

89
 Drug
D ug Interactions
Interacting TB Drug Effect of interaction Management
drug recommendation

Streptomyci In pregnancy it Avoid in

n causes deafness to pregnancy
the unborn baby

Nevirapine Rifampicin Lowers blood levels of Refer to/Consult

Nevirapine CCC

© M O H -D R H /D O M C /D LTLD /JH PIEG O

90
 Caution

ƒ If a client is on Anti-TB drugs, anti-convulsants

and/or
/ antiretrovirals,, the interactions between
w
these drugs and hormonal contraceptives may
lower the effectiveness of the latter
latter. Barrier
methods are preferred

(See annex for other drug interactions)

© M O H -D R H /D O M C /D LTLD /JH PIEG O

91
A we ttogether?
Are th ?

ƒ Signs and Symptoms of TB?

ƒ Procedure for TB diagnosis and
referral?
ƒ Documentation all along the way?
ƒ Plan for follow-up?
ƒ YES! We are together!

© M O H -D R H /D O M C /D LTLD /JH PIEG O

92
M l i in
Malaria i Pregnancy
P

© M O H -D R H /D O M C /N LTP/JH PIEG O
93
 M alaria in Pregnancy

ƒ K enya policy on m alaria prevention and

controlduringgppregnancy
g y in endem ic areas
em phasizes the use of:
1 IPT
1.
2.ITN ’s
3.Effective case m anagem entofm alaria
illnessand anem ia
© M O H -D R H /D O M C /N LTP/JH PIEG O
94
 Facts aboutM alaria in pregnancy
ƒ Pregnant
g w om en g
getm alaria m ore easily
than w om en w ho are notpregnant
ƒ M any pregnantw om en have m alaria
parasites,buthave no sym ptom s atall.
ƒ W hen a w om an is pregnantshe loses som e
ofthe ability to fightm alaria infection.
ƒ Blood testforperipheralparasitaem ia is often
negattive,despi
d ite m al
laria parasiites in th
he
placenta.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
95
W hathappens w hen a pregnantw om an gets
m alaria?
ƒ The m otherm ayy have no siggns/sym
y p ptom s ofm alaria
ƒ The m alaria parasites hide in the placenta and so m ay
notbe found w hen you take a fingerblood sam ple of
the m other.
ƒ M alaria parasites in the placenta interfere w ith the
passage ofnutrients and oxygen to the unborn baby,
slow ing dow n its norm algrow th.

© M O H -D R H /D O M C /D LTLD /JH PIEG O

96
S gns and
Signs an symptoms of uncomp
uncomplicated
cat
malaria
ƒ Fever with or without shivering.
ƒ Headaches
Headaches.
ƒ Weakness.
ƒ L
Loss off appetite.
ƒ Nausea and vomiting.g
ƒ Joint pains.
ƒ Backache and muscle pains.
pains
ƒ False labour pains (uterine contractions).

© M O H -D R H /D O M C /D LTLD /JH PIEG O

97
Effects ofm alaria to unborn baby and
m other
ƒ M alaria m ay cause up to 30% of
prevent tabl
ble low bit
birth w ei
ightand
ht d 3-
3 5% of
f
neonataldeaths
ƒ Low birth w eightbabies have a higher
chance ofdying than babies w ho are born
w ith a good w eight.
ƒ M alaria increases the risk ofprem ature
labour,spont
p aneous abortion and
stillbirths.
ƒ Anaem ia and febrile illness in the m other
© M O H -D R H /D O M C /D LTLD /JH PIEG O
98
 M alaria prevention in pregnancy
ƒ Pregnant
g w om en are m ore atrisk ofm alaria
infection because pregnancy reduces the
degree of partialim m unity
ƒ W om en in theirfirstand second pregnancy
are ata greaterrisk k (b
because ofl
flack
k of
f
exposur
p e to p
placentalinfection before)
ƒ Allpregnantw om en atrisk should be advised
on m alaria prevention m easures

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Interm ittentPreventive Treatm ent
Intermittent
P
Preventive
nti
Treatment
(IPTp)

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100
 Interm ittentPreventive Treatm ent(IPTp)
ƒ Interm ittentPreventive Treatm ent(IPTp)is an effective approach to
preventing m alaria in pregnantw om en by giving antim alarialdrugs in
treatm entdoses atdefined intervals afterquickening to cleara presum ed
burden ofparasites
ƒ The M inistry ofH ealth G uidelines on M alaria directs us to give SP to
p egnant
pr g w om en in endem ic m alaria areas,
,atleasttw ice during
g each
pregnancy,even ifshe has no physicalsigns and herhaem oglobin is w ithin
norm alrange.
ƒ Adm inisterIPTp w ith each scheduled visitafterquickening (16 w eeks)to
ensure w om en receive atleast2 doses atan intervalofatleast4 w eeks.
ƒ IPTp should be given underD irectly O bserved Therapy (D O T)in the AN C
clinic and can be given on an em pty stom ach
ƒ Fornow IPTp m eans using SP,butw e w illalw ays have to stay abreastof
changes and treatourpatients according to the latestM O H guidelines.

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101
G ive SP
SP! SP!
Keeps the placenta
p
parasite-free!

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102
W hatis Sulfadoxine Pyrim etham ine (SP)?
ƒ SP is a com binat
tion oft
ftw o differentdr
td ugs.
ƒ O ne tabletofSP contains 500 m g ofSulfadoxine
and 25 m g ofPyrim etham ine.
ƒ A single dose consists of3 tablets ofSP taken at
once.
ƒ Fansidaris the m ostcom m on brand nam e butthere
are m any othernam es thatcontain the sam e drugs
like Falcidin.

See annex 1 forlistofothernam es forSP drugs

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103
 Facts aboutSP for IPT
ƒ Itis bestto clearthe placenta ofparasites during the
period ofm axim um foetal grow thh.
ƒ Itallow s the m otherto recoverfrom anaem ia by
clearing peripheralparasitaem ia
a.
ƒ W H O recom m ends a schedule of4 AN C visits w ith 3
visits afterquickening
ƒ The delivery ofIPT w ith each scheduled visitafter
quickening w illassure thata high proportion of
w om en receive atleast2 doses.
ƒ There is no evidence thatreceiving 3 orm ore doses
ofSP as IPT w illresultin an increased risk ofadverse
drug reactions
ƒ W H O recom m ends thatSP is safe up to 40 w eeks
gestation
© M O H -D R H /D O M C /D LTLD /JH PIEG O
104
 Facts cont…

ƒ Studies have found thatm others w ho had

taken SP (Sulfadoxine Pyrim etham ine)in
the second and third trim esterofppregnancy
g y
had few erm alaria parasites in the placenta
than m others w ho had only taken m alaria
treatm entonce they feltill.

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105
 Facts cont…
ƒ Field experience has show n thatifthe clientdoes
nottake SP atthe clinic,she m ightnottake itat
all.
ƒ Taking SP undersupervision in the antenatalclinic
increases com pl liance.
ƒ C lean,safe drinking w aterand clean cups should
be available;decontam inate,w ash and rinse cups
betw een patientuse.
ƒ U se the D irectly O bserved Treatm ent(D O T)
system ,itw orks,its better!

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106
 Facts cont…
ƒ SP m ay be given along w ith tetanus toxoid
ƒ SP shoul
h ld notbe
tb taken
k toget th
herw ith fol
lic aci
id
ƒ Taking offolic acid should be delayed for2 w eeks
aftertaking SP (folic reduces the efficacy ofSP)
ƒ R ecord on the antenatalcard the date w hen SP is
given
ƒ Explain to the w om an the im portance ofcom ing
back forthe second dose
ƒ Alw ays ask aboutside-effects from the firstdose
ofSP before giving the second dose.

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107
 Side effects ofSP
ƒ Ask
A k th
he w om an ifshe
h is al
llergi
ic to sul
lfa-dr
d ugs.
ƒ SP can have side effects like m ild headaches,nausea
oroccasionalvom iting.These are notserious and
m others can generally receive the second dose.
ƒ Serious side effects are very rare butthey can occur.
There can be a skin and m ucous m em brane reaction
(m outh orgenitalulcerations)w hich is called Stevens
Johnson Syndrom e.
ƒ Each clinic should have a system forkeeping track of
the num berofclients w ho repor
p tsevere skin
reactions.

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108
 W hatifa patientis allergic to SP?
ƒ U nfortunately, no alternative to SP foruse as IPT forpregnant
w om en has been approved.
ƒ Ifyourclientis allergic to SP,
- carefully counselheraboutsym ptom s ofm alaria and early
seeking oftreatm ent,
- m onitorherforanaem ia and ensure thatshe know s she has
to prom ptly return to the clinic ifshe develops sym ptom s of
anaem ia orm alaria.
- advi
d ice h
hertto slleep under
d an ITN
ƒ M inim ize herrisk foranaem ia from othercauses such as iron
deficiency
ency,hookw
hookw orm ,etetc
c.by
by appropriate diet,suppl
supplem ents and
m edication.Ifshe becom es sym ptom atic ofm alaria she can be
treated safely w ith quinine.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Key
yppoints forp
providing
g SP to p
pregnant
g
w om en
ƒ Ask clientaboutgestationalage to determ ine thatclientis at
least16 w eeks pregnant. Ifshe is notcertain ofherdates,
ask herifand w hen she feltthe babbaby m o
ovee (Q ui
ickening).
Q uickening is a rough estim ate ofthe onsetofthe second
trim ester.
ƒ Ask abouta history ofsevere skin rash orm ucous
m em brane ulceration w ith sulpha drugs (Ifshe has had a
severe reaction to sulpha drug,do notgive SP and m ake
sure allergy is clearly m arked on herantenatalcard).
ƒ Ask aboutt
abo tthe use
se ofSP in the pastm onth. h
ƒ G ive client3 tablets ofSP as D O T w ith clean and safe
drinking w ater(can be given on an em pty stom ach )
ƒ Ask clientto return forthe second dose after4 w eeks.
ƒ She should also com e back ifshe has side effects.
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 SP and
d H IV+ve
V w om en
ƒ A fter quickening (16 w eeks), H IV+ w om an
requires atleast 3 doses ofSP atm onthly intervals,
untilshe delivers.
ƒ As w ith allw om en,determ ine firstthatshe is not
allerg
gic to sulfa-containing g drugs
g and discontinue
SP ifshe develops any signs orsym ptom s ofallergy.
ƒ Pregnantw om en w ho are H IV+ V and are also taking
AR V therapy forPM TC T should receive IPT
ƒ Pregnantw om en w ho are H IV+ and are on daily
cotrim oxazole chem oprophylaxis should notbe given
SP.
SP
ƒ Ensure H IV+ pregnantw om en are linked to other
com prehensi
h ive H IV servi
ices
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 Insecticide treated nets (ITN s)
ƒ The use ofI
Th fITN s is
encouraged forall
ƒ Itis recom m ended thatall
pregnantw om en and
children underfive y years of
age should sleep underan
ITN .These groups are the
m ostvul lnerabl
ble!
ƒ ITN use should be
encouraged d early and
d
consistently throughout
pregnancy and afterdelivery
ƒ Insecticide treated nets are
m uch m ore effective than
untreated nets
© M O H -D R H /D O M C /D LTLD /JH PIEG O
112
 ITN s cont…
ƒ There are tw o types oftreated nets
o Insecticide Treated N et(ITN s) s)–
requires re-treatm entw ith a
recom m ended insecticide KO -TAB 1-2-
3 to m ake ita long lasting ITN
o Long Lasting Insecticidalnet(LLIN s)
-have been specially treated to lastfor
the lifetim e ofthe netor21 w ashes
w hichevercom es first.
ƒ These nets are available from AN C clinics
ata reasonable subsidized cost.
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 O ther
h protective m ethods
h d
ƒ U se ofi
finsectr
t epelllent
ts.
ƒ W earingg pr
p otective clothing
g thatcovers
the body including arm s and legs.
ƒ H aviing m osquiito screeniing in w indow
d s,
eaves and m ain doors of houses.
ƒ Environm entalm anagem entincluding
draining stagnantw ater,w w here feasible
e.
ƒ IR S (epidem ic prone areas)

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114
H ow can w e preventm alaria in pregnancy

Intermittent
Antenatal Care P
Preventive
nti
& Treatment
Health Education (IPTp)

Case Insecticide
Management Treated
of Nets (ITNs)
S
Symptomatic
t ti WWomen

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115
 A ctin Tim e!
R em em ber the FA C TS aboutM alaria in Pregnancy

1. Pregnantw om en are m ore likely 5. SP is the only available option for

IPT
than non pregnantw om en to 6
6. Th benef
The b fits ofSP
fSP in pregnancy
have m alaria because their are:
resistance is low . • KEEPS TH E PLAC EN TA
2. Even pregnantw om en w ho look PAR ASITE FR EE!
• Keeps m otherand baby healthy.
and feelw ellm ay be carrying
m al
laria parasiites especiial
lly in
7. Alw ays as
ask fo
orsi
s de e
effects to su
sulfa
drugs before giving SP to pregnant
areas w here m alaria is com m on. w om en.
3 M alaria causing parasites hide
3. 8. SP is safe to use up to 40 w eeks of
pregnancy
m aking the m otheranaem ic.
9. R em em berthatevery pregnant
4. M alaria parasites in the placenta w om an should sleep under
m ay cause low birth w eightor insecticide treated nets (ITN )to
even death ofthe baby. protectherself.

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116
 Case management
g
•Malaria infection during pregnancy poses a risk to the
unborn child and for surviving births
•Effective case-management of malaria and anaemia during
pregnancy will be promoted at all levels of the antenatal
health services as part of the renewed efforts to
strengthen the Safe Motherhood Initiatives.
•Although women in their first and second pregnancy, and
all HIV infected women are at ggreatest risk of the effects
of malaria, all women should be advised on preventive
measures and clinical cases of malaria treated promptly
p p y
with effective ant malarial drugs

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117
Mild or uncomplicated malaria

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118
 M anagem entofuncom plicated m alaria
ƒ Alltrim esters ofpregnancy:a 7-day therapy oforalquinine given
at10m g/kg-m ax 600m g 8 hourly (3 tim es a day)is recom m ended.
ƒ A fulladultdose (4 tablets given tw ice a day for3 days)of
Artem ether-lum efantrine (AL)can also be used in the second and
third trim esters.D o notw ithhold AL in 1st trim esterifquinine is not
available.
ƒ G ive firstdose ofAL as D irectly O bserved Treatm ent(D O T)
ƒ Itis preferred thatAL is given w ith a m ealto enhance absorption.
D o notw ithhold the firstdose due to lack ofa m eal.
ƒ G ive Paracetam olto relieve pain and fever.
ƒ G ive plenty offluids!
ƒ R ule outanaem ia
ƒ Supportive treatm entand follow up.
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119
 D osing
g schedule forqquinine tablets
Q uinine sulphate 200m g salt
W eight(kg) N um ber oftablets

4 -7 1/4
8 -11 1/2
12 -15 3/4
16 -23 1
24 -31 11/2
32 -39 2
40 -47 21/2
48 and above 3
Referto nationalG uidelinesfordiagnosistreatm entand prevention of
m alaria forhealth w orkers in K enya – M O H 2006 pp 44

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120
 D osing schedule forquinine tablets
Q uinine sulphate 300m g salt(sulphate,
dihydrochloride,hydrochloride)
W ei
ight(
h (kg)
k ) N um b
ber oft
f abl
blets

6 -11
11 1/4
12 -17 1/2
18 -23 3/4
24 -35 1
36 -47 11/2
48 and above 2

R efer to nationalG uidelines for diagnosis treatm entand prevention ofm alaria for health
w orkers in K enya – M O H 2006 pp 44

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121
D osing schedule forArtem ether-lum efantrine (num ber
oftablets to be at0,
,8,
,24,
,36,
,48,
,60 & 72 H rs)
)

W eight(kg) Age ofpatient Num berof Contentofartem ether

in years tabs per dose (A)+ lum efantrine (L)

5 -<15 (< 3 y) 1 20m g A + 120m g L

15 -< 25 (3 – 8 y) 2 40m g A + 240m g L
25 -< 35 (9 – 14 y) 3 60m g A + 360m g L
Above 35 (above 14) 4 80m g A + 480 m g L

Referto nationalG uidelines fordiagnosistreatm entand prevention ofm alaria for

health w orkers in kenya–
kenya
y – M O H 2006 pp
pp42

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122
Severe/ complicated malaria

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123
Signs of severe/complicated
malaria
ƒAnaemia, high fever, breathing difficulties.
Si ns of
ƒSigns f cerebral
b lm malaria
l i ((convulsions,
n lsi ns coma
m and
nd
other behavioural change).
ƒSigns of low blood sugar (hypoglycemia)-sweating,
weakness and cold skin.
ƒSigns of severe dehydration, especially if she has
been vomiting repeatedly
repeatedly.
p
ƒSpontaneous bleeding
g from the gums,
g skin and vein
puncture sites.
ƒSevere jaundice of conjunctiva
conjunctiva, palms and skin
skin.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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Signs and Sym ptom s ofsevere orcom plicated
m alaria
In addition to othersym ptom s of
uncom plicated m alaria,the patientpresents
w ith atleastone ofthe follow ing:
ƒ Extrem e tiredness.
ƒ C hanges in behaviour:sleepiness/drow siness,
confusion,convulsions,unconsciousness,inability to
w alk,sit,speak orrecognize relatives.
ƒ Fastbreathing (due to pulm onary oedem a orcardiac
failure).
ƒ Passage ofvery dark coloured urine (coffee like or
coca-cola ).
© M O H -D R H /D O M C /D LTLD /JH PIEG O
125
Signs & symptoms of severe
malaria cont…
ƒAnaemia (Hb <7g/dl)
ƒHigh fever, breathing difficulties.
ƒSigns of cerebral malaria (convulsions, coma and other
behavioural change).
ƒSigns of low blood sugar (hypoglycemia)-sweating, weakness
and cold skin.
ƒSigns of severe dehydration, especially if she has been
vomiting repeatedly.
ƒSpontaneous bleeding from the gums, skin and vein
puncture sites (rare).
p
ƒSevere jaundice as seen on conjunctiva and palms

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126
Complications of severe malaria
ƒ Coma and/or convulsions due to cerebral malaria.
malaria
ƒ Severe anaemia (Hb <7 g/dl ).
ƒ R
Renallffailure.
il
ƒ Hypoglycemia.
yp g y
ƒ Fluid, electrolyte imbalance.
ƒ Pulmonary edema.
edema
ƒ Hypovolemic shock.
ƒ H
Haemoglobinuria
l bi i (coca
( cola
l coloured
l d urine).
i )
ƒ Intravascular coagulopathy
g p y (IC-spontaneous
p
bleeding).

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127
Treatment of severe/complicated malaria
ƒ The recommended medicine of choice for severe malaria is parenteral quinine
(IV route is preferred
preferred, however IM route can be used as an alternative where
IV route is not feasible),
ƒ Qu
Quinine
n n is safe
af to u
use in
n pr
pregnancy.
gnan y.
ƒ First dose: 20mg/kg in 1/2 litre of fluid in 5% dextrose or normal saline given
over 4 hours up
p to a max of 1,200mg. g
ƒ 8 hours after commencing the initial dose, give 10 mg/kg in 1/2 litre of fluid
over 4 hours to a max of 600mg.
ƒ Repeat 10 mg/kg 8 hourly until the patient can take orally.
ƒ Change to Oral quinine to complete 7 days of therapy
ƒ In the absence of weighing machine or evidence of weight, give loading dose of
900mg and 600mg as maintenance dose to an adult of average size.
ƒ (See National Guidelines on Management of Malaria, p. 23 -25)

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128
 Treatment of severe malaria with quinine
M anagem
g entofadults m ustbe apprpp opr
p iate to each com p
plication that
develops. Q uinine is notcontraindicated in pregnancy

IV Q ui
ini
ine

Firstdose
e:20m
20m g/kg in ½ litreoffluid in 5% dextrosegiven over4
hours (M ax.1,200m g)

8 hours aftercom m encing the initialdose

give 10m g/kg in ½ L offluid over4 hours
(m ax 600m g)

Repeat10m g/kg 8 hourly untilthe Change to

patientcan take orally
p oralquinineto com plete7 daystherapy
Taking orally?

Precautionsforquinine use:1)Loading dose ofquinine should notbe used ifthe patienthas received any quinine in the last24 hrs orm efloquinein the last7 days.
2)M
) ai
intenancedos
d e of
fqui
ini
ine shoul
h ld behal
b h lved
d in patientsw i
ih
th renalf
lfai
ilure af
fter2 days
d . 3)H
) ypogl
lycem ia shoul
h ld bel
b looked
k d forand
d corrected
d w ih
ith 50% d
dextrose(
(1m l/k
kg)
)

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129
 Pre referral management of severe
Pre-referral
malaria
Pre-referral
P f l ttreatment
t t if f
facility
ilit cannott admit
d it patient:
ti t
ƒ Take vital signs.
ƒ Give
Gi a loading
l di d dose off 20 mg/kg
/k of fQ
Quinine
i i IM STAT
STAT. A
maximum of 3 mls should be injected into one site. Repeat
dose at 10mg/kg 8 hourly until IV treatment is initiated.
initiated
ƒ In the absence of quinine Artmether injection 3.2mg/kg
STAT or artesunate injection 2 2.4mg/kg
4mg/kg STAT maybe
used to initiate treatment (in second and third trimester)
ƒ Arrange for transport.
ƒ Give oral glucose (non-comatose).
ƒ Accompany the patient.
patient

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130
 Side effects ofquinine
ƒ H yp
ypogl
gy
ycem ia;
ƒ H ypotension;
ƒ C inchonism characterised by tinnitus,hi
us high
tone deafness,visualdisturbances,
headache dysphoria,nausea,vom
headache,dysphor a nausea vom iting and
posturalhypotension
ƒ G IT:nausea,vom iiiting and diiarrhoea;
ƒ Vision:blurred vision,,distorted colour
perception,photophopia,diplopia and night
blindness;
;
ƒ C utaneous:flushing,pruritis,rashes,
ƒ Feverand
F d dyspnea
d
© M O H -D R H /D O M C /D LTLD /JH PIEG O
131
Precautions with Quinine

ƒ A loading
g dose of q
quinine should not be used if
the patient has received any quinine in the last 24
hours, or mefloquine in the last 7 days.
ƒ The maintenance dose of quinine should be halved
in patients with renal failure after 2 days
days.
ƒ Look for hypoglycemia
yp g y and correct it with 50%
dextrose (1ml/kg).

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132
Points to remember in management of
Severe Malaria
M l cont…
ƒ Any patient presenting with severe malaria should be
given a loading dose of quinine in any health care
g
setting.
ƒ Quinine drip should run over just 4 hours only, not
g
longer.
ƒ Next dose to be given after 8 hours from the start
of the previous dose
ƒ Quinine should be used as soon as it is
reconstituted.
ƒ Protect the Quinine drip from direct light.
ƒ The maintenance dose of quinine should be halved in
patients
ti t withith renall f
failure
il after
ft 2 d days.
ƒ Always look for hypoglycemia and correct it with
50% dextrose
d xt s (1 ml /k /kg)) or orall glucose.
lu s
© M O H -D R H /D O M C /D LTLD /JH PIEG O
133
Pointsto rem em berin m anagem entof
Severe M alaria Cont…
ƒ Malaria
Ma ar a progresses fast, leading
ead ng to severe
se ere illness
ness and
death.
ƒ Severe
S malaria
l i iis a medical
di l emergency.
ƒ Patients with severe malaria should be managed
promptly. Appropriate referral should be mentioned
in case the woman cannot be cared for in a given
facility

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134
Tim e factorin m anagem entofm alaria

ƒ The tim e betw een

onsetofsym ptom s and
startoftreatm entw ith
correctm edication is an
im portantfactorin
m anagem entofm alaria
in pregnancy.
egnancy

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135
 Sum m ary

U ncom pllicat
ted
d S
Severe m al
laria
m alaria ƒ W eigh patient!
ƒ O ralquinine
ƒ Adm inisterquinine as soon
as itis diluted
ƒ Treatfever ƒ M anage fever
ƒ Provide fluids ƒ m anage dehydration
ƒ M onitorhypoglycaem ia

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136
Are we together?

Mention:
ƒ 3 main components of
treatment for
f mild
ild
malaria
ƒ5ppoints to remember
when providing quinine to
patients with severe
malaria
© M O H -D R H /D O M C /D LTLD /JH PIEG O
137
 A
Anaem ia in pregnancy

ƒ Anaem ia is defined as H b <11 g/dl;severe

anaem ia is H b <7g/dlby W H O
ƒ A pregnantw om an w ho has H b <7g/
7g/dlis
severely anaem ic.Severe Anaem ia can cause
m aternaldeathh.

© M O H -D R H /D O M C /N LTP/JH PIEG O
138
 Anaem ia in pregnancy C ont…

ƒ The m ajjorhealth effectofm alaria on the m otheris

anaem ia
ƒ M alaria destroys red blood cells ofthe m other.
ƒ Any w om an from a m alaria endem ic area w ith severe
anaem ia (H b <7g/dl)should be assum ed to have
m alaria and treated foriteven ifshe has a negative
blood sm ear.

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139
Signs and Symptoms of severe
anemia
ƒ Dizziness
ƒ Paleness of mucous membrane
ƒ Awareness of fast heartbeats
(palpitations)
ƒ Breathlessness and
ƒ Tiredness.

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140
 W hatcauses
h t anaem ia in pregnancy?
?
Anaem ia in pregnancy is usually the resultofone or
m ore ofthese conditions:
ƒ M alaria
ƒ Iron and folate deficiency (due to poordietary
intake and/orincreased dem and due to
pregnancy)
ƒ H ookw orm infestation (increases blood loss)
ƒ Advanced
Ad d H IV inf
fect
tion
ƒ Blood loss e.g.bleeding from APH

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141
 Three approaches to m anagem entof
anaem ia in pregnancy:
ƒ PR EVEN TIO N ofanaem ia
ƒ Early D ETEC TIO N ofanaem ia
ƒ Ear
E ly TR EA TM EN T offanaem ia

© M O H -D R H /D O M C /N LTP/JH PIEG O
142
 Prevention ofanaem ia in pregnancy
ƒ G ive ferrous sulphate (200 m g tds)and folic acid (5m g
O D ).
ƒ C ounselon
l th he im portance ofi
firon andd fol
lic aci
id (to increase
com pliance).
ƒ Treathookw orm ifsuspected ed.GG ive anti-hel
i helm intics.
cs
ƒ G ive Interm itted Preventive Treatm ent(IPT)to pregnant
w om en to preventm alaria w hich m ay cause anaem ia in
m alaria endem ic areas.
ƒ Educate the m other on benefitofbalanced diet.*

*See appendix form ore inform ation on nutrition and anaem ia

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D etection ofm aternalanaem ia:
H aem oglobin testing in the
ant
tenattalcl
l lini
ic:
ƒ D oes yourclinic have the resources
to offerH b testing for pregnant
w om en?
ƒ Ifyes,do H b testing,
ƒ ifno,refer for H b tests !!

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 M any
y C entres cannottestH b
In these situations you can rely on the skills thatyou already
have:
ƒ Yourclinicalassessm entskills.
s
ƒ Listen to yourclients describe sym ptom s.
ƒ Exam ine yourclients to find signs ofanaem ia.

Trustyour skills to guide you!

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Alw ays look forsigns and sym ptom s ofanaem ia
in yourpatients.
ƒ Pale (pallor)palm s,nai
s nailbeds,i
lbeds innereyelids and tongue
ongue.
ƒ C lients w ho becom e easily tired.
ƒ Pregnantw om en w ho com plain ofsevere dizziness,
breathlessness orheavyy legs.
g

ƒ Increased respiratory rate.

ƒ Increased pulse rate.

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 Ask these questions to detectanaem ia!
ƒ D o yourlegs feelheavy and sw ollen?
ƒ D o you som etim es have difficulty
w alking?
ƒ D o you som etim es have buzzing in the
ears?
ƒ D o you som etim es feelpalpitations (heart
running fast)?
ƒ D o you som etim es experience dizziness
thatstops you from w alking?

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 Pregnant and breastfeeding women
require Vitamin A

ƒ Vitamin A prevents night blindness and helps

fight off some infections
ƒ Educate on foods rich in Vitamin A such as dark
green leafy vegetables and pumpkins

See Annex XI

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 Vitamin A supplements in pregnancy
are under review
ƒ The World Health Organisation (WHO) recommends a
m xim m d
maximum dose
s off Vit
Vitamin
mi A 10
10,000
000 IU/d
IU/day iin pregnancy.
ƒ The available doses of Vitamin A in Kenya are 100,000 IU
and 200,000
200 000 IU
IU. These doses are too high for pregnant
mothers (DO NOT divide the available doses).
ƒ If the woman cannot receive the recommended supplement
mentioned above, the provider should counsel the woman
y sources of Vitamin A – meat,, whole milk,,
about dietary
green leafy vegetables and orange-coloured
fruits/vegetables

Note: Given in early pregnancy, Vitamin A (in large doses), is

b li d tto b
believed be teratogenic
t t i (may( cause malformationlf ti off th
the
fœtus). © M O H -D R H /D O M C /D LTLD /JH PIEG O
149
Are w e together?
M ention:
ƒ 4 m easures to prevent
m aternalanaem ia
ƒ 2 m easures to detect
m aternalanaem ia
ƒ 2 m easures thatw ill
im prove treatm entof
m aternalanaem ia
YES, ,w e’re toget
g her!
© M O H -D R H /D O M C /D LTLD /JH PIEG O
150
 Preventing mother-to-child
transmission (PMTCT) of HIV

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 Preventing mother-to-child
transmission ((PMTCT)) of HIV
What is mother
mother-to-child
to child transmission of HIV?
Mother to child transmission occurs when the HIV
virus is passed
dffrom the
h mother
h to the
h baby.
b b
This happens
pp as follows:
ƒ During pregnancy (5-10%)
ƒ During labour and delivery (10
(10-20%)
20%)
ƒ During breastfeeding ( 5-20%)

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 Preventing
P ntin mmother-to-child
th t hild
transmission (PMTCT) of HIV

Not every b
N baby
b b born to an HIV iinfected
f d
mother will be infected: without intervention
about 1 out of 3 babies born to mothers with
HIV will get the virus

ƒ Simple interventions can reduce the chance

of getting the HIV virus by about half.

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153
 Benefits of PMTCT include:

ƒ Improved
p child health and child survival
ƒ Decreased burden to the health care system
ƒ Increased public understanding of the HIV/AIDS
epidemic
ƒ Help increase acceptance of people living with
HIV/AIDS ((PLWHA)) by y reducingg stigma
g

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F
Four Pillars
Pill of
f WHO to
t Reduce
R d MTCT

1. Prevention of unintended pregnancy in HIV+

women through family planning services
2. Prevention of HIV infection in women through
use of ABCD (abstinence
(abstinence, be faithful
faithful, condom use
and dual protection)
3. PMTCT ini pregnancy: testing
i and d counseling
li to
identify HIV+ women; provide ARVs to mother
and
dbbaby;
b use off infection
f prevention practices
4. Care and support
pp of
f those living
g with HIV/AIDS

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 What are the main risk factors
for MTCT?
ƒ Viral Factors:
– Clinical
Cli i l stage
t of
f iinfection:
f ti new and
d advanced
d d
infections
– Low maternal CD4 count (the number of cells
per cubic millimeter of blood)
– High viral load in blood and genital tract

Note: the Lower the maternal CD4 count the more sick
the mother is likely to be.

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What are the main risk factors for
MTCT? (continued)
ƒ Maternal factors:
– Unprotected sex with multiple partners
– Substance abuse
– Smoking
– STIs and other co infections
– Vitamin A deficiency
– Motherr not
M n takingng ARV V agents
g n
– Unprotected sex with an infected partner
– HIV infection during pregnancy
– Malaria infection in pregnant women

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Wh t are the
What th main
i risk
i k f
factors
t f
for
MTCT? (continued)
ƒ Obstetric factors:
– Invasive fetal monitoring
– Duration of membrane rupture
– Routine episiotomy
– Placental disruption
– Vaginal delivery

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What are the risk factors for
MTCT (continued)

ƒ Infant factors:
– Breastfeeding
– Preterm delivery
– Neonatal birth injuries
– Vigorous naso-gastric tube suction

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159
 Best
st Practices
ract c s During
Dur ng F
FANC
N
ƒ Treating clients with dignityy and privacy.
p y
ƒ Using good interpersonal communication skills-
g explaining
listening, p g procedures
p and sharing
g your
y
k
knowledge
l d ((counselling).
lli )
ƒ Clean,, safe service deliveryy points,
p , with well-
organised client flow.
ƒ Providing access to consistent services, for
example clinic is open when it is supposed to be
p
open.
ƒ Self assessment by providers themselves,
includingg identification of clinic problems,
p
solutions
l i and
d ways of f measuring
i progress.

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160
Best Practices During FANC (continued)
ƒ A thorough
h h history
hi taking
ki andd physical
h i l
examination.
ƒ Every pregnant woman should be offered HIV
testing
g
ƒ HIV testing should be voluntary
ƒ Rapid HIV tests are available which can give
results in less than an hour
ƒ PMTCT depends on being able to identify women
who can benefit from interventions
Note: PMTCT should be integrated in the FANC clinic

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161
Care of HIV +ve women in FANC
ƒ Women withh HIV
H V should
h ld have
h medical
d l care during
d
pregnancy
– look for and treat other infections
– nutritional counseling and supplements
– monitor the HIV infection
– counseling about infant feeding, other
infections,
f , danger
g signs,
g , condom
m use and
contraceptive options

© M O H -D R H /D O M C /D LTLD /JH PIEG O

162
 Care of HIV Positive women

ƒ Nevirapine
p should be available in the antenatal
clinic for easy access for the HIV positive clients
ƒ AZT is given
i nf from
m 28
28weeks
ks
ƒ Pregnant
g women with HIV should deliver in a
hospital or health center to reduce the risk of
MTCT and to receive ARV's
ARV s during labour
(mother) and after birth (baby)

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163
Best practices
B i d
during
i llabour
b and
d
delivery
ƒ The mother should take Neverapine at
the onset of labour
ƒ Monitor labour using partogram
ƒ Only
O l perform
f episiotomy
i i t if necessary
ƒ Don
Don’tt routinely perform artificial rupture
of membranes

© M O H -D R H /D O M C /D LTLD /JH PIEG O

164
 Best Practice cont…

ƒ C-section should be p f
performed before
f
onset of labour and rupture of membranes
ƒ Avoid invasive vaginal delivery
ƒ For the baby Nevirapine should be given
within 72 hours of birth

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165
Best practices during postpartum

ƒ Informed choice”:
choice : the HIV+
woman should receive education
and counseling about her options
and helped to choose what is best
for her

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166
 B t practices
Best ti cont…
t

ƒ Exclusive breastfeeding
f g reduces the
chance of HIV transmission to the baby
– Mixed
Mi d f feeding
di (b(breast, f
formula
l and d
other foods), presence of mast
mastitis
t s and
cracked nipples increases the risk of
HIV transmission

© M O H -D R H /D O M C /D LTLD /JH PIEG O

167
 Best practices cont…
ƒ Breastfeeding should be exclusive for six months
ƒ If breastfeeding is chosen teach the mother good
breastfeedingg technique
q to avoid cracked nipples
pp
and mastitis which can increase MTCT.
ƒ If breastfeeding give breast milk only
ƒ Use formula if it is available, affordable, safe and
acceptable
bl to the
h motherh and d safe
f water iis
available.

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168
 Breastfeeding
ƒ The
h problem:
bl b
breastfeeding
f d reduces
d the
h risk
k off
infection and death in infants but can lead to the
baby getting HIV
ƒ Formula is safe but can be expensive and requires
clean water and does not give many of the benefits
of breastfeeding
ƒ HIV Positive women should be linked to care,
treatment and support to enhance follow-up

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169
 Changing
g g from Breast Feeding
g
After 6 months
ƒ If a child whose mother is HIV positive or of
unknown status has reached age 6 months &
replacement feeding is still not AFASS, then:
– Continue
C breast
b f
feeding
d with
h additional
dd l
complementary
p y foods while regularly
g y assessing
g
mother and baby.
– Stop breast feeding once a nutritionally adequate
and safe diet can be provided without breast milk.
NB: Based on latest WHO Consensus Statement during an HIV &
Infant Feeding Technical Consultation held Oct 2006

© M O H -D R H /D O M C /D LTLD /JH PIEG O

170
 Integration
ƒ Integrating a comprehensive prevention of MTCT
of
f HIV
H Vw with M
MCHHp
programs
g m Significantly
g f y reduce
u
the number of HIV-infected infants
ƒ Promote better health for children,
children mothers and
their families
ƒ PMTCT is integrated in to MCH FP and maternity
service p
provision in clinic settings
g

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171
 Care and Support
ƒ HIV positive women and their families need care
and support to live well with HIV. Care includes:
– Prevention
P ti and d ttreatment
t t of
f opportunistic
t i ti
infections
– Good nutrition
– Social support
– HIV drugs (antiretrovirals/ARVs)
– Plan for care of the children when the mother
or father ggets sick or dies
– Avoiding re-infection during pregnancy.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
172
 What can y
you do to help
p prevent
p
MTCT?
ƒ Don’t discriminate against HIV+ people!
ƒ Encourage every pregnant woman to get an HIV test
ƒ Encourage every pregnant woman to get antenatal
care
ƒ Encourage every pregnant woman to plan to deliver
h baby at a hospital
her h l or clinic
l with
h PMTCT services
ƒ Provide counseling
g about infant feeding g choices
ƒ Counseling on family planning (dual method) to
prevent pregnancy in HIV positive women

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173
We Have the Tools to Prevent MTCT.
Do We Have the Will to Implement Them?

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174
 Improving
p g communication
ƒ Providers need to LISTEN to their clients
instead of just lecturing to them.
ƒ Providers need to give integrated quality
counselling that involves the client in
decision making
making.
ƒ Providers teach clients
n aboutu IBP,, to
recognise danger signs in pregnancy and seek
help.
p

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175
 Referral
f rra of F
FANC
N cclients
nts
ƒ Within the facility there is need for internal
referral
f l e.g. tto
– Lab
– Comprehensive care centre
– TB clinic
– Wards/specialists
ƒ Out of facility referrals e.g to
– Community
– Social support groups
– To higher level facilities for Lab, CCC, specialists
etc
* Use available tools for documentation/referral
© M O H -D R H /D O M C /D LTLD /JH PIEG O
176
 Referral
f sites
Keep a regular line of communication
open with your REFERRAL SITES...
Providers:
P id
ƒ To which referral sites do you send your patients with
complications, services not available in your facility?
ƒ How do they y get
g there? How long g does it take? How
much does it cost to transport a patient to this facility?
ƒ How do y you communicate the patient’s
p historyy to the site?
ƒ Are you able to stay in touch with the referral site
rregularly,
gu r y, that is share
r nnew
w information
nf rm n etc.. ?
ƒ Do you know the names of some providers who work at
this facility?
© M O H -D R H /D O M C /D LTLD /JH PIEG O
177
 Infection Prevention

ƒ Antenatal care providers must adhere to good

infection prevention practices in all procedures.

Let’s brainstorm about these practices:

p
ƒ What are they?
ƒ Which ones are most important?

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178
 I f ti P
Infection Prevention
ti M Measures
Adhere to universal precautions on infection
control
control:
ƒ Hand washingg
ƒ Decontamination of the environment and
qu pm n including
equipment n u ng examination
am na n couch
u
ƒ High level disinfection/sterilization
ƒ Use of disposable (gloves
(gloves, syringes needles and
pipettes etc)
ƒ Proper
P disposal
di l of
f wastes
t

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179
Activity: Small groups discussion.
discussion
Brainstorming-why clients decide to deliver
att h
home rather
th than
th a health
h lth facility?
f ilit ?
ƒ What kinds
Wh ki d of f things
hi do
d clients
li expect when
h they
h
come for antenatal care?
ƒ What aspects of your centre makes a client want to
come to yyou ?
ƒ Is the atmosphere welcoming, clean and organised ?
ƒ Wh t do
What d yourur cli
clients
nts think of
f you?
u?
ƒ Are the opening hours acceptable? Does the clinic
actually open and close at the posted times?

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180
 Activity
ct ty cont…

ƒ Does the
D th pharmacy/lab
h /l b have
h similar
i il hours?
h ?
ƒ Are clients treated in a friendly
y manner?
ƒ How long do clients have to wait for services?
ƒ How can you make sure that you receive regular
feedback from your clients ?
ƒ What can you do to improve the quality of care
provided at your site?
ƒ H
How can you make
k your clients
li t value
l you andd your
facility?

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181
 Some answers
Barriers
arr rs for th the c clients
nts
ƒ Perceived lack of facilities providing high quality
ss nt a obstetric
essential o st tr c car
care?
?
ƒ Services not accessible?
ƒ Services not affordable?
ƒ Services not acceptable?
Barriers for the staff
ƒ Unskilled staff
ƒ Frequent shortage of essential equipment and
supplies and staff
ƒ Poor infrastructure
ƒ Poor referral system
© M O H -D R H /D O M C /D LTLD /JH PIEG O
182
 What are the myths in your area
about pregnancy and delivery?
ƒ Are there some traditional beliefs and customs
that
h do d not encourage planning
l for
f d delivery?
l
ƒ Is it taboo to discuss danger
g signs?
g Taboo to
discuss complications, emergency funds and
g
emergency y transport?
p
ƒ What foods are taboo for pregnant mothers in
your community?

Failing to plan contributes to maternal mortality

mortality.

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183
Keep a regular line of communication open
with your community health workers
(CHW)
ƒ Trained CHWs play an important role during pregnancy
and childbirth
childbirth, acting as links between the community and
healthcare system.
ƒ The efficiency
ff n y and
n effectiveness
ff n offmmaternal
n health
service delivery may be increased by promoting an
association with all CHWs in the area and encouraging
th
them tto refer
f as soon as d danger signs
i are id
identified.
tifi d
ƒ How does your facility communicate with trained CHWs?
ƒ Do you have
h a system for
f updating
d them
h on changes
h in
antenatal care?
Note:
N t :
Include CHWs in your antenatal updates if they are providing
care. Your clients and communities will benefit. They form a
l k a between
link b the
h community and d health
h l h facility.
f l
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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All service providers who care
for clients antenatally,during
delivery and postnataly should
enthusiastically embrace the
integration of FANC,MIP,TB,
PMTCT

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185
 List of Annexes
ƒ Annex i - FANC/MIP/PMTCT/TB Schedule
ƒ Annex ii - Instructions for facility
y level Orientations
ƒ Annex iii - Case studies
ƒ Annex iv - Questionnaire
ƒ Annex v - Other names of SP
ƒ Annex vi - Other malaria Drugs
ƒ Annex vii - Other drug interactions
ƒ Annex viii - Review:
R IBP
BP WWorksheet
k h f
for mother
h
ƒ Annex ix - Fathers-to-be checklist
ƒ Annex x - Eat a variety
var ety of foods
ƒ Annex xi - Role of Vitamins
ƒ Annex xii - Goal Oriented Checklist
ƒ Annex xiii - Check List for Antenatal physical examination and basic care
ƒ Annex xiv - Malaria in Pregnancy Job Aid
ƒ Annex xv - Focused Antenatal Care Job Aid
ƒ Annex xvi - Community Brochure
ƒ Annex xvii - List of contributors
ƒ Annex xviii - References
© M O H -D R H /D O M C /D LTLD /JH PIEG O
186
 A nnexI
O R IEN TA TIO N O N FA N C /M IP/TB FO R SER VIC E PR O VID ER S
SC H ED U LE
Day 1 Day 2 Day 3 Day 4
• Welcome • Warm up • Overview of TB in Practicum
• Introduction • Malaria in pregnancy Pregnancy • Antenatal Clinic
• Participants Expectations • Chest Clinic
• Group Norms • Laboratory
• Workshop goals and objectives • CCC
• Review of workshop materials
and Introduce job aid as a concept
• Logistics
• Pre course questionnaires

TEA BREAK
• Begin orientation package • Malaria in pregnancy • Management of TB in Practicum cont…
• Focused Antenatal Care Pregnancy
• Exercise 1: Small group
• Discussion/brainstorming. Why are
our clients deciding to deliver at
home?
• Birth preparedness
• Danger signals

LUNCH
• Transport and referral • Prevention-of-Mother • Case studies • Discussion of morning’s
• “Pregnancy partner” to-Child-Transmission • Post course clinic
• Attitudes about adolescents questionnaire Experiences
• and antenatal care • Work plans • Using instruction sheet
• Activity: Role play/
demonstration on how Closure
participants will conduct
OJT orientations to
colleagues,

• Review of Day’s activities

• Review of Day’s • Review of Day’s activities
activities

Assignm ent:Review the FANC Assignm ent:Review MIP & Assignm ent:Review TB in
com ponentofthe training m aterials PMTCT com ponentofthe pregnancy com ponentof
training m aterials the training m aterials

© M O H -D RH /D O M C/N LTP/JH PIEG O 187

 A N N EX II

IN STR U C TIO N FO R FA C ILITY LEV EL O R IEN TA TIO N

Focused A ntenatalC are /M alaria in Pregnancy (FA N C /M IP)O rientation
Instructions for the Service Provider

Each participantis requested to orientate others back in their stations as follows:

Tools:
• N ationalG uidelines for D iagnosis Treatm entand Prevention ofM alaria for
H ealth W orkers in K enya.
• N ationalLeprosy and Tuberculosis Program G uidelines,M inistry ofH ealth
• O rientation package
• Focused A N C Job A id
• ΤΒ Job A id
• M alaria in Pregnancy Job A id
• IndividualBirth Plan (IBP)pam phlet

3-4 hour FA N C /M IP update (can be a series of3-4 one-hour updates)

1.Provide feedback to allFA N C service providers in the health facility especially the
outpatient,antenatalcare,nutrition staffand field w orkers including CBD s /
CH W s.Ifin a H ospital& H ealth Centre,yourparticipants should also include
m atrons and ClinicalO fficers and incharges.

2.A llstaffin the dispensary should be orientated.

3.U se the orientation package w hen providing updates.Constantly referto the

N ationalM alaria guidelines forD iagnosis Treatm entand Prevention ofM alaria.

4.G o through the FA N C/M IP orientation package page by page w ith the participants
and allow them to ask questions frequently.

5.Show the participants how to use the lam inated FA N C/M IP Job A id and TB Job A id

6.Evaluate know ledge gained by asking random questions and also adm inisterthe
pre/postcourse questionnaire atthe end ofthe session.Send the com pleted post
testform s to JH PIEG O .

7.Rem em berto m ake yourpresentation lively and very interactive.U se the m ethods
you w ere show n during yourow n orientation to do this.

© M O H -D RH /D O M C/D LTLD /JH PIEG O 188

 A nnex III
FANC/MIP/TB CASE STUDIES

PMTCT
Case No 1
Maria is a 35year old mother with six children. S he was diagnosed as HIV sero positive about 1year
ago. She does not take ARVs but has been taking cotrimoxazole 69m
0 g bid.

She complains of coughing for the past three weeks. O

n examination the clinician detects fine
crepitations in both lungs.

.1 How would you manage this patient?

.2 What questions would you ask?
.3 What tests would you request?

Three sputum examinations were requested. The 2spot sputum samples were reported negative but
morning sample was positive.

.4 How would you manage this patient?

.5 What advice would you offer?
6. What medicines would you prescribe?

Three days later Maria is enrolled at the chest clinic and started on rifampicin, pyrazinamide, isoniazid,
ethambutol and streptomycin. She was advised not to get pregnant. She was referred to a nearby
family planning clinic where she was given oral contraceptives (levonorgestrel 0.15mg.and ethinyl
estradiol 0.3m
0 g).

Six weeks later Maria returns and reports that she missed her monthly period.

.7 What questions would you ask?

.8 What tests would you request?

The pregnancy test was positive.

.9 How would you manage this patient?

.01 What questions would you ask?
.1 What tests would you request?
.21 What advice would you offer?

Case No 2

Sarah is a 23year old nulliparous woman in her firs t trimester of pregnancy. She has come to the ante-
natal clinic for routine care. Through PMTCT program, she accepted HIV testing and was found to be
sero-positive.

.1 How would you manage this patient?

.2 What questions would you ask?
.3 What tests would you request?
.4 What advice would you offer?

She is referred to the CCC for HIV care and advice. Upon examination, the clinician discovers a
swelling on the right side of her neck. She admits that she has been coughing for the past 2months
and has lost three kilograms in her body weight.

189
.5 How would you manage this patient?
6. What questions would you ask?
.7 What tests would you request?

oYu request for sputum tests wh ich are reported negative for AFB. A CBC shows 5,04WBCs, with
64%
neutrophils and 3%lymphocytes. Hemoglobin is .95grams/dl.

.8 How would you manage this patient?

.9 What questions would you ask?
.01 What tests would you request?
.1 What medicines would you prescribe?
.21 What advice would you offer?

MIP

Case study no.3.

Leah aged 52years is brought to t he outpatient department. She is a local resident, the wife of a
business executive, and is in the seventh month of her pregnancy. The patient became ill five days
ago, with chills, sweating and headaches. An antibiotic was prescribed and her condition seemed to
improve, but yesterday she developed rigors and persistent vomiting. A blood film at the local clinic
revealed malaria parasites, and oral quinine (600mg every 8hours) was pr escribed. She took two
doses.

Today she has been referred to your hospital because of confusion. Examination reveals a
semiconscious woman who is unable to talk. She withdraws her hand from a painful stimulus but
cannot localize a stimulus applied to the sternum or forehead. There is no neck stiffness, jaundice,
pallor or rash. Axillary temperature is 39°C, pulse 90beats/min, blood pressure 10/7mmHg. The
uterine fundus is palpable (26 - 82wee ks) and the foetal heart can be heard.

.1 What other questions would you ask the patient’s relatives?

.2 What tests are urgently required?
.3 If the whole blood glucose is .12mmol L/ , what treatment will you give?
If the blood film shows P falciparum 46520,/ and the cerebrospinal fluid is normal except for low
glucose, what antimalarial drug would you administer and by what route?
.4 Would you prefer an alternative to quinine because of the pregnancy?
.5 Would you give a loading dose of quinine?
6. What nursing procedures are important during this treatment
.7 After 6 hours, the patient becomes increasingly restless. The respiratory rate increased to
m
/40 inute. The blood glucose level is normal. U nder these conditions, what special observations
would you make?
.8 What other observations are particularly important in this patient?

PMTCT/MIP

Case no.4
Rachel is 25years old mother wi th two children aged less than 5years. She lives in a malaria endemic
area. She has been experiencing nausea and vomitting for several weeks and has decided to come to
the outpatient clinic today.

.1 How would you manage this patient?

.2 What questions would you ask?
.3 What actions would you take?
190
A blood slide for malaria parasites is requested and it is reported negative. Rachel admits that she has
missed her menses for the past two months. However, she is not worried about pregnancy because
she is still breast feeding her 61-month old daughter.

.4 How would you manage this patient?

.5 What questions would you ask?
6. What actions would you take?
.7 What advice would you offer?

A pregnancy test is requested and it turns out positive.

.8 How would you manage this patient?

.9 What advice would you offer?
.01 What medicines would you prescribe?

Case no.5.
Rose is a 30years nulliparous woman who comes fr om a non-malaria endemic area. She has come to
the ANC clinic to begin her routine check-up. uQickening has taken place the previous week.

.1 How would you manage this patient?

.2 What questions would you ask?
.3 What advice would you offer?
.4 What actions would you take?

All her ANC profile tests are reported negative except for her HIV test.

.5 How would you manage this patient?

6. What questions would you ask?
.7 What medicines would you prescribe?
.8 What advice would you offer?

Rose returns 1month later and reports that the CCC has advised her to take cotrimoxazole daily. Her
CD
4count is reported as 03cells/ml.

.9 How would you manage this patient?

.01 What questions would you ask?
.1 What medicines would you prescribe?
.21 What advice would you offer?

TB/HIV IN PREGNANCY
Case no.6
uJ ne 03years old at 23weeks gestation. She comes to the ANC clinic with a history of cough for
2weeks which has persisted despite her being on antihistamines.

.1 How would you manage this patient?

.2 What questions would you ask?
.3 What tests would you request?
.4 What medicines would you prescribe?
.5 What advice would you offer?

191
Three sputum examinations were requested. The 3sputum samples were reported positive. Her HIV
test is negative

.1 How would you manage this patient?

.2 What advice would you offer?
.3 What medicines would you prescribe?
.4 What other tests would you want to do?

She delivers a healthy baby girl at term. She returns two months later and decides to repeat HIV test.
The results are positive.

.5 How would you manage this patient?

6. What questions would you ask?
.7 What further tests would you request?
.8 What medicines would you prescribe?
.9 What advice would you offer?

192
 ANNEX IV
FANC,MIP,PMTCT,TB INTEGRATION
QUESTIONNAIRE

Focused AntenatalCare

.1 Antenatal history should ideally be taken:

a) After counseling on individual birth plan
b) Before performing a physical examination
c) Before results from the laboratory are obtained
d) After giving SP

.2 nOe of the following is NO

T par t of an Individual Birth Plan:
a) K nowing when the baby is due
b) Identifying a skilled birth attendant
c) Planning to deliver in the comfort of home
d) Having a birth partner/companion

.3 Preventing complications during PREGNANCYdoes NO

T include:
a) Providing tetanus toxoid
b) Giving Iron/folate supplements
c) Use of IPT and ITNS
d) Providing emergency funds

.4 Which one of the following is NO

T part of Health Promotion in FANC?
a) Nutrition
b) Rest and hygiene
c) Blood donation
d) Family planning

.5 aDnger signs in PREGNANCYinclude:

a) Reduced fetal movement
b) Labor pains for more than 12hours
c) Placenta not delivered within 30minutes
d) Cord, arm or leg prolapse

6. The recommended schedule for 4comprehensiv e, personalized antenatal visits is:

(NO
TE:’<‘ implies less than or before; ’>‘ implies greater than or after)
a) 1 visit>16 wks, 2
st nd 61-28wks, 3 rd 28-32wks, 4 th -2 363 wks
b) 1 visit<16 wks,2
st nd 61-28wks, 3 rd 28-32wks, 4 th -23w 04 ks
c) 1 visit<16 wks,2
st nd 61-24wks, 3 rd 24-32wks, 4 th -2383wks
d) 1st visit<12wks,2 nd 2-124wks, 3 rd 2 4-32wks, 4 th -2 304wks

.7 aDnger signs in pregnancy O

DNO
T include:
a) Vaginal bleeding
b) Severe headache
c) Swelling in the face
d) Puerperal sepsis

© M O H -D RH /D O M C/D LTLD /JH PIEG O 193

 Malaria in Pregnancy

.8 Pregnant women are more prone to get malaria because:

a) Most of them have malaria but have no symptoms
b) They loose some of their ability to fight infection
c) Blood tests for parasites are often negative
d) Their hemoglobin levels Increase during pregnancy

.9 nOe of the following st atements is FALSE about malaria in pregnancy:

a) Malaria parasites in the mother hide in the placenta
b) Malaria parasites obstruct oxygen passage to fetus
c) Malaria decreases the risk of still births
d) Red blood cells are destroyed by the parasites

.01 When should a provider NO T administe r SP during routine antenatal care?

a) When giving tetanus toxoid
b) Together with Folic acid on the same day
c) When a woman has no reported allergy to sulfa-drugs
d) After the 1st trimester

.1 Which one of the following conditions is NO

T a cause of anemia in pregnancy?
a) Hookworm infestation
b) High blood pressure
c) Malaria
d) Advanced HIV infection

.21 nOe of the following st atements is FALSE about malaria prevention:

a) ITNs reduce the number of mosquitoes in the house by killing them
b) First dose of IPT should be given around 01weeks of pregnancy
c) Administer IPT with each scheduled visit after quickening at an interval of at least 4
weeks apart
d) All pregnant women should have their Hb checked routinely in the clinic

.31 nOe of the following statem ents is TRUE about management of severe malaria:
a) Give single dose of 3tablets of SP
b) Give parenteral quinine per kilogram body weight
c) Chloroquine clears malaria parasites quickly and reduces fever
d) Amodiaquine is a 1st line drug for treating severe complicated malaria

PMTCT

.41 The risk of mother-to-child transmission increases when:

a) Breastfeeding is continued over time
b) Non-invasive delivery procedures are used
c) Maternal viral load is low
d) Sexually transmitted infections are treated early

.51 nOe of the following can increase the ri sk of HIV transmission via breastfeeding:
a) Teaching mothers good breastfeeding techniques
b) Supporting mothers to use exclusive breastfeeding for up to 6 months
c) Instructing mothers to supplement breast milk with other feeds
d) Encouraging mothers to obtain early treatment of breast problems

© M O H -D RH /D O M C/D LTLD /JH PIEG O 194

61. When should Nevirapine be given to prevent MTCT?
a) To the mother during pregnancy
b) At onset of labor within 27hours of birth
c) Postpartum period to the mother
d) D
uring pregnancy and to the baby for 7days after birth

.71 To confirm that a baby is HIV infected, a rapid antibody testing needs to be performed at :
a) 12months
b) 18months
c) 6 months
d) 4months

.81 Which one of the following statements is FALSE in pregnancy:

a) Individual pre-test counseling is a pre-requisite for HIV testing
b) HIV testing is a must for all pregnant women
c) HIV testing is an opt-in or opt-out option
d) Pre-test counseling is a priority intervention for individual preparedness.

Tuberculosis

.91 Which one of the following is NO

T a predis posing factor of Pulmonary Tuberculosis?
a) Malnutrition
b) Extreme ages
c) vOercrowding
d) Trauma to chest cavity

.02 The best readily available way to make a diagnosis of PTB is:
a) Chest X-ray
b) Sputum for AFB
c) Blood examination
d) Sputum for culture

.12 Which one of the following statements is TRUE about TB treatment:

a) TB drugs are only used in HIV negative persons
b) It is not necessary to always follow treatment guidelines
c) Use correct drugs and dosages for every case defined
d) Initial phase of treatment is always done at home without supervision

.2 When should an infant receive BCG if the mother is on TB treatment?

a) 3days after Isoniazid pr ophylaxis is stopped
b) Immediately the infant is born
c) After the infant shows no signs of ImmunoSuppression
d) 3months after birth

.32 When used in pregnancy, one of the following drugs may cause deafness to the infant:
a) Streptomycin
b) Rifampicin
c) Isoniazid
d) Ethambutol

.42 T
O
D implies that:
a) Patient adheres to treatment during intensive phase only
b) Patient takes every treatment dosage under supervision in the intensive phase
© M O H -D RH /D O M C/D LTLD /JH PIEG O 195
 c) iDrectly observed treatment with weekly monitoring
d) Getting TB treatment as close to home as possible

Infection Prevention

.52 Which one of the following is NO

T a measure of Infection Prevention?
a) Hand washing
b) Pre –rinse soiled linen
c) Environmental cleaning
d) Use of disposable supplies

© M O H -D RH /D O M C/D LTLD /JH PIEG O 196

Annex v:
v Other names for Sulfadoxine
Pyrimethamine (SP).

ƒ Fansidar*
F sid * ƒ Falcidin*
ƒ Malaraxin* ƒ Orodar*
ƒ Malodar* ƒ Intadoxine
ƒ Fansidin
Fansidin* ƒ Malocide
ƒ Metakelfin+* ƒ Viparum

* Names with a star were quality controlled in Kenya

Kenya.
+Sulfalene pyrimethamine

© M O H -D R H /D O M C /D LTLD /JH PIEG O

197
 Annex vi: Other Malaria Drugs

Prophylaxis: Second Line Treatment:

ƒ Paludrine
P l d i (one
( d
daily)
il ) ƒ Quinine
Q i i
ƒ Doxycycline (one daily)
contraindicated in
pregnancy
ƒ Mefloquine (weekly)

First
F rst line:
n
ƒ Artermether Lumefantrine
(AL)
© M O H -D R H /D O M C /D LTLD /JH PIEG O
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 Annex vii: Interaction of oral /other
contraceptives with Antiretroviral Drugs
Interacting ARV Effect of interaction Management
drug recommendation
DMP
DMPA EFV EFV not affected
ff d
NVP Slight increase in NVP AUC with DMPA co-
administration
Ethinyl Estradiol DLV Ethinyl Estradiol levels decreased by 20% Recommend alternative birth
control method
EFV Ethinyl Estradiol AUC increased 37% Recommend alternative birth
control method
LP/r Ethinyl Estradiol AUC decreased by 42% Recommend alternative birth
control method
NFV Ethinyl Estradiol AUC decreased by 47% Recommend alternative /or
Northindrone decreased 18% additional birth control method

RTV Ethinyl Estradiol AUC decreased by 41% Warn patient of interaction.

Use barrier method of
contraception
SQV No data
© M O H -D R H /D O M C /D LTLD /JH PIEG O
199
 FP Drug Interaction
METHOD DRUG INTERACTION
PILLS Because of its low dose of hormone,
-Progestin only pill (POP) the risk of pregnancy increases
with:-
with:
- Carbamazepine Phenytoin
- Phenobarbitone
- Primidone
- Phenybutazone
- Rifampicin

-COC ((Combined)) both estrogen

g and The risk of p
pregnancy
g y increases
progestin with the following medications.
- Carbamazepine Phenytoin
- Phenobarbitone
- Primidone

© M O H -D R H /D O M C /D LTLD /JH PIEG O

200
 FP Drug Interaction cont
cont…
METHOD DRUG INTERACTION
PILLS-COC – Phenybutazone
– Rifampin
– Griseofulvin
– Topirimate
– Antiretroviral drugs
ART Drugs
(NNRTIs PIs)
(NNRTIs,
Lower oestrogen and or norethidrone levels in
th blood
the bl d off women using
si COCs
COCs.

© M O H -D R H /D O M C /D LTLD /JH PIEG O

201
 FP Drug Interaction cont
cont…
METHOD DRUG INTERACTION
IUCDs None
Abstinence None
Fertility awareness None
Condoms None
Implants Some medications may cause the liver
to metabolize progestin decreasing
already low doses and decreasing
effectiveness
– Rifampicin
– Dilantin ((Phenytoin)carbamazepine
y ) p
© M O H -D R H /D O M C /D LTLD /JH PIEG O
202
 FP drug interaction cont…
METHOD DRUG INTERACTION
Implants – Primidone

– Phenylbutazone

™ NB: the same may be true for ART but studies have not
b
been conducted
d t d tto d
determine
t i thi
this.

© M O H -D R H /D O M C /D LTLD /JH PIEG O

203
 FP Drug Interaction cont
cont…

Method Drug Interaction

Injectables There is not enough data
Spermicides None
Vasectomy None
Tubal Occlusion None
Emergency None
Contraceptive pill

© M O H -D R H /D O M C /D LTLD /JH PIEG O

204
 FP drug interaction cont…
Ethinyl TPV/r Ethinyl Estradiol AUC Alternative form of
E
Estradiol
d l d
decreaseddbby 50%% contraception should
h ld be
b
used
NVP Ethinyll Estradiol
Ethi Est di l :AUC Patients
P ti ts sh
should
ld use
s
decreased by 23% alternative form of
Norethindrone:AUC birth control methods
decreased 18% (e.g. barrier
contraceptive methods)
Ethinyl IDV Northindrone increased Patients should use
Estradiol/ by 26%and barrier methods
Norgestim Ethinylestradiol
ate increased by 24%

TDF No significant drug Use standard dose

interaction

© M O H -D R H /D O M C /D LTLD /JH PIEG O

205
 Annex viii:
R i
Review: I B P Worksheet
W k h for
f the
h mother
h

ƒ When is your baby due?

ƒ Where iss your baby to be born?
ƒ Which skilled attendant will be there?
ƒ Who else will p
provide support?
pp
ƒ What supplies do you need to gather?
ƒ Who will care for the rest of the family?y
ƒ If you were to develop complications, to
y will y
which health care facility you go?
g
ƒ How will you get there?
ƒ Do y
you have the basic expenses?
p How will
you come up with the additional funds if
y
necessary?
© M O H -D R H /D O M C /D LTLD /JH PIEG O
206
 Annex ix: Fathers checklist
ƒ Does your wife have vitamins, iron, folate and
hookworm medicines, if indicated?
ƒ Does your wife sleep under a mosquito net? Has
she had ((SP)) malaria medicine? Does she know when
to return for her next appointment?
ƒ Do you know the danger signs in pregnancy and
labour?
ƒ Do you have a plan for financing complications?
ƒ Do you have a plan for emergency transport?
You are a prepared father to be!!
Congratulations!

© M O H -D R H /D O M C /D LTLD /JH PIEG O

207
 Annex x: mothers should eat
a variety of these foods
Foods from each of these groups should be
eaten as often as possible with each meal of
the day:
ƒ Staples and grains-maize, ƒ Vegetables-beans, green
potatoes,, bananas,, yams,
p y , grams groundnuts
grams, groundnuts, tomatoes
tomatoes,
cassava, rice and millet. carrots, spinach, sukuma and
ƒ Fats such as cooking oils,
oils f some
the leaves of m p plants..
coconut oil, margarine and ƒ Fruits such as oranges,
butter
butter. bananas pineapples
bananas, pineapples, mangoes
ƒ Animal products like meat, and pawpaw.
fish milk and eggs
fish,
© M O H -D R H /D O M C /D LTLD /JH PIEG O
208
Eat a variety
ar ty of foods
foo s cont…
What these foods p
provide...
ƒ Vitamin C helps the woman to absorb iron more efficiently-
rich
i h sources are: citrus
it f
fruits
it and
d some vegetables-
t bl
cabbage, potatoes, cauliflower and carrots.
ƒ Ri h ssourcess of
Rich f iron
i are:: egg yolk,
lk groundnuts,
d ts d dried
i db
beans,
s
dried fruit, dates, raisins, sugar molasses, fish, veal, lamb,
pork turkey
pork, turkey, chicken
chicken, grasshoppers and termites
termites.
ƒ Rich sources of folic acid: dark green leafy vegetables
(such as cassava leaves, leaves kale/sukuma wiki,
leaves pumpkin leaves,
spinach), terere, liver, fish, nuts, yeast, legumes, eggs,
whole g grains and mushrooms.
Note: Avoid over-cooking since this destroys many of the
nutrients in foods
foods.
© M O H -D R H /D O M C /D LTLD /JH PIEG O
209
 Annex XI
The Role ofSom e Vitam ins and Minerals in the Body and Sources ofNutrients
Nutrient Its Role Sources

Vitam in A Required for maintenance of epithelial cells, mucous Full-cream milk (when fortified), cheese, butter, red palm oil, fish
membranes, and skin. Needed for immune system function oil, eggs, liver, carrots, mangoes, papaya, pumpkin, green leafy
and resistance to vegetables, yellow sweet potatoes.
infections. Ensures good vision. Needed for bone growth.

Vitam in BI/Thiam ine Used in energy metabolism, supports appetite, and central Whole-grain cereals, meat, poultry, fish, liver, milk, eggs, oil,
nervous system functions. seeds, and legumes.

Vitam in Used in energy metabolism, supports normal vision, health Milk, eggs, liver, meat, fish, yogurt, green leaves, whole grained
B2/Riboflavin and integrity of skin. cereals, and legumes.

Vitam in B6 Facilitates metabolism and absorption of fats and proteins, Legumes (white beans), potatoes, meat, fish, poultry, shellfish,
coverts tryptophan to niacin, helps to make red blood cells watermelon, oil seeds, maize, avocado, broccoli, green leafy
vegetables. Alcohol destroys vitamin B6.

Folate (folic acid) Required for synthesis of new cells, especially red blood cells Liver, green leafy vegetables, fish, legumes, groundnuts, oil seeds.
and
gastrointestinal cells.

Vitam in B12 Required for synthesis of new cells, helps to maintain nerve Meat, fish, poultry, shellfish, cheese, eggs,
cells. Works together with folate. milk

Vitam in C Helps the body to use calcium and other nutrients to build Citrus fruits such as baobab, guava, oranges and lemons;
bones and blood vessels walls. Increases resistance to cabbage, green leaves, tomatoes, peppers, potatoes, yams,
infection and acts as an antioxidant. Important for protein cooking plantains, and fresh milk. Vitamin C is lost when food is
metabolism. cut up, heated, or left standing after cooking.

Vitam in D Required for mineralization of bones and teeth. Produced by milk, butter, cheese, fatty fish, eggs, liver.
skin on exposure to sunshine
Vitam in E Acts as an antioxidant. Protects cell membranes and Green and leafy vegetables, vegetable oils, wheat germ, whole-
metabolism, especially red and white blood cells. Protects grain products, butter, liver, egg yolk, peanut, milk fat, nuts, seeds.
vitamin A and other fats from oxidation. Facilitates resistance
against disease, particularly in lungs.

Iron Required to make hemoglobin for red blood cells, and to Heme iron sources (high absorption) include red meat, liver, fish,
transport oxygen from lungs to cells throughout the body. Acts poultry, and shellfish. Non-heme iron sources (low absorption)
as an antioxidant. Required for utilization of energy and include eggs, legumes, peanuts, some cereals, and dried fruits.
metabolism Vitamin C, heme iron foods, and some fermented foods increase
non-heme iron absorption. Tea, coffee, and some grain and green
leafy vegetables (with phylate) decrease non-heme iron
absorption.

Calcium Required from building strong bones and teeth. Important for Milk, yogurt, cheese, green leafy vegetables, broccoli, dried fish
normal heart and muscle functions, blood clotting and with bones that are eaten, legumes, peas.
pressure, and immune defenses.

Zinc Important for function of many enzymes. Acts as an anti- Meat, fish, poultry, shellfish, whole grain cereals, legumes,
oxidant. Involved with making genetic material and proteins, peanuts, milk, cheese, yogurt, vegetables.
immune reactions, transport of vitamin A, taste perception,
wound healing, and sperm production.

Selenium Acts as an antioxidant together with vitamin E. Prevents the Meat, eggs, seafood, whole grains, plants grown in selenium rich
impairing of heart muscles. soil.

Magnesium Important for building strong bones and teeth, protein Nuts, legumes, whole grain cereals, dark green vegetables,
synthesis, muscle contraction, transmission of nerve impulses. seafood.

Iodine Ensures the development and the proper functioning of the Seafood, iodized salt, plants grown in
brain and the nervous system. Important for growth, iodine-rich soil.
development, metabolism.

Source:Piwoz and Preble (November2000).HIV/AIDS and Nutrition:A Review oftheLiterature and recommendations forNutritionalCare
and Supportin Sub-Saharan Africa

© M O H -D RH /D O M C/D LTLD /JH PIEG O 210

 Annex XII

Goalorientated checklist

GOAL-ORIENTED ANTENATAL CARE

W EEKS OF GESTATION
Param eter First visit or 16-28 28-32 32-40
<16 weeks weeks weeks weeks

Registration
• Comprehensive history taking(History 9 9 9 9
of contact with TB, chronic cough)
• Personal history 9

• Family history 9
9
• Social history 9
• Past medical/surgical history 9
• Past obstetric history 9
• History of current pregnancy 9
• History of complaints in current 9 9 9 9
pregnancy
PhysicalExam ination
• Head-to-toe (whole 9 9 9 9
body)lymphadenopathy
o Pallor 9 9 9 9
o Oedema 9 9 9 9
o Breast 9 9 9 9
o Lungs and heart 9
Observations and clinicalinvestigations
• Temperature 9
• Pulse 9 9 9 9
• Blood pressure 9 9 9 9
• Weight 9
• Height 9
• Gait 9
Obstetric exam ination
• Fundal height 9 9 9 9
• Foetal poles/lie 9 9
• Foetal presentation 9 9
• Engagement of presenting part 9
• Foetal heart sounds 9 9 9

Pelvic (vaginal)exam ination 
• Soft tissue assessment (genital ulcers, 9  9
vaginal discharge, cervix, uterine

© M O H -D RH /D O M C/D LTLD /JH PIEG O 211

 GOAL-ORIENTED ANTENATAL CARE
W EEKS OF GESTATION
Param eter First visit or 16-28 28-32 32-40
<16 weeks weeks weeks weeks

enlargement/position, adnexal
masses)
• Bony pelvis assessment  9
(cephalopelvic relationship)

Laboratory investigations  

• Blood  
• Haemoglobin 9  9
• Grouping and rhesus factor 9  
• VDRL (the standard 9  
• nontreponemal antigen serologic
• test for syphilis)
• HIV testing (earliest opportunity) 9  
• Sputum(if history of cough) 9 9 9 9
Urine  

• Protein 9 9 9 9
• Sugar 9 9 9 9
• Acetone 9 9 9 9
Drug adm inistration and im m unization  

• Iron 9 9 9 9
• Folic acid 9 9 9 9
• Antimalarials (Fansidar 3 tablets) 9 9 9
• Tetanus toxoid 9 9 

• Ensure compliance 9 9 9 9
• Anti-TB (if indicated)
• ARV (if indicated)
Clienteducation and counselling (forthe  
couple)

• Process of pregnancy and its 9 9 9 9

complications
• Diet and nutrition 9 9 9 9
• Rest and exercise in pregnancy 9 9 9 9
• Personal hygiene 9 9 9 9
• Danger signs in pregnancy 9 9 9 9
• Use of Drugs in pregnancy 9 9 9 9
• Effects of STI/HIV/AIDS/TB 9 9 9 9
• Voluntary confidential counselling and 9  
testing for HIV

• Care of breasts and breastfeeding 9  9

© M O H -D RH /D O M C/D LTLD /JH PIEG O 212

 GOAL-ORIENTED ANTENATAL CARE
W EEKS OF GESTATION
Param eter First visit or 16-28 28-32 32-40
<16 weeks weeks weeks weeks

• Symptoms/signs of labour 9 9 9
• Plans for delivery (emergency 9 9 9 9
preparedness, place of delivery,
transportation, financial arrangements)

• Plans for postpartum care 9 9 

• Family Planning 9 9 9
• Harmful habits (e.g. smoking, drug 9 9 9 9
abuse, alcoholism)

• Schedule of return visits 9 9 9 9

© M O H -D RH /D O M C/D LTLD /JH PIEG O 213

 Annex XIII
CHECKLIST FOR ANTENATAL HISTORY,
PHYSICAL EXAMINATION AND BASIC CARE
(To be used by the Learnerfor practice and by the Teacherat the end of the course)

Place a “ ” in case box if task/activity is performed satisfactorily,an “X” if it is notperformed 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

NotObserved: Step, task or skill not performed by participant during evaluation by trainer

LEARNER ______________________________________

CHECKLIST FOR ANTENATAL HISTORY,

PHYSICAL EXAMINATION AND BASIC CARE
STEP/TASK OBSERVATIONS

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 and encourage her to ask questions.

5. Listen to what the woman has to say.

CHECKLIST FOR ANTENATAL HISTORY,

PHYSICAL EXAMINATION AND BASIC CARE
STEP/TASK OBSERVATIONS

SKILL/ACTIVITY PERFORMED SATISFACTORILY

HISTORY (ASK/LISTEN)

1. Ask the woman how she is feeling and respond immediately to any urgent
problems.
2. Ask the woman her name, age, number of previous pregnancies, number
of children, menstrual history and contraceptive history.

3. Calculate the EDD.

4. Ask the woman about past pregnancy problems.

© © M O H -D RH /D O M C/D LTLD /JH PIEG O 214

5. Ask the woman about medications.

6. Ask the woman about alcohol use and smoking.

7. Ask the woman about HIV status.

8. Ask the woman about tetanus immunization.

9. Ask about coughing, chest pain and night sweats.

10. Ask the woman about general health problems.

11. Ask the woman if she has taken the prescribed treatment to prevent
malaria, and whether she is using treated bednets at all times.

12. Ask the woman about social support.

13. Ask the woman about other problems or concerns related to her
pregnancy.

14. Record all pertinent information on the woman’s record/antenatal card.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

PHYSICAL EXAMINATION (LOOK/FEEL)

1. Ask the woman if she needs to empty her bladder. Save and test urine, if
necessary.

2. Observe the woman’s 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 woman’s blood pressure and respiration rate.

7. Check the woman’s conjunctiva and palms for pallor.

8. Examine the breasts.

9. Examine the chest.

10. Examine abdomen and measure/estimate fundal height.

© © M O H -D RH /D O M C/D LTLD /JH PIEG O 215

11. Determine lie and presentation (after 36 weeks).

12. Listen to the fetal heart (second and third trimesters).

13. Put high-level disinfected gloves on both hands.

14. Check external genitalia for sores and/or swelling.

15. Check the vaginal orifice for bleeding and/or abnormal discharge.

16. Check for signs of female genital mutilation (country/population specific).

17. Immerse both gloved hands in 0.5% chlorine solution:

· Remove gloves by turning them inside out.
· If disposing of gloves, place in leakproof container or plastic bag.
· If reusing surgical gloves, submerge in 0.5% chlorine solution for 10
minutes to decontaminate.
18. Wash hands thoroughly with soap and water and dry.

19. Record all relevant findings from the physical examination on the
woman’s record/antenatal card.

Screening Procedures

1. Put high-level disinfected gloves on both hands.

2. Draw blood and do hemoglobin and RPR tests, interpreting results

accurately.

3. Do sputum examination for TB if Indicated.

4. Empty and soak the test tubes in 0.5% chlorine solution for at least 10
minutes.

5. If reusing needle or syringe, fill syringe (with needle attached) with 0.5%
chlorine solution and submerge in solution for 10 minutes for
decontamination.

6. If disposing of needle and syringe, place in puncture proof container.

7. Immerse both gloved hands in 0.5% chlorine solution:

· Remove gloves by turning them inside out.
· If disposing of gloves, place in leak proof container or plastic bag.
· If reusing surgical gloves, submerge in 0.5% chlorine solution for 10 minutes to
decontaminate.

8. Wash hands thoroughly with soap and water and dry.

9. Record the results on the woman’s record/antenatal card and discuss them with
her.

© © M O H -D RH /D O M C/D LTLD /JH PIEG O 216

 SKILL/ACTIVITY PERFORMED SATISFACTORILY

IDENTIFY PROBLEMS/NEEDS

SKILL/ACTIVITY PERFORMED SATISFACTORILY

PROVIDE CARE/TAKE ACTION

1. Treat the woman for syphilis if the RPR test is positive, provide
counseling on safer sex, and arrange for her partner to be treated and
counseled.

2. Provide tetanus immunization based on need.

3. Provide counseling about necessary topics such as nutrition, hygiene, etc.

4. Provide counseling about the use of insecticide-treated bednets.

5. Dispense medication for IPT of malaria according to protocol.

6. Dispense other necessary medications such as iron and folate.

7. Develop or review individualized birth plan with the woman.

8. Discuss danger signs and what to do if they occur.

9. Record the relevant details of care on the woman’s record/antenatal card.

10. Ask the woman if she has any further questions or concerns.
11. Thank the woman for coming and tell her when she should come for her
next antenatal visit.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

© © M O H -D RH /D O M C/D LTLD /JH PIEG O 217

 Annex XIV
MALARIA IN PREGNANCY

A dm inister IPTp w ith each scheduled visitafter quickening to

ensure w om en receive atleast2 doses one m onth apart

FIRST DOSE (AFTER QUICKENING) 4 W EEKLY AFTER FIRST DOSE

Size of
uterus

R em em ber the FA C TS aboutM alaria in Pregnancy

1. Pregnantw om en are m ore likely than 5. SP is the only available option for IPTp
non-pregnantw om en to have m alaria
because their resistance is low . 6. The benefits ofSP in pregnancy are:
• K EEPS PLA C EN TA PA R A SITE
2. Even pregnantw om en w ho look and feel FR EE!
w ellm ay be carrying m alaria parasites • K eeps m other and baby healthy.
especially in areas w here m alaria is
com m on. 7. A lw ays ask for side effects to Sulfa drugs
before giving SP to pregnantw om en.
3. M alaria parasites hide in the placenta
m aking the m other anaem ic. 8. R em em ber thatinsecticide treated nets
(ITN )are a good protection againstthe
4. M alaria parasites in the placenta m ay m alaria m osquito.
cause low birth w eightor even death ofthe
baby.

July 2007 © M O H -D RH /D O M C/D LTLD /JH PIEG O 218

 MALARIA KWA MWENYE MIMBA

W apatie m am a w aja-w azito IPTp w akija clinic kutoka w ikiya

16 na uhakikishe w ote w am epata dosi2 au zaidi.

K ipim o cha kw anza (kutoka w iki16) K ila w ikinne baada ya kipim o cha kw anza

U kubw a
w a kizazi

K um buka H A BA R I M U H IM U kuhusu M alaria katika uja uzito

1. N irahisikw a m am a w aja-w azito kushikw a na 5. SP nidaw a pekee inayofaa kukinga m alaria

m alaria kuliko w ale w asikuw a w aja-w azito kw a kw a m am a w aja-w azito.
sababu nguvu zao za kujikinga zim epungua.
6. M anufaa ya SP kw a m am a w aja-w azito ni:-
2. H ata m am a w aja-w azito w anao-onekana na • H U O N D O A V IIN I K W EN Y E U ZA ZI!
kujisikia w azim a huenda w ana viinivya • H U W A W EK A M A M A N A M TO TO
m alaria,hasa katika sehem u am bazo ugonjw a K A TIK A H A LI Y A A FY A .
huu uko zaidi. 7. D aim a uliza ikiw a daw a za sulpha zinam dhuru
kabla ya kum pa m w anam ke m ja-m zito daw a ya
3. V iinivya m alaria hujificha kw enye uzazina SP.
kum fanya m am a kupungua dam u .
8. K um buka kw am ba chandarua kilichow ekw a
4. V iinivya m alaria kw enye uzazihuenda daw a nibora katika kuzuia m bu
vikasababisha m toto akazaliw a bila uzito w a w anaosababisha m alaria.
kutosha na hata kifo cha m toto.

July 2007 © M O H -D RH /D O M C/D LTLD /JH PIEG O 219

 Annex XV
FOCUSED ANTENATAL CARE
1ST VISIT
• Advise on individual birth plan
• Take history
• Do physical exam
G- Greet her • Look for anaemia
A- Ask if she has made an individual birth plan? • Screen for syphilis
T- Tell her about Danger Signs • Give tetanus toxoid, iron and
H- Help her make an individual birth plan folate
E- Explain about Malaria, IPT, treated nets and TB • Give SP if more than 16 weeks
R- Remind her about Dangers Signs, individual birth plan and • Tell her about danger signs
4 ANC visit schedule (< 16 weeks; 16 – 28; 28 – 32; 32-40) • Counsel for HIV
• Screen for TB

2ND VISIT 3RD VISIT 4TH VISIT

• Check on individual birth • Check on individual birth • Update on individual birth
plan plan plan Look for anaemia
• Give 1st SP, iron and folate • Give 2nd SP, iron and folate • Check foetal presentation
• Listen for foetal heart • Give tetanus toxoid (if 4 • Do vaginal exam
sound weeks from 1st dose) • Give iron and folate
• Counsel and Educate • Listen to foetal heart sound • Counsel and Educate
• Counsel and Educate

Remember to ask about her Individual Birth Plan (IBP)

• Does your client know when her baby is due?

• Has she identified a skilled birth attendant?
• Has she identified a health facility for delivery/emergency?
• Can she list danger signals in pregnancy and delivery?
• Has she identified a decision-maker in case of emergency?
• Does she know how to get money in case of emergency?
• Does she have a transport plan in case of emergency?
• Does she have a birth partner for the birth?
• Has she collected the basic supplies for the birth?
Yes!

Before the woman leaves your clinic, STOP and ask her if she:
• Has a supply of iron and folate tablets
• Has taken her SP and has had her tetanus toxoid injection
• Knows the danger signs in pregnancy and child birth
nd
• Knows her appointment for the next ANC visit and 2 SP dose
• Has a birth plan
• Has a method of postpartum family planning in mind
• Knows the signs and symptoms of TB and has been screened if indicated

You have now prepared your client!

July 2007 ©MOH-DRH/DOMC/DLTLD/JHPIEGO 220

 HUDUMA THABITI ZA CLINIK KWA
MWENYE MIMBA
ZIARA YA KWANZA
• M shaurikuhusu m atayarisho ya
kujifungua
Msalimie M uulize ikiw a am ejitayarisha kw a kila hali • Akueleze historia yake ya uzazi
kuhusu kujifungua na gharam a zake. • H aliya m w ili
• M chunguze kam a ana dam u ya
Mwambie kuhusu dalilihatari kutosha
Msaidie kupanga jinsiya kujitayarisha kw a uzazi • M chunguze kasw ende
Mueleze kuhusu m alaria,jinsiya kuzuia kuam bukizw a • M pe chanjo ya pepo-punda m adiniya
iron na folate
na juu ya vyandarua vyenye daw a ya kuzuia m bu.
• M pe SP ikiw a nizaidiya w iki16
Mkumbushe kuhusu D aliliH atari,m atayarisho ya • M ueleze kuhusu dalilihatari
kujifungua na ziara nne za kliniki(w iki<16; 16 – 28; • kupima kifua kikuu
28 – 32; 32-40) • Ushauri nasaha wa Virusi vya Ukimwi

ZIARA YA PILI ZIARA YA TATU ZIARA YA NNE

• Kagua m pango w ake w a • Kagua m pango w ake • Kagua m pango w ake w a
m atayarisho ya kujifungua w am atayarisho ya kujifungua m atayarisho ya
• M pe kw a m ara ya kw anza • M pe kw a m ara ya piliSP na kujifunguaC hunguza kam a
SP na m adiniya Iron na m adiniya iron na folate ana dam u ya kutosha
folate • M pe chanjo ya pepo- • Kagua haliya m toto
• Sikiliza m pigo w a m oyo w a punda(ikiw a niw ikiya 4 baada tum boni
m toto tum boni ya kipim o cha kw anza • C hunguza njia ya uzazi
• M shaurina M uelim ishe • Sikiliza m pigo w a m oyo w a • M pe m adiniya iron na folate
m toto tum boni • M shaurina M uelim ishe
• M shaurina M uelim ishe

Kumbuka kumuuliza mpango wake wa matayarisho ya kuzaa

• M teja w ako anajua atajifungua lini?
• Am epata m kunga m w enye ujuzi?
• Anajua nikituo ganiatajifungulia au atakakokw enda kukiw a na hali
ya dharura?
• Anajua dalilihatarikabla na w akatiw a kujifungua?
• Am em tam bua m w am uzi/m saidizikukiw a na haliya dharura?
• Anajua jinsiya kupata pesa kukiw a na haliya dharura?
• Anao m pango w a usafiriukihitajika haraka?
• Anaye m tu w a kuw a naye w akatiw a uzazi?
• Ana vitu vyote vinavyohitajika kw a w akatiw a kuzaa?
N dio!

K abla ya m w anam ke huyo kuondoka klinik yako kw anza

m uulize iw apo:
• Am epew a daw a zenye m adiniya iron na folate
• Am etum ia daw a za SP na am epata chanjo ya pepo-punda
• Anajua dalilihatariza m im ba na w akatiw a kuzaa
• Anajua atarudilinitena klinik na kupata kipim o cha pilicha SP
• Am ejitayarisha kikam ilifu kw a uzazi
• Ashafikiria kuhusu jinsiya kupanga uzazibaada ya
kujifungua.

Sasa umemtayarisha mteja wako!

July 2007 © M O H -D RH /D O M C/D LTLD /JH PIEG O
221
 Are you going to be a father?
ARE YOU PREGNANT?

CONGRATULATIONS!

CONGRATULATIONS! But please remember

Every pregnancy can be at risk!
Attend the antenatal clinic regularly
Remember to:
Individual birth plan
l Support and encourage your wife / partner
throughout the pregnancy.
l Knows when her baby is due.
l E
ncourage your wife/partner to attend the
l Choose a skilled birth attendant to help antenatal clinic. G
o with her if you can.
with your delivery.
l Make sure that she does not get sex ually
l Choose a clinic for your delivery / transmitted infection or HI V during
emergency. pregnancy. B
e sure to remain faithful or use
condoms consistently and correctly (and
l Know danger signs in pregnancy, delivery get prompt treatment in case of infection).
and after delivery.
l Make a plan for transport to the clinic in
l Chooses a decision-maker in case of an case of an emergency, including saving some
emergency. money for emergency use

l Know how to get money and have a l Plan together with your partner for your
transport plan in case of an emergency. future children. Space them at least 2
years apart, and only have the children you
l Collect the basic supplies you will need can afford.
for the birth. Ministry of Health JHPI O
G
E
Division of R
eproductive Health th F
4 loor, B
lock E
, Peponi Plaza
P.O
.B
ox4
,N
19
3airobi Peponi Road, Westlands
l Have a birth partner/companion for your P.O
.B
ox5
7-0
4
2
8 2
antenatal visits and the birth if wanted. Division of Malaria Control airobi, Kenya
N
P.O
.B
ox2
,N
5
7
0airobi, Kenya

Division of L
eprosy, T
.B
. and other lung diseases
P.O
.B
ox2
10
8
7
0,N
2airobi, Kenya

© MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO

Why go to the Antenatal Clinic? Danger signs in pregnancy
Communities should:
When you do, the service provider will: l E
ncourage A L women, where possible,to
l A
ny bleeding.
deliver in a health facility with a skilled
l Make sure that you and your baby are birth attendant
healthy and doing well.
l Swelling of the face and hands.
l Help you prepare an individual birth plan. l E
ven where they plan to deliver at home,
pregnant women should have a plan to get
to a clinic if they have an emergency l Convulsions / o
Lss of consciousness.
l T
ell you about:

â Danger signs during pregnancy and

l E
nsure that A
Lpregnant women:
childbirth. l Severe headache or blurred vision.

â Malaria during pregnancy. m A

ttend at least four focused antenatal
visits if the pregnancy is normal. l V
aginal discharge.
â amily planning after delivery.
F
m Know the danger signs in pregnancy,
â dvice on food you should eat during
A delivery, and after delivery, as well as l B
ad pain in the belly.
where to go for help.
pregnancy.
Develop an individual birth plan and share
â he importance of four focused
T
m
with family members:
l Pain on passing urine.

antenatal visits
m A
rrange transport to health facilities in l V
omiting and heartburn that do not stop.
â T
he importance of sleeping under case of emergency.
treated mosq
uito nets.
m rArange funds/money to pay for transport l High fever.
l iGve you medicines: and care when needed.

â SP to protect you against malaria. m Tke two doses of SP during pregnancy to

a l F
eeling tired easily.
prevent malaria.
â e
Ttanus tox
oid injection twice to protect
your baby from tetanus after delivery.
m Sleeping under n
Isecticide T
reated e
Nts l L
ooking very pale.
â rIon and folate tablets, to prevent (I
s)
N
T
anaemia.
m R
ecognize the signs and symptoms of l F
eeling the baby moving less or not at all.
l Many clinics offer you: Malaria.

â Vluntary Counselling and e

o Tsting for m vAoid, or get quick treatment for ST
's
I
HI.
V especially syphillis
© MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO
 Je, utakuwa baba?
JE, UNA MIMBA?

PONGEZI !
PO
ZI!
E
G
N
Kumbuka: Tfadhali kumbuka
a
Kila mimba huweza kuwa na hatari zake!
l Kumsaidia na kumtia imani mkeo/ rafiki yako Kwa hivyo, tembelea kliniki ya akina mama
Ratiba ya uzazi wakati wote akiwa mja mzito. wajawazito mara kwa mara.

l Kumpa moyo mkeo / rafiki yako kuzuru kliniki za

l ahamu tarehe ya kujifungua.
F
wajawazito na ikiwezekana nenda / andamana
naye.
l Chagua mkunga mwenye ujuzi atakaye
kusaidia kujifungua / kuzaa salama.
l Kuhakikisha kuwa haambukizwi magonjwa ya
zinaa au virusi vya ukimwi wakati akiwa mja
l Chagua hospitali utakayokwenda kujifungua
mzito. Kuhakikisha unaendelea kuwa mwaminifu
au wakati kutakapotokea matatizo yeyote.
au utumie mipira ya kondom wakati wote na kwa
njia ifaayo (na upate matibabu ya haraka wakati
l F
ahamu dalili hatari za ujauzito, wakati wa
unapoambukizwa ugonjwa).
kujifungua na baada ya kujifungua iwapo
kutakuwa na matatizo.
l Kufanya mpango wa usafiri hadi katika kituo cha
afya wakati wa matatizo, uwe na pesa za kulipia
l Chagua mtu atakaye kusaidia kuamua iwapo
usafiri pamoja na huduma za matibabu wakati
kutakuwa na dharura/matatizo.
wa matatizo.

l Weka pesa za kukusaidia na mipango ya

l Kufanya mpango pamoja na mwenzako kuhusu
?
usafiri iwapo kutakuwa na matatizo.
watoto wa baadaye. iNvizuri watoto hao
wapitane kwa zaidi ya umri wa miaka miwili na
l Weka tayari vifaa vya muhimu ambavyo
mzae idadi ya watoto ambao mtaweza kuwalea.
utahitaji wakati wa kujifungua.
Ministry of Health JHPI O
G
E
Division of R
eproductive Health
l Kuwa na mwenzako atakaye kusaidia wakati th F
4 loor, B
lock E
, Peponi Plaza
P.O
.B
ox4
,N
19
3airobi
Peponi Road, Westlands
wa kuhudhuria kliniki za wajawazito na hata Division of Malaria Control P.O
.B
ox5
7-0
4
2
8 2
P.O
.B
ox2
,N
5
7
0airobi, Kenya airobi, Kenya
N
unapojifungua.
Division of L
eprosy, T
.B
. and other lung diseases
P.O
.B
ox2
10
8
7
0,N
2airobi, Kenya
© MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO
Kwa nini uende Kliniki ya Wajawazito? Jamii zinastahili: Dalili za hatari wakati wa ujauzito
Unapoenda kliniki, wauguzi: l Ziwatie moyo wanawake wote, ikiwezekana,
l Kutokwa na damu.
wajifungue katika kituo cha afya huku
l Watahakikisha kwamba wewe na mtoto mko
wakisaidiwa na mkunga mwenye ujuzi.
na afya njema. l Kuvimba uso na mikono.
l
l Watakusaidia kupanga ratiba yako ya uzazi Kuhakikisha kuwa hata ikiwa akina mama waja
wazito wamepanga kujifungulia nyumbani,
l Watakueleza kuhusu: lazima wawe na mpango wa kwenda kliniki iwapo l Kupoteza fahamu /
â Dalili hatari wakati wa ujauzito/mimba au kumetokea matatizo. degedege.
l
unapojifungua. Kuhakikisha akina mama wote:
m
Wanatembelea kliniki mara nne ikiwa mimba l Maumivu makali ya
âHatari za ugonjwa wa malaria wakati wa
iko katika hali ya kawaida. kichwa na kukosa
ujauzito / mimba.
m
kuona vizuri.
â Mpango wa uzazi baada ya kujifungua Wanaelewa dalili hatari wakati wa mimba,
wakati wa kujifungua na baada ya kujifungua
/kuzaa. l Kutokwa na majimaji sehemu ya siri.
pamoja na mahali watakapopata msaada.
â Chakula unachotakiwa kula wakati wa
m
ujauzito/mimba. Wametayarisha ratiba ya uzazi na Maumuvu makali tumboni.
wamehusisha familia zao.
â Umuhimu wa kwenda katika kliniki za akina l
m
mama wajawazito / mimba. Wamefanya mpango wa usafiri wakati wa Maumivu makali
â Umuhimu wa kulala kwenye chandarua (neti) dharura/matatizo. l wakati wa kwenda
chenye dawa za kuzuia mbu (malaria). m haja ndogo.
Wameweka akiba ya pesa kwa matumizi ya
l Utapata matibabu: wakati wa matatizo, wana pesa za kulipia
usafiri pamoja na huduma za matibabu. Kutapika na kupata
â Kwa mfano dawa za SP ili kujikinga na
m lk i u n g u l i a
malaria. Wametumia dozi mbili za SP wakati wa
ujauzito kujikinga na malaria. kisichokwisha.
â Sindano ya kuzuia ugonjwa wa pepopunda
m
(tetenus) baada ya kujifungua/kuzaa. Wanalala ndani ya chandarua (neti) Joto mwingi mwilini na homa kali.
kilichotiwa dawa.
â Dawa za kuongeza chechemba za chuma l
m
(iron) mwilini ili kuzuia ukosefu wa damu. Wanajua ishara au dalili za malaria. Kuchoka haraka.
l Kliniki nyingi zitakupatia: m l
Wanajiepusha au wamepata matibabu ya Kutohisi mtoto akichezacheza
â Ushauri kuhusu ugonjwa wa ukimwi. magonjwa ya zinaa hasa kaswende. l tumboni.

© MOH-DRH/DOMC/JHPIEGO
© MOH-DRH/DOMC/ DLTLD/JHPIEGO © MOH-DRH/DOMC/ DLTLD/JHPIEGO
 Annex XVII
ListofContributors

Ministry ofHealth Headquarters

• Dr. Hezron Nyangito, Permanent Secretary
• Dr. James Nyikal, Director of Medical Services
• Dr. Shenaz Sharif, Head, Preventive and Promotive Health Services
• Mr. Chris Rakoum, Chief Nursing Officer
• Mr. Alfred Odhiambo, Chief Clinical Officer
Division ofReproductive Health
• Dr. Josephine Kibaru, Head
• Dr. Margaret Meme
• Mrs. Charity Ndwiga
• Mrs. Melissa Mulimba
• Mrs. Rose Maina
• Ms. Diana Kamar
Division ofMalaria Control
• Dr. Willis Akhwale, Head
• Dr. Dorcas Alusala
• Mr. Zablon Barake
• Mr. Peter Njiru
• Mr. Julius Kimitei
NationalAIDS & STIControlProgram
• Dr. Robert Ayisi
• Mr. Josphat Deya
Division ofLeprosy,Tuberculosis and Lung Disease
• Dr. Joseph. Sitienei, Head DLTLD
• Dr. iVctor Ombeka, Deputy Head DLTLD
• Ms. Susan Gacheri
• Ms. Florence Y onga
Departm entofOb/Gyn UoN
• Prof. James Oyieke, Chairman
• Dr. Joseph Karanja
Obstetrician and Gynecologists
• Dr. Chris Oyoo
• Dr. Jennifer Othigo
• Dr. J. Githiru
• Dr. Jacinta Njagi
ClinicalOfficers Office
• Mr. Micah Kisoo
Division ofNursing
• Ms. Anne Kibet
MOH KilifiDistrict
• Dr. Samuel Were
Population Council
• Ms. Charlotte Warren
• Ms. Annie Mwangi
APHIA IIEastern
• Dr. William. Obwaka
• Dr. Wilson Muriithi
JHPIEGO
• Dr. Pamela Lynam
• Mrs. Dorothy Andere
• Dr. Saade Abdallah
• Mrs. Eileen Welsh
• Mrs. Teresia Mutuku
• Ms. Sanyu Kigondu
• Ms. Joygrace Muthoni

© M O H -D RH /D O M C/D LTLD /JH PIEG O

226
References

National Guidelines For Diagnosis Treatment And Prevention Of Malaria For Health Workers. Ministry of
Health, Kenya January 2006.

National malaria strategy 2001-2010. Ministry of Health, Kenya. April 2001.

A Simplified National Guidelines on Malaria Control for Community Resource Persons. Ministry of Health ,
Kenya September 2002.

National Leprosy and Tuberculosis Program Guidelines, Ministry of Health, August 2006

Kenya demographic Health Survey 1998.

Malaria Anaemia in Pregnancy : Importance Of Detection and Protection by Caroline Shulman.

National Reproductive Health Strategy. Ministry of Health, Kenya.1997-2010, November 1996.

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 Ministry of Health

M any organizations contributed to the developm entofthese m aterials. W e w ould like to

thank U SA ID ,M inistry ofH ealth (D RH /D O M C/D LTLD /N A SCO P)and JH PIEG O staff