To all the patients I have ever cared for, whether at the dawn or in the twilight of their lives, whose courage, strength, humility and nobleness of spirit -whose glances and smiles -have brought me and taught me so much.# Introduction

# PURPOSE OF THIS DOCUMENT
These guidelines are designed for ICRC and other health professionals -nurses, midwifes, doctors -who either lack experience in antenatal care or are not used to working in countries where medical infrastructure is underdeveloped or non-existent.

# Their purpose is to:
-provide staff involved in running antenatal care programmes with a concentrated source of information on the subject, with no claims to exhaustive coverage -direct readers to other works that deal with antenatal care in greater depth -ensure that a standard approach is taken to ICRC antenatal care programmes Each team will have to adapt the guidelines locally according to:
-the type of community in which it is working -the available health facilities -the ICRC's constraints in the country where the team is based
These guidelines deal only with the first level of health care, that is to say the community health centre, and not with the second and third levels (reference and district hospitals). They cover the antenatal period, which begins when a woman suspects that she is pregnant and ends when she starts labour, but not the delivery or the postpartum period.

# INTRODUCTION
Throughout the years, the ICRC has been improving its ability to protect and assist conflict victims with a view to saving lives, alleviating suffering and restoring human dignity in an ever more complex world. In April 2004 it adopted a new assistance policy defining core activities in the areas of water and habitat, economic security and health care.With regard to health care, it decided to focus its efforts on emergency hospital care, hospital management, first aid, primary health care, support for victims of sexual violence, health in detention and physical rehabilitation.
Taking the comprehensive meaning of primary health care into consideration, the health services unit defined a minimum package of activities that could be carried out in acute and chronic crisis conditions. The package includes treatment for most common diseases using essential drugs; mother and child care; vaccination campaigns; and water, sanitation and nutrition programmes.
Within the area of mother and child care, antenatal care plays a key role in reducing death, disease and suffering among women, whose vulnerability is always exacerbated by armed conflict and poor security conditions.
The death of a mother during pregnancy or delivery is a tragedy that affects not only families but society as a whole. The risk of dying during pregnancy or delivery is 175 times higher for African women than it is for women in developed countries. At the global level, 13 underdeveloped countries account for 70 per cent of maternal deaths. The highest figures are for Sierra Leone, Afghanistan,

# AIMS OF ANTENATAL CARE
Pregnancy and childbirth are not illnesses and as long as the mother is healthy there is usually no cause for alarm. Nevertheless, conditions may arise during pregnancy that are not necessarily obvious and may not always make the mother feel ill, but that if left untreated could be dangerous for the mother or baby. Such conditions may need to be monitored by a well-trained health professional and the baby may need to be delivered in a hospital.
The purpose of antenatal care is to diagnose any dysfunction during pregnancy so as to anticipate problems and take the appropriate steps for a healthy delivery.
This can be achieved by:
monitoring the health of the mother monitoring the health of the foetus detecting risk factors advising the mother how to look after her health and that of her baby
The ICRC works in countries where mothers may not always be in good health or have access to appropriate medical care. The guidance provided in the following chapters is tailored to the specific situations that can be found in those countries.
Even if from a physiological point of view pregnancy is the same for each woman on earth, it is always surrounded by specific cultural beliefs. Everyone should be aware that such beliefs exist, remain open to them and, in so far as there is no danger for the mother or her foetus, not oppose them.

# p | 15
In April 2004 the ICRC adopted a new Assistance Policy (AP) defining core activities in the fields of water and habitation, economic security and health care. In order to clarify the framework in which the ICRC conducts its activities in the area of primary health care, and more specifically in that of mother and child care (including antenatal care), various points of this policy are summarized below.
If assistance activities are to be effective, they must go hand in hand with protection work aimed at ensuring respect for the fundamental rights of conflict victims.
For more information about the rights of expectant mothers under international humanitarian law, see annex I.A, page 48.

# Implementation
See AP 5.3 Implementation and 5.3.3 Health
The ICRC adapts its response to the situation.
In emerging or acute crises, the ICRC provides support for basic health services, prehospital and emergency hospital care. The basic services are selected from among the components of primary health care, 2 which include mother and child care.
In chronic crises and post-crisis situations, the ICRC may consider providing support for a broader range of primary health care activities.
See AP Annex 4. 6 Minimum package of activities derived from primary health care Within this preventive, curative and participative framework, primary health care provides a vast range of services. Among these the ICRC has designated a minimum set of core activities including mother and child care, which encompasses antenatal care.

# ICRC ASSISTANCE POLICY
2 Primary health care is a process in which the community takes part. Carried out in consultation with civil society, it aims to assess health related needs and to implement health activities in the following fields: (1) ambulatory health care using essential drugs; (2) mother and child care, including family planning; (3) expanded immunization programmes; (4) programmes to fight communicable diseases; (5) health and hygiene promotion; (6) health education; (7) mental health; (8) water; and (9) nutrition.

# p | 16
Modes of action See AP 4.3 Strategies: 4.3 Combining different modes of action
The ICRC uses persuasion, mobilization and, where necessary, denunciation to induce the authorities to meet their obligation to provide essential services for the affected groups. Where the ICRC considers that its efforts are not going to bring about a satisfactory, timely response from the authorities, and that the problem is a serious one, it may simultaneously engage in appropriate support and/or substitution / direct provision activities.
However, a problem can only be a priority for action to the extent that it is truly possible to act. Consequently, it is essential to determine: the feasibility of a technical solution the weight of constraints the impact that action will have on the problem. Depending on the technical feasibility of taking action, the specific constraints encountered on the spot and the expected impact of the operation, it may be necessary to confine oneself to certain types of problems, certain categories of victims or certain geographical areas. However, such restrictions must not be considered permanent. When action is impossible for security reasons, for example, negotiations must be started with the responsible authorities with a view to overcoming this difficulty. Initially, therefore, the priority will be to negotiate. In case of success, it will then be possible to act.
Setting up an antenatal care programme
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# At the time of initial assessment it is important to ensure that:
The programme is adapted to local conditions, to this end: meet with representatives from the Ministry of Health and with professionals who can provide the required information and the advice and support needed to set up the programme take into consideration the views of the population and local staff since they know the country, place or culture better than expatriates do and their direct involvement will help ensure that the programme is sustainable comply with the national health policy and with national health standards assess (with the help of any anthropological studies that may be available) the cultural factors that bear on the management of pregnant women, such as:
-beliefs surrounding birth -customs surrounding birth -sexual behaviour -the place of women in society and their usual occupations -the place of men and children in society and their usual occupations -population movements -any other relevant cultural factors

# The necessary human resources are available
It is essential to determine what kind of professionals are needed, national ones as well as expatriates with the right profile, and whether they are available or not.
The sustainability of the programme will depend mainly on the capacity of national staff to provide high-quality antenatal care services on a long-term basis. If there is a lack of well-trained professionals on the spot, then look for them elsewhere in the country, if possible with the help of the authorities. Another possibility is to select people for training courses, which should be conducted in accordance with national standards so as to ensure that any certificates or diplomas delivered are recognized.
Training local personnel is always an essential component of antenatal care programmes. If further training is considered, remember that it is often uncertain whether after obtaining a diploma trainees will return to their former workplaces or look for jobs elsewhere. One solution could be to have them make a commitment.
The first step to take when starting an antenatal care programme is to find a welltrained local midwife to work with, or, if none can be found, to set up a team comprising an expatriate midwife and an untrained local midwife.
Setting up an antenatal care programme
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# Final remarks
In order to establish a solid base right from the start, it is essential to spend time on the spot gathering the necessary information before launching the programme. This will save time, energy and money later on.
Remember that an adequate referral facility should be available in case of complications (for further information, see "Emergency obstetric care" pages 100-105). Owing to poor security conditions, long distances, lack of transport and other problems, this may not always be possible. However, every effort must be made to overcome whatever problems there are and to prepare for potential difficulties ahead.
Before offering a new service to pregnant women, it is important to know exactly what can and cannot be done in order to avoid raising false hopes.
Setting up an antenatal care programme
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Once the ICRC has decided to set up an antenatal care programme after considering the initial assessment, the following steps should be taken before planning it. 

# Setting objectives

# Concept
Setting objectives is the most difficult part of the planning process. It consists in translating often very general ideas into specific activities.

# Describing objectives
Objectives should be defined according to the following rules with a view to moving from abstract to concrete:
Always use an active verb to express an objective Describe and quantify the content of each objective "An objective must mention:
-What: the situation or condition to be reached -How much: the quantity or amount to be reached -How long: the expected time it will take to produce the desired effect -Who: the group of people or catchment area targeted by the programme -Where: the catchment area covered by the programme." 3
For further information on antenatal care objectives, see annexes I.C.1-3, pages 52-54.

# Breaking down activities into tasks
Further along in the planning process activities must be broken down into specific tasks. This will make it easier to determine what resources are needed.

# Mobilizing resources
Preliminary investigations will already have been made during the initial assessment. At the planning stage, the following questions are essential:
-Do local resources exist? -Does the target population have access to local resources?
Resources may be divided into four categories:
-Human resources -Material resources -Means of transport -Financial resources Lack of resources may make it necessary to modify objectives.
Setting up an antenatal care programme 

# Final remarks
When drawing up a plan of action it is important to ensure that it is realistic and adapted to existing constraints. Particular consideration must be given to what resources are needed and which are available. The referral system must also be taken into account in case of complications or emergencies (see Emergency obstetric care, pages 100-105).
Given the frequent turnover of expatriate staff, it is also vital to have a plan of action so as to guarantee the quality and sustainability of services. This will lead to greater professionalism and credibility.
Setting up an antenatal care programme
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Monitoring as defined in ICRC Assistance Policy (6. Operational Directives)

# Monitoring
From the beginning, a system is put in place for situation monitoring and performance monitoring to ensure the systematic and continuous assessment of progress over time in using selected indicators. This monitoring system will promote timely and appropriate decision making.

# Review and evaluation
Monitoring must be supplemented by reviews and independent evaluations. These are intended to draw lessons that can be used to improve policies and practices, and help enhance the organization's overall performance, transparency and accountability. One of the aims of every antenatal care programme is to give national staff the training they need to provide quality care and be able to run the programme on their own. Once the specific objectives of the programme have been set, it will be necessary to ensure that expatriates have the tools they need to evaluate the quality of care provided by the programme. These tools include checklists and indicators, for which the necessary data will have to be collected (see below).

# General information on monitoring
When evaluating the quality of care, do not forget that it can also be useful to ask the referral hospital for its opinion about the relevance of the cases referred to it. Moreover, it is essential to ensure that staff members enjoy good personal relations and respect one another so that criticism can be taken in a positive and constructive way.

# MONITORING AN ANTENATAL CARE PROGRAMME
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# Collecting and analysing data
Before starting an antenatal care programme it is important to determine what data need to be collected and analysed.
What should be measured?
-Decide what to look for. Which features of the programme are most critical or valuable to describe?
-Decide how much effort will be required. What data must be collected in order to ensure that each feature is accurately described?
How to assess?
-See how you can make good use of existing records.
-If possible, set up a record-keeping system that will give you the needed information without burdening the staff.
Quantitative data are always necessary, both for monitoring progress and for comparing the programme with others.They should be of immediate practical use, understandable to those in charge, easy to analyse and collected according to the national data collection system, if one exists. Remember that is better to have a few reliable figures than a great many figures that cannot be analysed.
Encourage staff not to underreport owing to misplaced feelings of guilt. Remind them that a high number of complications treated shows that women are coming to the facility and receiving care.
Concerning the data that must be collected for the indicators, in accordance with the national data collection system, if one exists, various tools can be used such as antenatal care registers or cards, immunization registers or cards, etc.The best solution will have to be found for each programme depending on what is available on the spot.
Monitoring an antenatal care programme
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# Checklists
The purpose of checklists is to help determine training needs and the areas in which there is need for improvement. They must be practical to use and easy to analyse. A few examples are given in annexes I.D to I.F, pages 55-63. However, it is important to remember that any checklist will have to be adapted to the local situation.

# Indicators
The following monthly and annual indicators were chosen by the ICRC health unit in Geneva. They must be used for each programme, according to the local antenatal care package, (see page 18).
Given the conditions in which the ICRC works in the field, some bias 4 may be expected as a result of:
-unreliable census figures -the definitions used -the methods of calculation used, etc.
Other indicators may be used as well, since normally there are as many indicators as there are objectives, the number of which will depend both on the directives issued by the Ministry of Health and the level of antenatal care provided.

# Target population
Pregnant women 5 living in the health post catchment area: 4 % total population.
Monitoring an antenatal care programme p | 30

# TARGET POPULATION FOR CHILD AND MATERNAL CARE

# Monthly indicators 1.Total number of antenatal consultations
Use: -Provides information on the overall volume of activities and the workload of staff members. -Provides a numerator for calculating the average number of antenatal consultations per woman.
Source: antenatal care register.

# Number of new patients (number of first consultations)
Definition: a new patient is any pregnant woman who consults the antenatal care service for the first time.
Use:
-Provides information on the use of the antenatal care service.
-Serves as a basis for calculating the antenatal care coverage rate (see page 34).
-Provides a denominator for other indicators such as the detected risk rate and the proportion of patients who consulted the antenatal care service during the third trimester.
Source: antenatal care register.

# Number of third trimester consultations
The third trimester is the best period for detecting risk pregnancies and deliveries.
Use:
-Provides information on the quality of the antenatal care service.
-Provides a numerator for calculating the average number of consultations per woman during the third trimester.
Source: antenatal care register.

# Number of risk pregnancies detected
Definition: according to national guidelines (see next page).
Use: provides information on the quality of the service and its ability to detect risk.
Source: antenatal care register.

# Number of risk deliveries detected
Definition: according to national guidelines (see next page).
Use: provides information on the quality of the service and its ability to detect risk.
Source: antenatal care register. This list will vary from country to country depending on the quality of medical care, the accessibility of health services and the existence of risks that are specific to certain countries (e.g. female genital mutilation). That is why it is important to attach the list drawn up for each antenatal care programme to the monitoring indicators.

# SAMPLE LIST OF RISK PREGNANCIES AND DELIVERIES p | 32
Monthly indicators (contd.)

# Number of patients who received five doses of tetanus toxoid before the first consultation
Use:
-Indicates how well the Expanded Programme of Immunization (EPI) is functioning.
-Provides a numerator for calculating the overall immunization coverage of patients.
Source: immunization card / antenatal care register

# Number of patients who received at least a second dose of tetanus toxoid during pregnancy
Use:
-Provides information for monitoring the EPI.
-Provides a numerator for calculating the percentage of women who were properly vaccinated.
Source: immunization card / antenatal care register / monthly EPI data report.

# Number of women referred to the second level of health care
It can be useful to compare this indicator with the number of risk pregnancies/deliveries detected.

# Source: antenatal care register
Monitoring an antenatal care programme
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# Annual indicators
In order to compare the results year by year, use the national norms if possible. If not, use the international ones.

# Coverage rate
Definition: the coverage rate is the percentage of women in the total target population who consulted the antenatal care service at least once during pregnancy.
Method of calculation: 
Routine

# p | 34
Annual indicators (contd.)

# Average number of consultations per patient
Objective: to ensure that all women have at least four consultations during pregnancy, as recommended by WHO.
Method of calculation:
Routine reporting system -Total number of consultations during the year -Divided by -Total number of patients (= number of first consultations) during the year Use: provides information on the use and quality of the service.
Source: routine reporting system -monthly data report.

# Proportion of patients who consulted the antenatal care service during the third trimester of pregnancy
A significant proportion of risk pregnancies and deliveries are detected during the third trimester of pregnancy.

# Method of calculation:

# Effective tetanus immunization coverage rate among patients
Objective: to ensure that all antenatal care patients and their newborn babies are effectively protected against tetanus. Definition: patients effectively immunized until delivery are those who received five doses of tetanus toxoid before the first consultation or at least a second dose of tetanus toxoid during pregancy.
Source: antenatal care register / immunization card.
It is important to find a means of indicating that a vaccination has been registered so as to ensure that it will not be counted more than once.  

# M O N T H T LY / A N N U A L D A T A C O L L E C T I O N R E P O R T

# BASIC AND EMERGENCY EQUIPMENT
The equipment used will depend on the budget, the place where patients will be examined and the qualifications and abilities of national staff. Above all, it is essential to have a place that affords privacy so that the patients cannot be seen (screens can be installed if necessary) or overheard during examinations. 

# Home delivery kits
Depending on the situation, home delivery kits can be given to the traditional birth attendants or to the pregnant women themselves. Before distributing any equipment, it is important to consider:
-the capacities of those who will be using it (are instructions required before use?) -the cost, especially when multiplied by the number of users -the importance of not creating needs (it is always preferable to use local products if they are suitable) -local conditions: cultural factors, weather conditions, availability or not of electricity and clean running water, etc.

# Contents of a basic home delivery kit
-soap -razor blade -umbilical tape -non-sterile gloves -iodine -gauze -cotton -plastic sheet (one square meter, easy to clean)
The quantities distributed will depend on the number of deliveries usually carried out by traditional birth attendants each month and on how often the items are received.
Traditional birth attendants whose work is being monitored can also be given a tube of tetracycline and various other items depending on needs: a torch, if batteries and bulbs are available locally; a jerrycan for water; a basin; nail clippers (may be preferable to a razor blade); and of course a bag or box, solid and easy to clean, where the material can be stored. For health professionals who perform house calls, a medical satchel will be needed, or, better still and less expensive, a solid lightweight plastic toolbox with spacious compartments.

# Emergency medical kit
The following list of essential drugs and supplies is not exhaustive. The contents of an emergency medical kit will depend on the user's skills and the health services available. Some drugs and supplies will already be available in the primary health care centre. Remember that the user is responsible for keeping the medical kit in order. It must be kept clean and complete; items that have reached their expiry date must be replaced and used needles must be disposed of in safety containers.

# Basic and emergency equipment
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# HEALTH EDUCATION
Health education is usually aimed at getting people to change their behaviour. However, it is important to remember that people are not necessarily interested in changing their behaviour and that they do not always agree to do so.
For many reasons (new scientific discoveries, financial considerations, national policies, etc.) the information given can change in the course of years, which means that it must be presented with due caution and humility. Moreover, it is all the more difficult to present such information convincingly when one comes from another culture. It is thus very important to ensure that experiences are shared in a climate of mutual trust and respect and that conclusions are drawn without judgement.
Rather than focus on getting people to change their behaviour, the aim should therefore be to open a critical discussion aimed at examining problems and finding possible solutions together. Remember that learning is not a one-way street: people can give as well as receive information and it is up to them to take decisions on issues that affect their lives.

# When preparing a health education session, start by determining:
what the customs and beliefs of local people are where health care is placed on their scale of priorities among other issues such as food, shelter and security (health being understood here in the broadest sense of the term as meaning physical, psychological and social health) where antenatal care is placed on their scale of priorities among other health issues whether local people have the means to improve or change their behaviour if they want to The above information can be used to organize health education sessions in such a way as to: take the specific needs of the participants into account adapt the content of the session and the teaching tools used to the level of the participants give the participants the means to change their behaviour When preparing a health education session, do not hesitate to ask colleagues or other partners with experience in this field for information or for help in finding appropriate teaching tools.

# Training traditional birth attendants
Since most traditional birth attendants are illiterate and have never received any proper training leading to a diploma, they are usually not recognized by the health system. However, they can provide a very useful link between pregnant women and the health services since they live in rural areas and have extensive practical experience working there. Whatever the status of traditional birth attendants may be, it is important to comply with the national health policy regarding their use.
Professionals who work with traditional birth attendants have a responsibility to train them, monitor their work and provide them with the materials needed for safe deliveries. At the same time, it is important to make sure that they do not engage in dangerous practices and that they understand their limits. Providing that they do, they can play a useful role in the referral system in case of complications.
In places where traditional birth attendants do not exist, it would be better not to create them, especially if there is no referral system. Instead, hold health education sessions on the topic of pregnancy for the women of the villages. It is necessary to work with whatever and whomever is found on the spot and to accept that changes will only come slowly. With the exception of beginners, all traditional birth attendants already have some knowledge of these topics and it is important to build on it. Start by finding out what they know. Remember that the aim is not to turn traditional birth attendants into professionals, but to give them enough knowledge to be able to detect problems and refer cases in time. Since they will not be able to remember everything they are told, priority messages must be selected for each topic and duly emphasized.

# Teaching tips:
As most traditional birth attendants can neither read nor write, it is essential to take a very practical and visual approach.
Ask the trainees to explain what they do and why they do it so as to find out what they already know.
If possible, use an interpreter who is already familiar with the topic. Trainees must be given enough time to learn from one other and share experiences. Do not hesitate to repeat the same message in different ways so as to be sure that it is understood.
Local culture and beliefs must be respected. Remember that trainers can also learn from trainees.
When giving information, it is important to explain why you are giving it and to keep things as simple as possible.
Make trainees understand how important they are for their community by emphasizing their knowledge and skills.
Although this is a touchy issue, it is essential to make sure that everyone recognizes his limits and knows when to ask for help.
Taking time to observe the trainees carefully and being patient with them are important aspects of good teaching.
Alternate speakers so as to avoid monotony, using teams that already exist (e.g. ICRC hygiene promotion teams) whenever possible.
Participatory dynamics can be very effective, especially if the trainers are acquainted with different methods.
Since traditional birth attendants have been delivering babies for centuries, it will take time for them to understand why they have to acquire new skills, learn to recognize risk pregnancies or deliveries and refer pregnant women to the appropriate services.

# Health education p | 43
Health education

# Example of teaching tool that can be made in the field: model built with material used for orthopaedic prosthesis (polypropylene)
p | 44

# Health education

# Health education for pregnant women
When discussing health issues with pregnant women, it is essential to make sure that they can understand what is being said to them. With this in mind, it is important to: use a good interpreter if one is necessary (preferably a person who is familiar with the subject) adapt one's explanations to the women's level of understanding use teaching tools such as drawings, pictures or dolls whenever necessary (such tools can be made if they are unavailable) choose the most appropriate information to give to each woman, taking her specific situation into account give the women time to ask questions and express any fears they might have.
Sometimes a pregnant women will only come for one antenatal consultation during her pregnancy. In such cases it is better to focus on the essential, bearing her particular situation in mind (culture, available health services, security conditions, local health problems, etc.) than to burden her with too much information.
Often the best solution is to hold meetings with several women at the same time so as to benefit from the dynamics of group communication. Given the great number of subjects that will need to be discussed, however, this will take more time. Many meetings will usually be required and in addition it will be necessary to repeat things and ask questions to make sure that everyone has understood.
For various reasons, some women will not be able to attend such meetings. In such cases, it may be possible to go to the villages and hold health education sessions on the spot, both for the women and -if the culture allows -for their husbands, who often have a lot to do with the decisions taken.
It would be impossible to provide an exhaustive list of all the topics that may need to be discussed with a pregnant woman. However, a number of antenatal problems are dealt with in the second and third parts of these guidelines, each section of which contains a paragraph that explains what to say. Obviously, other topics (post-partum care, general health, etc.) may be discussed as well. 

# ANNEX I.A INTERNATIONAL HUMANITARIAN L AW
Every place of internment must have an adequate infirmary. Isolation wards must be set aside for cases of contagious or mental diseases. Maternity cases and internees suffering from contagious diseases, or whose condition requires special treatment, surgical procedures or hospital care, must be admitted to an institution where adequate treatment can be given, and must receive care not inferior to that provided for the general population.
The wounded and sick, as well as the infirm and expectant mothers, must be the object of particular protection and respect.
Belligerents must endeavour to conclude agreements for the removal from besieged or encircled areas of the wounded, sick, infirm, elderly, children and maternity cases, and for the passage of medical personnel and equipment to such areas.
Civilian hospitals organized to provide care for the wounded and sick, the infirm and maternity cases shall be protected from attack.
In situations of occupation, the Occupying Power may not hinder the application of any preferential measures with regard to food, medical care and protection against the effects of war which may have been adopted prior to the occupation in favour of children under fifteen, expectant mothers and mothers of children under seven years of age.
The definition of wounded and sick expressly includes maternity cases, newborn babies and other persons who may be in immediate need of assistance or care, such as expectant mothers, and who refrain from any act of hostility.
In the distribution of relief consignments, including medical items, priority should be given to children, expectant mothers, maternity cases and nursing mothers. Desired impact: The desired impact is the statement of the long-term result expected. When this result is reached, humanitarian work, protection and assistance provided by international humanitarian actors, should be diminished or cease.This does not mean that all needs are definitely covered nor all problems are solved, but that the people and the local authorities and institutions are again selfreliant and able to cope with their daily life and to sustain the necessary basic social infrastructure.

# Health
GO | Three elements defining the General Objective:
Status: General Objectives have a range of validity of one to several years. They represent the mid-term outcome.

# Formulation of GO:
In this section it is requested to formulate the outcome or midterm result according to what might reasonably be achieved in a time period from one to several years. The formulation must be as SMART as possible.
Institutional strategy: This section exists only in headquarters PfR databases. The General Objectives can be linked to an institutional strategy.
SMART criteria | General Objectives as well as Specific Objectives must be formulated as much as possible according to the SMART criteria outlined below:
Specific: the objective/result is distinct from others and is as precisely defined as possible;
Measurable: the objective/result mentions quantitative and qualitative elements concerning beneficiaries and the protection and assistance services offered;
Achievable : the objective/result must be realistically attainable. It is not a hypothetical result nor an objective/result out of scope compared to what the ICRC is able to implement at its best;
Relevant: the objective/result is appropriate and makes sense in relation with the target group and the problem assessed; Time-bound: any time element that indicates the necessary time for its implementation and situates the projected validity of the objective.

# SO| Specific Objectives linked to the GO:
There number is not limited. Specific Objectives specify the short-term or output results within the year.

# ANNEX I.B.2 PL ANNING for RESULT S (PfR)
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# GLOSSARY OF TERMS
Impact: An examination of the wider long-term effects that the action contributes tosocial, economic, technical, environmental -individuals, communities, and institutions. Impact can be immediate and long-range, intended and unintended; positive and negative, macro and micro. Impact studies address the question what real difference has the action made in improving the capacity of communities to reduce their level of vulnerability? How many people have been affected, and how have they benefited from the action?
Input: Organizational, human information, or physical/material, financial resources invested directly or indirectly to achieve results in favour of intended beneficiaries.
Outcome: At the general objective level, these are the effects over the mid-term (one to several years). These intermediate benefits are generated over time and are directly linked to the accumulated achievement of programme outputs.
Output: Short-term, tangible results of ICRC actions or programme inputs achieved within a 12-month period.

# Performance:
The extent to which a programme, project, or operation is implemented in an effective, efficient and timely manner and produces expected results for an identified target population without causing unintended negative consequences.
Result: A describable and/or measurable change in state, planned and unplanned, at the output, outcome, impact level, that can be attributed to ICRC action.

# ANNEX I.B.3 PL ANNING for RESULT S (PfR)
This annex "Planning for Results" (PfR) comes from: ICRC "Planning, Monitoring, Evaluation" database.  

# In Emergency Phase:
Provision of delivery kits: UNICEF midwifery kits for health centres and clean delivery kits for home use Identification of referral system for obstetric emergencies -One health centre for every 30,000 -40,000 people -One operating theatre and staff for every 150,000 -200,000 people -Skilled health care providers trained and functioning ( one midwife for 20,000 -30,000 people, one CHW/TBA for 2,000 -3,000 people) -Community beliefs and practices relating to delivery are known -Refugee women are aware of service availability This checklist is intended for use in supervision and monitoring of antenatal services provided by health workers, community-based health workers, and traditional birth attendants. The list is comprehensive and includes some clinical tasks that the traditional birth attendants and other peripheral workers do not routinely carry out.The checklist should be modified and simplified according to the local situation. This checklist is intended for use in the observation of service delivery. It is recommended that you review the checklist carefully before using it to be sure that you understand the questions and know how to use the form. For observation of service delivery, mark "yes" if the service provider carries out these activities during service delivery. For interview questions, mark "yes" if the respondent answers correctly. 

# M E D I C A L R E C O R D S
To ensure proper follow-up of the pregnant woman, it is useful to have a file recording basic information, both medical and other. With a well-organized filing system, pertinent information can be obtained on previous pregnancies.
Here again, certain adjustments are necessary.

# The records must :
be in the local language be adapted to the professional abilities of the local staff and to their writing skills (capital letters, etc.) be well-spaced, easy to use, and printed on stiff paper that remains in good condition be affordable focus on specific antenatal information cover the entire duration of the pregnancy, which may mean recording a number of consultations
As for the filing of obstetric records, it is important to find a system which suits the professionals using them and which makes it easy to find a specific file on the basis of information given by the patient (name, village, number, etc.).
Depending on the situation, the best method might be to send the woman home with the file, especially if she has the opportunity to attend different health facilities. In other cases, however, this would not be a good idea because the file might be lost or damaged, or the woman might forget to bring it with her at the next visit.
This is not because she does not have a responsible attitude; it may be because the antenatal file is not the most important concern among the many other worries of the family concerned, or because the family's living conditions do not allow her to keep the file in good condition.
If the woman has to be referred, it is advisable to have a standard referral letter in which you just have to fill in the spaces.
Please, see the illustrations,  Examples of obstetric records  on next pages.
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#  AN E X A M P L E O F O B S T E T R I C R E CO R D S 

#  A N OT H E R E X A M P L E O F O B S T E T R I C R E CO R D S  p | 71 D I A G N O S I S O F P R E G N A N C Y A N D C A L C U L A T I O N O F T E R M
Pregnancy is diagnosed on the basis of the symptoms, the date of the last menstrual period and the clinical signs.

# Possible symptoms of pregnancy
Amenorrhoea (but there can be some spotting) Tense and sensitive breasts Nausea Sleepiness Pollakiuria

# Last menstrual period: LMP
If the woman knows the date of the first day of her last menstrual period, the number of weeks of pregnancy and the expected date of delivery (EDD) can be calculated.If necessary, check for Hegar's sign (with an empty bladder).

# If necessary, check for Hegar's sign (with an empty bladder)

# Clinical signs
At a certain stage, pregnancy is obvious and easy to confirm by abdominal palpation. 

# Menstrual age, conceptional age and prenatal events

# Diagnosing pregnancy
If the woman has regular periods, presents secondary amenorrhoea, knows the exact date of the LMP and shows the symptoms listed above, it is easy to make a diagnosis of pregnancy.
If the woman does not have regular periods, does not know the date of the LMP and has some chronologically abnormal bleeding, it is more difficult to be sure about the diagnosis, especially if she has no clear symptoms.

# Pregnancy test
The urine test should be performed only if there is a need to know the result as quickly as possible (in case of rape, before treatment contraindicated during pregnancy, ectopic or molar pregnancy, etc.). Usually, however, it is not necessary and the clinical evolution will confirm the pregnancy. (For the test to be reliable, the instructions must be followed scrupulously).

# Different methods of calculating EDD
If the date of the first day of the LMP is unknown, the calculation will be approximate.

# The easiest way of calculating the EDD is by using an obstetric wheel or calculator.
Otherwise, choose the most appropriate method of calculation from the following examples (bearing in mind that none of them is exact, but that delivery at term takes place between 37 and 42 weeks of pregnancy) :
LMP + 40 weeks = EDD LMP -3 months = X + 1 year = EDD LMP + 7 days = X + 9 months = EDD LMP + 10 days = X -3 months = EDD LMP + 280 days = EDD or 10 months of 28 days (lunar cycle)
In some countries women are used to calculating according to the moon. This corresponds to the last method listed above, the moon having a cycle of 28 days. Thus if the woman has regular periods, when she has missed the first period she has already gone through one cycle of 28 days. She will look at the moon and count nine more cycles of the same phase of the moon to know approximately when she will deliver.
Always check first for pregnancy in case of abnormal bleeding or amenorrhoea.

# Note
Diagnosis of pregnancy and calculation of term
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# PHYSIOLOGICAL CHANGES IN PREGNANCY
The physical and psychological changes that occur in a pregnant woman are often due to the effects of specific hormones : human chorionic gonadotrophin, oestrogen, progesterone, human placental lactogen. The consequences of these changes during pregnancy are as follows :

# Cardiovascular and haematological changes
Haemodilution, leading to physiological anaemia compensated by an increase in red cell mass in response to the extra oxygen requirements of maternal and placental tissue.

# Increased cardiac output :
-leading to heart enlargement -leading to an increase in ejection volume -but offset by reduced peripheral resistance (arterial walls relax and dilate, capacity of veins and venules may increase by a litre).
The excess blood flow, directed mainly to the uterus, goes to the placenta.
Changes in clotting factors increase clotting capacity during pregnancy, resulting in greater risk of thrombosis or embolism. In the event of complications, disseminated intravascular coagulation or clotting failure may occur, with a high risk of maternal death if no appropriate treatment is available.
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# Blood pressure (see page 92)
In advanced pregnancy women should avoid lying on their back, as this can cause deep hypotension because of the pressure of the gravid uterus on the vena cava. As a result, cardiac output is reduced and there may be feelings of faintness and paresthesia of the fingers, and even a risk of maternal shock which will precipitate changes in the foetal heart rate.

# Oedema (see page 92)
The combination of a higher level of proteins and haemodilution during pregnancy leads to a decrease in osmotic pressure and moderate oedema of the lower limbs. This is considered to be physiological and the prognosis is favourable.

# Respiratory system
Changes are necessary in order to maximize maternal oxygen intake and ensure efficient carbon dioxide excretion for the mother and hence for the foetus.

# These changes are as follows:
The respiratory rate (<20/min) does not change, but the tidal volume increases by approximately 40%.
Oxygen consumption increases by 20% during pregnancy.
In later pregnancy, the ribs spread in order to compensate for the effect of pressure of the enlarged uterus on the diaphragm, and thus to maintain the capacity of the thoracic cavity.
There is often nasal congestion due to increased vascularization during pregnancy, and nosebleeds are common.

# Vena cava
Physiological changes in pregnancy p | 75

# Gastrointestinal system MOUTH
Owing to a hygroscopic effect, gums may become spongy and there may be some bleeding. Dental problems that occur may be due to gingivitis rather than to dental caries.
There may be an increase in salivation (ptyalism).
Women often experience changes in their sense of taste, leading to dietary changes or even food cravings ("pica": craving for non-food substances such as coal or earth, is rare).

# OESOPHAGUS
Heartburn is common and associated with gastric reflux (60% of pregnancies) due to relaxation of the lower sphincter.

# Advise the mother to:
-divide meals into smaller separate portions -avoid spicy, fatty or acid foods, alcohol, coffee, fizzy drinks, etc.
-raise the head of the bed 

# STOMACH
Gastric emptying and peristalsis are slowed in order to maximize absorption of nutrients, and acidity is reduced.
Nausea and vomiting occur in 50% of pregnancies, mainly during the first trimester. This can be more severe in cases of multiple pregnancy or hydatiform mole.

# Advise the mother to :
-divide meals into separate small portions throughout the day -avoid food which is difficult to digest or irritates the stomach Complication : hyperemesis gravidarum (1-2% of pregnancies), which means severe vomiting associated with dehydration, loss of weight and electrolytic disturbances that can lead to icterus or renal failure, refer the pregnant woman.

# SMALL BOWEL
Increased absorption of calcium and iron.

# LARGE BOWEL
Increased absorption of water.
Constipation is the result of sluggish gut motility.

# Advise the mother to :
-drink at least 2 litres per day -eat fibre-rich foods, fresh or dry vegetables and fruits.
Haemorrhoids, which may occur as a result of relaxation of the smooth muscles of the vein wall, can be exacerbated by constipation.

# Physiological changes in pregnancy
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# Urinary system
During pregnancy, pollakiuria occurs as bladder capacity is restricted by the growth of the uterus. On average, the urinary flow increases by 25%.
Renal blood flow : -500 mL/min in normal conditions -700-800 mL/min during pregnancy Glomerular filtration : -100 -130 mL/min in normal conditions -150 mL/min during pregnancy
Owing to hormonal action, there is dilatation of the renal cavities and ureters.This leads to urinary stasis which, together with compression of the ureters by the gravid uterus, increases the risk of infection.

# Advise the mother to:
-drink at least 2 litres per day -pass urine frequently.
As a result of increased glomerular filtration in the prone position, urine output is greater at night.

# Physiological changes in pregnancy
The renal tract 

# Skin changes
Increased activity of the melanin-stimulating hormone causes deeper pigmentation during pregnancy.
Chloasma: patchy colouring on the face, resembling a mask.
Linea nigra: pigmented line running from the pubis to the umbilicus. The nipples and perineal area also become darker.
Striae gravidarum or stretch marks: red streaks on breasts, abdomen, and areas with fat deposits such as the thighs during pregnancy, fading to residual white streaks about 6 months after delivery.
Increased blood supply to the skin causes sweating, and women often feel hot during pregnancy.

# Skeletal changes
Relaxation of ligaments and muscles occurs in pregnancy, with maximum effect during the last weeks.
This relaxation enables the pelvis to increase its capacity so as to facilitate the descent of the foetus at term and during labour.
The symphysis pubis softens, as do the sacroiliac joints. The sacrococcygeal joint loosens, allowing the coccyx to be displaced backwards.
This can cause pain in the joints and pelvic ligaments. 

# SAGGITAL SECTION OF THE PELVIS SHOWING THE RELATIONS OF THE BLADDER

# Immune system
Systematic maternal immunodepression during pregnancy has not been confirmed, but many studies suggest it may occur.

# Possible means of foetal infection during pregnancy:
Direct transplacental infection by blood A Secondary endometritis site D, transmitted by blood B or by ascending (eg. vagina) infection C

# From this site D, the infection can spread:
to the placenta and reach the foetus by way of the umbilical cord a to the amniotic fluid b which can infect the foetus by digestive or respiratory way E : Endometritis site remained quiescent during pregnancy.

# Physiological changes in pregnancy
How infection in the mother can affect the foetus :
A E D B C a b p | 80

# Physiological changes in pregnancy
Braxton-Hicks contractions:
These begin at two months and can be felt by the mother at four; they are painless and sporadic. They continue throughout pregnancy, becoming more intense and painful at the later stage, and eventually lead to labour contractions.
At 36 weeks the uterus reaches the level of the xiphisternum. Softening of the pelvic floor tissues together with good uterine tone and the formation of the lower uterine segment encourages the foetus to sink into the lower pole of the uterus. This is described as "lightening":
In the primigravida, this process also encourages the beginning of a gradual descent into the pelvis (uterine height decreases), and the foetal head becomes engaged. In the multiparous woman, descent often occurs only when labour starts.

# Cervix
The cervix acts as an effective barrier against infection and also retains the pregnancy.
The thickened mucus secreted by the endocervical cells forms a cervical plug called the operculum, which provides protection from ascending infection.
Cervical vascularity increases during pregnancy and the cervix becomes softer.

# Uterus

# Uterus sizes
Before pregnancy: size of a fresh fig

# At one month: size of a tangerine
At two months: size of an orange At three months: size of a grapefruit, and the fundus (upper part) of the uterus may be palpated above the symphysis pubis.
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# Sizes of embryos and foetus between 3 and 12 weeks gestation

# Vagina
Vascularity of the vagina increases during pregnancy.
The muscle layer hypertrophies, and changes in the surrounding connective tissue make the vagina more elastic.These changes enable it to dilate during the second stage of labour so as to accomodate the descending foetus.
There is marked desquamation of the superficial epithelial cells, which increases the amount of normal white vaginal discharge called leucorrhoea.
The epithelial cells also have increased glycogen content, which interacts with Doderlein's bacillus, a normal commensal of the vagina, to produce a more acid environment. This provides an extra degree of protection against some organisms, but unfortunately causes increased susceptibility to others, such as Candida albicans.

# Breast changes in chronological order

# -4 weeks
Prickling, tingling sensation due to increased blood supply particularly around nipple.

# weeks
Developing ducts and glands cause the breasts to be enlarged, painful and tender particularly in women who normally experience pre-menstrual changes.

# weeks
Bluish surface veins are visible.

# -12 weeks
Montgomery's tubercles become more prominent on the areola. These sebaceous glands secrete sebum which keeps the nipple soft and supple. The pigmented area around the nipple darkens and may enlarge slightly. This area is known as the primary areola.

# weeks
Colostrum can be expressed. Further extension of the pigmented area occurs and is often mottled in appearance, secondary areola.

# Late pregnancy
Colostrum may leak from the breasts; progesterone causes the nipple to become more prominent and mobile.

# Physiological changes in pregnancy
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# Psychological changes
Although for most women pregnancy is a time of great joy and satisfaction, as they have fulfilled a biological function, many experience a period of anxiety.
Decisions have to be made about the future, and motherhood has to be accepted as a new status.
A loving, supportive relationship in which the two partners communicate and discuss their feelings will help resolve these early anxieties.
Mood swings are common because of hormonal changes, and can often be frightening for both partners.
Libido is likely to decrease, not only because of changes in the body but also because of fear of harming the baby.
It must be borne in mind that this is a time when a woman requires a great deal of support and sensitivity.
The mother often feels a unique and exclusive closeness with the foetus. Her partner may feel left out, as he is unable to share this experience.
She also becomes increasingly aware of her new responsibilities and realizes that she will lose some of her freedom.

# Much depends on the circumstances:
whether the woman is primigravida or multiparous her cultural, social and economic situation whether the pregnancy was desired or otherwise whether there are major security problems where she lives.
Even women without any psychiatric history may suffer from specific conditions such as depression during pregnancy, or depression or psychosis during the post-partum period.This has nothing to do with what is called baby blues, which is a very common and less serious problem.
Physiological changes in pregnancy p | 85

# I N I T I A L M E D I C A L A S S E S S M E N T
This section focuses on the general state of health of the pregnant woman.
More specific details of the antenatal check-up will be given in the following section  Standard antenatal consultation .
It is important to keep in mind that, depending on the local medical services, it may not be possible to treat all the health problems encountered.
Laboratory tests and other procedures such as ultrasound examinations and complicated surgery will in most cases be unavailable or very expensive to organize.

# THUS FOCUS ON CLINICAL FINDINGS
First check the general appearance of the pregnant woman:
-Is she able to walk properly or does she need assistance?
-Is she alert or apathetic?
-Does she present signs of malnutrition or skin lesions?
More detailed examination of functions or organs:
-Evaluation of breathing and heartbeat 

# S TA N D A R D A N T E N ATA L C O N S U LTAT I O N
When, and how many times, is a pregnant woman supposed to attend an antenatal consultation ?
WHO recommendations are as follows:
The first consultation during the first trimester, or before 12 weeks The second around 26 weeks or 6-7 months The third around 32 weeks or 7-8 months The fourth around 38 weeks or 8-9 months Such recommendations concern only physiological pregnancies without complications or risk of complications requiring closer and more specific attention.
In conflict situations, lack of security or accessibility and other problems often make it difficult or impossible for pregnant women to keep to such a schedule.

# What are the priorities ?
As most maternal deaths occur around the time of delivery, the most important consultation is the one that takes place during the last month of pregnancy, as it allows screening of cases to be referred to hospital for delivery.
This does not mean, however, that the previous consultations are not important; they are also useful for detecting and preventing the complications outlined below.
Health education activities focusing on antenatal care should be carried out at every opportunity and pregnant women should be encouraged to take part (see pages .
It should be borne in mind that pregnant women will attend antenatal consultations only if they themselves are convinced that this is in their interest to do so.

# p | 87

# Standard antenatal consultation
What has to be checked at each antenatal consultation, whatever the stage of pregnancy ?

# Body weight
Taken together with height, this provides an indication of the mother's nutritional status.
This assessment makes basic follow-up possible : vomiting, diarrhoea or reduced food intake may decrease body weight, whereas oedema, water retention or hydramnios may increase it.
During pregnancy there is an increase in basic metabolism, more specifically of carbohydrates, as the main source of energy for the foetus is glucose.

# Needs in terms of calories are in the order of 2500 cal/day.

# Uterine height (during second and third trimester)
Uterine height will depend on the size of the foetus, which varies according to the ethnic origin of the parents, the mother's diet and other factors. This is useful only if several consultations take place to monitor progress (foetal growth retardation, screening for foeto-pelvic disproportion, twins, hydramnios, etc.). This makes it possible to detect multiple pregnancies.

# Distribution of weight gain in pregnancy
It also indicates the presentation of the foetus, so as to:
-facilitate foetal auscultation by localization of the foetal chest -refer the mother to hospital for delivery in case of malpresentation (remember that foetal presentation can change up to the last month)
It allows assessment of: -foetal weight -the amount of amniotic fluid -uterine contractions
Walking the finger tips across the abdomen to locate the position of the foetal back.
Pelvic palpation. If the hands are in the correct position, the outstreched thumbs will meet at about umbilical level. The fingers are directed inwards and downwards.
Pawlik's manoeuvre. The lower pole of the uterus is grasped with the right hand, the midwife facing the woman's head.
Method of pelvic palpation used to determine a position in a vertex presentation. The higher cephalic prominence (the cincipital) will be on the side opposite to the back.
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# P A L P A T I O N S

# Standard antenatal consultation

# Auscultation of the foetal heart
This is possible from weeks or 5 months of pregnancy using an obstetric stethoscope such as the Pinard stethoscope (a sort of ear trumpet, see below).
Normal rate : between 120 and 160 beats per minute, but not regular; there is a baseline rate specific to each foetus with some accelerations in between. Abnormal rate : decelerations, bradycardia or tachycardia occur more often during labour or delivery, so are not dealt with in this work.
The aims of auscultation are: -to check that the foetus is alive -to confirm foetal presentation -to check the foetal cardiac rhythm in order to detect any distress.
Auscultation can be difficult to perform because of: -uterine contractions -a large amount of amniotic fluid -a thick layer of abdominal subcutaneous fat -extensive foetal movement -pulsations of the maternal aorta (to distinguish between the foetus and the mother, compare the pulse on the mother's wrist with foetal auscultation) -pulsations of the umbilical cord (funicular souffle), which is more a murmur than a beat.

# Auscultation of the foetal heart.
Looking at the second hand of a watch permits to count the foetal heartbeats.

# p | 91

# Standard antenatal consultation

# Vital signs of the mother Blood pressure: normal <140/90 mmHg
When taking the mother's blood pressure, avoid placing her in a position that causes compression of the vena cava (see page 75). This means that the mother should be in a semi-seated position, especially in the last months of pregnancy, and not in left lateral decubitus, as this can give an erroneously good result.
The procedure makes it possible to screen for hypertension and pre-eclampsia.

# Pulse: normal between 60 and 100 beats per minute.
A higher rate may be due to anaemia, haemorrhage, fever, anxiety or other conditions.

# Temperature:
Should be taken if relevant symptoms and signs observed (suspicion of infection being the main reason).

# Urine test strips
To be used when indicated by symptoms or by complaints from the mother, in order to check for proteinuria (in case of hypertensive disorders) or urine infection (presence of leucocytes and/or nitrites) and as a diagnostic aid.
Note that if the urine is contaminated with blood, infected vaginal secretions or amniotic fluid, proteinuria may test positive. The same applies to examination for urine infection: when infected vaginal secretions are present in the urine, the test for leucocytes may be positive.

# Oedema (see page 75)
If oedema is observed in the lower extremities, hands or face, this indicates an increase in plasma volume and/or poor blood circulation. Oedema associated with high blood pressure and proteinuria indicates pre-eclampsia, (see pages 148-151).
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# Standard antenatal consultation

# Procedures for: First-trimester consultation
If possible, confirm the pregnancy and calculate the term. Take action and give advice in accordance with the findings, the mother's complaints and medical history, and local community health problems. Check tetanus vaccination status. Give prophylaxis for anaemia (see page 139). Set a date for the next appointment, making it clear that the mother should attend at once should any problem arise in the meantime. Answer any questions.

# Second-trimester consultation
Same procedure as for the first-trimester consultation, adapted to the mother's situation.
Give prophylaxis for malaria if in an endemic zone (see pages 143-146).

# Third-trimester consultation
Same procedure as for the first-trimester consultation, adapted to the mother's situation.
Give prophylaxis for malaria if in an endemic zone. Give mebendazole 500mg or albendazole 400mg to every pregnant woman once in 6 months (do not give it in the first trimester). Determine whether the mother will have to deliver in hospital and give appropriate advice.

# Comments concerning health services
The quality of a health service depends on:
-the qualifications of staff -their professional experience and skills -the technical resources available
These guidelines are intended for nurses, midwives and doctors dispensing antenatal care.

# Note
Not everyone has the expertise needed to perform all the procedures involved in the clinical examination of a pregnant woman, whether presenting complications or otherwise. Some of those procedures are deliberately omitted from this work because they have to be acquired by practice and not merely by reading a book. But that does not mean they cannot be performed by someone who has the necessary expertise and resources, if this is in the interest of the pregnant woman. Those who lack expertise in certain procedures can try to acquire it with the help of a more experienced colleague. In some cases the latter may even be a mother-and-child health worker or a traditional birth attendant. But remember that in all circumstances it is better to ask for advice in case of doubt rather than to risk doing something without the necessary expertise.
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# Talking with women and their families
Pregnancy is typically a time of joy and anticipation. It can also be a time of anxiety and concern. Talking effectively with a woman and her family can help build the woman's trust and confidence in her health-care providers.
Women who develop complications may find it difficult to talk to the providers and to explain their problems. It is the responsibility of the entire health-care team to treat the woman concerned with respect and to put her at ease. This means:
respecting the woman's dignity and her right to privacy; being sensitive and responsive to the woman's needs; being non-judgmental about the decisions that the woman and her family have made thus far regarding her care.
It is understandable that health personnel may disapprove of a woman's risky behaviour or of a decision which has resulted in delay in seeking care. It is not acceptable, however, to show disrespect for a woman or to disregard a medical condition that is a result of her behaviour. Corrective counselling should be given after the complication has been dealt with, not before or during management of the problem.

# RIGHTS OF WOMEN
Providers should be aware of the rights of women receiving maternity care services:
Every woman receiving care has a right to information about her health. Every woman has the right to discuss her concerns in an environment in which she feels confident.
A woman should know in advance the type of procedure that is going to be performed.
A woman (or her family, if necessary) should give informed consent before the provider undertakes any procedure.
Procedures should be conducted in an environment (e.g. labour ward) in which the woman's right to privacy is respected.
A woman should be made to feel as comfortable as possible when receiving services.
A woman has the right to express her views about the services she receives.
When a provider talks to a woman about her pregnancy or a complication, he or she should use basic communication techniques. These techniques help the provider to establish an honest, caring and trusting relationship with the woman. If a woman trusts the provider and feels that the provider has her best interests at heart, she will be more likely to return to the facility for delivery or to come early if there is a complication.

# Standard antenatal consultation
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# COMMUNICATION TECHNIQUES
Speak in a calm, quiet manner and assure the woman that the conversation is confidential. Be sensitive to any cultural or religious considerations and respect her views.

# In addition:
Encourage the woman and her family to speak honestly and to give a full account of events surrounding the complication.
Listen to what the woman and her family have to say and encourage them to express their concerns; try not to interrupt.
Respect the woman's sense of privacy and modesty by closing the door or drawing curtains around the examination table.
Let the woman know that she is being listened to and understood.
Use supportive non-verbal means of communication such as nodding and smiling.
Answer the woman's questions directly in a calm, reassuring manner.
Explain what steps will be taken to manage the situation or complication.
Ask the woman to repeat the key points to ensure that she has understood.
If a woman must undergo a surgical procedure, explain to her the nature of the procedure and the risks involved, and help to reduce her anxiety. Women who are extremely anxious have a more difficult time during surgery and recovery.

# Standard antenatal consultation
This section Talking with women and their families comes from : 

# C A S E S TO B E R E F E R R E D F OR D E L I V E RY
This section describes all the indications for referral to hospital at the time of delivery.

# Screening for cephalopelvic disproportion
Measurement of the mother's pelvis requires special skills.

# (For information)
A) Outlet of android pelvis.The head does not fit into the acute pubic arch and is forced backwards onto the perineum.

# B)
Outlet of gynaecoid pelvis. The head fits snugly into the pubic arch.

# Characteristic inlet of the 4 types of pelvis. (For information)
Anthropoid Gynaecoid Android
Platypelloid (flat)
A B
Without going into details, the parameters to be considered are:
The presumed foetal weight (determined by palpation)
Pelvic assessment of the mother (see Another way of assessing the mother's pelvis, next page)
Problems occur if there is a disproportion between foetal weight and pelvic measurement. Prognosis remains difficult, however, as such disproportion is not always obvious and may become evident only during labour. Any history of previous pregnancy with cephalopelvic disproportion or related complications, such as obstructed labour or vesico-vaginal or recto-vaginal fistula.
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# Another way of assessing the mother's pelvis
One simple method of detecting women at risk of cephalopelvic disproportion (CPD) is to measure, using a measuring tape, the mother's height and the transverse diagonal of the Michaelis sacral rhomboid area. 13 This method may be very useful in peripheral antenatal clinics for identifying such cases and referring them to district hospitals before the onset of labour.
Maternal height <150 cm or transverse diagonal <9.5 cm indicates a risk of CPD.

# A) Lumbar vertebra n5 B -D) Transverse diagonal between the two dimples of the Michaelis sacral rhomboid area.
Cases to be referred for deliver y 

# p | 97
Cases to be referred for deliver y

# Indications for referral to hospital for delivery
This list is not comprehensive, as many factors play a role:
-quality of medical care -accessibility to a hospital -the mother's own wish to give birth in hospital or at home, etc.

# Previous history of:
caesarean section obstructed labour vesico-vaginal or recto-vaginal fistula retained placenta perineal tear -degree 3 (anal sphincter ruptured)
-degree 4 (degree 3 + rupture of rectal mucous membrane) The decision whether or not to recommend a Caesarean section will be taken on a case by case basis (for more information on HIV/AIDS, see pages .

# p | 98
Cases to be referred for deliver y

# T W O E X A M P L E S O F F LO W C H A R T S F O R T H E R E F E R R A L O F P R E G N A N T W O M A N I N T H E P R E S E N C E O F F E M A L E G E N I TA L M U T I L A T I O N ( F G M )
A 

# D I S T R I C T H E A LT H C A R E
Reassessment by midwife -Severe scarring: incision by midwife during labour/delivery -Very severe scarring 

# E M E R G E N C Y O B S T E T R I C C A R E
These guidelines to antenatal care are intended for nurses, midwives and doctors who work in health centres with very low technical input.
The centre concerned may be the only one or the nearest one accessible to the local community.This means that it will receive not only antenatal patients but also obstetric emergencies.
Such cases will have to be referred to a hospital, but if skilled staff and some medical supplies are available first aid can be given to improve the prognosis and possibly avoid maternal death.
In this section the following topics are covered:
-general information on obstetric emergencies -emotional and psychological support for women and their families -what can be done in different obstetric emergencies

# General information
The following information on obstetric emergencies draws attention to some matters that should be taken into consideration when an initial assessment is being carried out prior to setting up an antenatal care programme.
Before offering a new service to pregnant women, it is important to know exactly what can and cannot be done in order to avoid raising false hopes.

# WHO definition of maternal death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental cause.
Women can die during any of the following three periods: the antenatal period, which lasts from conception until the beginning of labour the intrapartum period, which lasts from the beginning of labour until after the delivery of the afterbirth (placenta and membranes) the postnatal period, which conventionally lasts for 42 days (6 weeks) from after the completion of the intrapartum period.
In any "safer motherhood" project, the first priority should be to ensure that essential emergency obstetric care is: available accessible affordable p | 100
There are many reasons why a pregnant woman can die. One of them may be a problem with the three delays, which are:
Delay in deciding to seek care, due to:
-ignorance of the seriousness of the condition -low status of the sick woman -cost of care Delay in reaching care once the decision has been made to seek it, due to:
-cost of travel -distance to the health facility -impracticalities of travel -the need to secure permission to travel from an absent family member Delay in receiving care on reaching the reference hospital, due to:
-bureaucratic mismanagement/poor-quality care -attending the wrong health facility (e.g., a caesarean section is required and is only available at the district hospital, not at the reference hospital to which the woman has come, so a further transfer is required)
The three levels of technical care are:
Level 1 : the community health centre, with the lowest level of technical input Level 2 : the reference hospital, with skilled staff able to deliver basic emergency obstetric care Level 3 : the district hospital, which should provide the highest technical level of care

# Essential emergency obstetric care (EEOC) includes basic emergency obstetric care (BEOC) and comprehensive emergency obstetric care (CEOC).
The crucial procedures or "signal functions" of basic emergency obstetric care are: administration of parenteral (intravenous or by injection) antibiotics administration of parenteral oxytocic drugs administration of parenteral anticonvulsants manual removal of placenta removal of retained products assisted vaginal delivery (vacuum extraction, forceps delivery)
The signal functions of comprehensive emergency obstetric care are: all six basic signal functions surgery (caesarean section) -requiring anaesthesia blood transfusion Emergency obstetric care p | 101

# Emergency obstetric care

# Emotional and psychological support
Emergency situations are often very distressing for all concerned and give rise to a range of emotions that can have significant consequences.

# EMOTIONAL AND PSYCHOLOGICAL REACTIONS
How each member of the family reacts to an emergency situation depends on:
-the marital status of the woman concerned and her relationship with her partner;
-the social status of the woman/couple and their cultural and religious practices, beliefs and expectations;
-the personalities of the people involved and the quality and nature of social, practical and emotional support;
-the nature, gravity and prognosis of the problem and the availability and quality of health-care services.
Common reactions to obstetric emergencies or death include:
-denial (feelings of it can't be true);
-guilt regarding possible responsibility;
-anger (frequently directed towards health-care staff but often masking anger that parents direct at themselves for their failure);
-bargaining (particularly if the patient hovers for a while between life and death);
-depression and loss of self-esteem, which may be prolonged;
-isolation (the feeling of being different or separate from others), which can be reinforced by care-givers who may avoid people who experience loss; -disorientation.

# p | 102
Emergency obstetric care

# GENERAL PRINCIPLES OF COMMUNICATION AND SUPPORT
While each emergency situation is unique, the following general principles offer guidance. Communication and genuine empathy are probably the most important keys to effective care in such situations.

# At the time of the event
Listen to those who are distressed. The woman/family will need to discuss her/their hurt and sorrow.
Do not change the subject and move on to easier or less painful topics of conversation. Show empathy.
Tell the woman/family as much as you can about what is happening. Understanding the situation and its management can reduce their anxiety and prepare them for what will happen next.
Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters more than appearing knowledgeable.
If language is a barrier to communication, find a translator.
Do not pass the problem on to nursing staff or junior doctors.
Ensure that the woman has a companion of her choice and, where possible, the same care-giver throughout labour and delivery. Supportive companionship can enable a woman to face fear and pain and help reduce loneliness and distress.
Where possible, encourage companions to play an active role in care. Position the companion at the bedside to allow him or her to focus on looking after the woman's emotional needs.
Both during and after the event, provide as much privacy as possible for the woman and her family.

# p | 103

# After the event
Give practical assistance, information and emotional support.
Respect traditional beliefs and customs and accommodate the family's needs as far as possible.
Provide counselling for the woman/family and allow for reflection on the event.
Explain the problem, so as to help reduce anxiety and guilt. Many women/families blame themselves for what has happened.
Listen and express understanding and acceptance of the woman's feelings. Nonverbal communication may speak louder than words: a squeeze of the hand or a look of concern can say an enormous amount.
Repeat information several times and give written information if possible. People experiencing an emergency will not remember much of what is said to them.
Health-care providers may feel anger, guilt, sorrow, pain and frustration in the face of obstetric emergencies, and this may lead them to avoid the woman/family. Showing emotion is not a weakness.
Remember to care for staff who may themselves experience guilt, grief, confusion and other emotions. 

# Management of emergency cases
Management of emergency cases will depend on different factors, the most important being the professional skills of staff and the availability of materials.
For further information on the above subject, see: Comments concerning health services (page 93).
Find on next pages how to take care of women in different obstretic emergencies at primary health care level.

# Note

# Emergency obstetric care
The skills of a nurse, a midwife and a doctor will naturally be different, which means that the contents of their medical kits may also be different.
This section outlines what each of these three professionals can do at health-centre level. They themselves will then add any further procedures that they know and can perform.
Remember that if the professional concerned lacks the required expertise, it is better to do nothing than to put the woman at even greater risk by doing the wrong thing.
p | 105

# RAPID INITIAL ASSESSMENT IN CASE OF CONVULSIONS OR LOSS OF CONSCIOUSNESS ASSESS

# Ask
Pregnant ? Length of gestation ?

# Examine
Blood pressure: systolic > 140 mm Hg OR diastolic > 90 mm Hg Temperature: 38C or more

# STABILIZE
Shout for help -Never leave the woman alone.
Protect the woman from injury, but do not actively restrain her.

# If she is unconscious
-Check the airway.
-Position the woman lying down on her left side with two pillows supporting her back. -Check for neck rigidity.
If she is convulsing, turn her on her side to minimize the risk of aspiration should she vomit and to ensure that an airway is open. 

# CONSIDER

# HEADACHE, BLURRED VISION, CONVULSIONS, OR LOSS OF CONSCIOUSNESS
If a pregnant woman or a woman who has recently given birth complains of severe headache, blurred vision or has elevated blood pressure, test her urine for proteinuria.
A small proportion of women with eclampsia have normal blood pressure. Treat all women with convulsions as if they have eclampsia until another diagnosis is confirmed.
If a pregnant woman living in a malarial area has fever, headaches or convulsions and malaria cannot be excluded, it is essential to treat the woman for both malaria and eclampsia.

# SIGNS/SYMPTOMS
Convulsions, blood pressure >140/90 mm Hg after 20 weeks of pregnancy Proteinuria 2+ or more 

# If the woman is convulsing
Give diazepam 10 mg IV slowly over 2 minutes. Repeat if convulsions recur after 10 minutes.

# Refer urgently

# If convulsions occur
Give diazepam 10 mg IV slowly over 2 minutes.

# If eclampsia is not ruled out
Prevent subsequent convulsions with magnesium sulfate. Refer urgently.

# If complicated malaria is diagnosed and the woman is conscious
Give three tablets of sulfadoxine pyrimethamine OR chloroquine. Refer urgently.

# Do not give ergometrine to women with pre-eclampsia, eclampsia, or high blood pressure because it increases the risk of convulsions and intracranial haemorrhage.
Emergency obstetric care p | 107

# MAGNESIUM SULFATE 14 SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

# Loading dose
Magnesium sulfate solution 4 g IV over 5 minutes. Follow promptly with 10 g of magnesium sulfate solution, 5 g in each buttock as deep IM injection with 1 mL of 2% lignocaine in the same syringe. Ensure that aseptic technique is practiced when giving magnesium sulfate deep IM injection.
Warn the woman that a feeling of warmth will be felt when magnesium sulfate is given.
If convulsions recur after 15 minutes or more, give an additional 2 g magnesium sulfate IV over 5 minutes. 

# Keep antidote ready:
In case of respiratory arrest: Assist ventilation (mask and bag).
Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly to antagonize the effects of magnesium sulfate until respiration restarts.

# If referral is delayed or the woman is in late labor
Continue treatment with magnesium sulfate: -Give magnesium sulfate 5 g IM plus 1 mL of 2% lignocaine (in alternate buttock) every 4 hours. -Continue treatment for 24 hours after the birth or after the last convulsion, whichever occurs last.
Monitor urine output.
Emergency obstetric care 14 Magnesium sulfate comes in different concentrations (e.g., 20%, 40%, 50%). When giving injections IM, it is best to use higher concentrations (e.g., 50%) to decrease the total volume required.
In the ICRC, the concentration of 50% is the only one provided.
p | 108

# DIAZEPAM SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Use diazepam only if magnesium sulfate is not available.

# INTRAVENOUS ADMINISTRATION

# Loading dose
Give diazepam 10 mg IV slowly over 2 minutes. If convulsions recur, repeat loading dose.

# Maintenance dose
If woman is in late labour or referral is delayed, give a maintenance dose as follows:
Give diazepam 40 mg in 500 mL IV fluids (Ringer's lactate or normal saline) over 6-8 hours, titrated to keep the woman sedated but rousable Stop the maintenance dose if respirations drop below 16 breaths per minute. Maternal respiratory depression may occur when dose exceeds 30mg in 1 hour. Do not give more than 100 mg of diazepam in 24 hours.

# RECTAL ADMINISTRATION WHEN IV ACCESS IS NOT POSSIBLE

# Loading dose
Give 20 mg in a 10 mL syringe:
-Remove the needle, lubricate the barrel and insert the syringe into the rectum to half its length. -Discharge the content and leave the syringe in place, holding the buttocks together for 10 min to prevent expulsion of the drug. -Alternatively, the drug may be instilled in the rectum through a catheter.
If convulsions are not controlled within ten minutes, administer an additional 10 mg or more, depending on the size of the woman and her clinical response. 

# Be prepared to assist ventilation.

# FEVER DURING PREGNANCY AND LABOUR (TEMPERATURE OF 38C OR MORE)

# MANAGEMENT
Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until woman is fever-free for 48 hours. Prior to 16 weeks Refer urgently after giving antibiotics for manual vacuum aspiration (MVA). After 16 weeks Refer urgently after giving antibiotics.
Immediately give ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours. Refer for childbirth.

# If woman is conscious
Give three tablets of sulfadoxine/pyrimethamine OR chloroquine and refer urgently. If woman is unconscious or convulsing Give diazepam 10 mg IV slowly over 2 minutes.

# Refer urgently.
Give ampicillin 1 g by mouth 4 times per day OR amoxicillin 1 g by mouth three times per day for 14 days. Alternative therapy will depend on local sensitivity patterns. Refer urgently. 

# MANAGEMENT
Give ampicillin 1g by mouth 4 times per day OR amoxicillin 1g by mouth 3 times per day for 14 days.
Alternative therapy will depend on local sensitivity patterns. Refer urgently.
Antibiotic treatment in both cases, whether infective or not.
Give cloxacillin 500 mg by mouth four times per day for 10 days OR erythromycin 250 mg by mouth three times per day for 10 days.
Give paracetamol 500 mg by mouth as needed. Do not stop breastfeeding. Give the mother advice on good feeding technique.
Complication: breast abscess (antibioticsurgery-stop breastfeeding temporarily from the breast concerned).
Emergency obstetric care p | 113

# RAPID INITIAL ASSESSMENT IN CASE OF RESPIRATORY DISTRESS ASSESS

# Look for
Absence of breathing Rapid breathing (30 breaths or more per minute) Obstructed breathing or gasping Pale or bluish (cyanotic) skin colour

# Examine
Mouth for foreign bodies (such as pieces of food) Lungs for wheezing or rales

# STABILIZE

# If the woman IS NOT breathing

# Shout for help.
Keep the woman in supine position with her head tilted backwards. Lift her chin to open the airway. Inspect her mouth for foreign body and remove if found. Clear secretions from her throat. Ventilate with bag and mask until she starts breathing.

# If the woman IS BREATHING BUT still in respiratory distress

# Shout for help.
Rapidly evaluate vital signs (blood pressure, pulse, breathing). Position the woman lying down on her left side with two pillows supporting her back. Give oxygen at 4-6 L per minute if available. Refer urgently. Infuse normal saline or Ringer's lactate at the rate of 1 L over 8 hours.

# CONSIDER

# Refer urgently for transfusion.
Start an IV infusion using a large-bore cannula or needle.
Infuse normal saline or Ringer's lactate at the rate of 1 L over 8 hours.

# Refer urgently for transfusion.
Start an IV infusion using a large-bore cannula or needle.
Infuse normal saline or Ringer's lactate at the rate of 1 L over 12 hours.
Position the woman on her left side. 

# STABILIZE
The aim is to stop the bleeding.
Assess the cause of bleeding on the basis of the stage of gestation and treat accordingly. -Insert IV line and infuse normal saline or Ringer's lactate 1L in 15-20 minutes (as rapidly as possible).

# CONSIDER
-Repeat 1 L every 30 minutes until pulse slows to less than 100 beats per minute and systolic BP increases to 100 mm Hg or more then 1L in 6-8 hours -Record time and amount of fluids given.

# If diagnosis is uncertain
Stabilize and refer urgently for MVA.
(Manual vacuum aspiration)

# IF UNSAFE ABORTION IS SUSPECTED
Examine for signs of infection or uterine, vaginal, or bowel injury.
If infection is present, begin antibiotics before referring for manual vacuum aspiration (MVA).
If uterine, vaginal, or bowel injury is present, infuse IV fluids and refer urgently for surgery and MVA.
If herbs, local medications or caustic substances were used, thoroughly irrigate the vagina to remove them.
More information on abortion follow. 

# PROLAPSED CORD Definition
The cord lies in front of the presenting part or alongside it following rupture of the membranes. It may remain in the vagina or be visible outside.

# Aetiologies
Transverse 

# Management
Refer the pregnant woman if foetal heart sounds can no longer be heard and one of the following complications is present:
-Multiple pregnancy: the first foetus may be dead but not necessarily the other(s) -Malpresentation of the foetus, which needs to be delivered in hospital or by caesarean section -Bleeding, which can be due to placenta praevia (rare) Wait for delivery if there are no more foetal heart sounds and none of the above complications is present, it is a case of foetal death.
Refer the pregnant woman if there are foetal heart sounds and/or the cord is pulsating:
-Replace the cord inside the vagina if it is protruding, in order to avoid arterial spasm due to temperature difference. -Never attempt to replace the cord inside the uterus, because failure is guaranteed and the additional manipulations increase the risk of spasm. 

# UNSATISFACTORY PROGRESS IN LABOUR
Woman in the knee-chest position.
Thighs must be straight. The foetus gravitates towards the fundus and pressure on the cord is relieved. This position is not useful during transportation.
Woman in the exaggerated Sims' position. Two large foam-rubber wedges or pillow elevate the buttocks further.

# Prolapsed cord
Emergency obstetric care p | 125

# TRAUMA IN PREGNANCY Introduction
Trauma of any kind is the most frequent cause of maternal death which is not obstetric in origin. Maternal compromise and the severity of the injury are the principal factors in traumarelated foetal demise. In such cases, attention is often focused on the abdomen because of the pregnancy. However the pregnancy may not easily be detected, especially if it is at an early stage and the woman is unable to make herself understood.

# Principles of trauma management
Save the mother, save the foetus In fact, the mother takes priority over the foetus. This does not mean that the foetus does not have to be considered in the management of maternal trauma, but the mother's health will be the first concern. It must be remembered that a woman is in charge of the family.
Pregnant women are more vulnerable to injury. Initial treatment priorities for an injured pregnant patient remain the same as for a non-pregnant patient: A, B, C, etc.
Finally, trauma during pregnancy does not necessarily put the health of the foetus at risk. This will depend on:
-which part(s) of the mother's body are affected (whether or not the abdomen or lower back is involved) -whether there is haemodynamic problem -whether the trauma causes uterine contractions that can lead to premature birth, vaginal bleeding, etc.

# Aetiologies
Blunt trauma may be caused by:
-road accidents -assaults -falls Common consequences are abruptio placentae, foetal skull fracture, rupture of the uterus, premature labour.
Penetrating trauma may be caused by: -gunshot wounds -stab wounds -shrapnel injuries

# Burns
In general, the survival of the mother allows survival of the foetus.
Emergency obstetric care p | 126

# Risks for the mother
Complications are related to the stage of the pregnancy and the corresponding physiological changes.
Uterus: larger, becoming intra-abdominal after 12 weeks with higher blood flow Placenta: lack of elasticity (abruptio placentae), decreased blood flow with maternal hypotension.
Pelvis: venous engorgement. Gastrointestinal tract: intestinal displacement into upper quadrant, gastric emptying time extended (full stomach).
Respiratory tract: elevated diaphragm, hypocapnia (alkalosis), decreased tolerance of hypoxaemia.
Cardiovascular system: increased heart rate, increased cardiac input, increased plasma volume, signs of ongoing haemorrhage delayed.
The hypervascularization of pelvic organs increases the risk of haemorrhage.
Uterine rupture is rare and is more likely to occur at the end of pregnancy. Foetal death is inevitable, unless the woman can immediately undergo caesarean section. Maternal death, however, depends more on associated lesions and the availability of treatment.
Risks for the foetus abortion foetal death foetal injury abruptio placentae premature birth foeto-maternal haemorrhage

# Management
In triage conditions a pregnant woman has priority. The best early treatment for the foetus is optimum resuscitation of the mother. Do not attempt foetal assessment in the field. Before referring the pregnant woman:
-Follow The guidelines for Rehydration (see annex II.B, page 135).
-To avoid compression syndrome on the vena cava (see page 75), place the patient on her left side for transport. If this is not possible, let her lie on her back and raise her right buttock so that she can lean on her left side, or manually displace the uterus to the left side. -Dress the wound(s) as appropriate.
-Raise her legs for better venous return.

# Premature contractions
Uterine contractions frequently start secondary to trauma, but in most cases they will cease with rest and good intravenous hydration (as long as the cervix is not already excessively dilated), and delivery remains exceptional.
In case of imminent delivery, let the woman deliver before transferring her, especially if the referral hospital is far away. 

# ANNEXES PART II

# Antenatal Consultations
Clamp the cord close to the perineum using sponge forceps within 1 minute of birth. Hold the clamped cord and the end of the forceps with one hand. Place the other hand just above the woman's pubic bone and stabilize the uterus by applying counter-traction during controlled cord traction. This helps prevent inversion of the uterus. Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes).
When the uterus becomes rounded or the cord lengthens, pull downward on the cord very gently to deliver the placenta. Do not wait for a gush of blood before applying traction on the cord. Continue to apply counter-traction to the uterus with the other hand.
If the placenta does not descend during 30 to 40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord.
-Gently hold the cord and wait until the uterus is well contracted again. If necessary, use sponge forceps to clamp the cord closer to the perineum as it lengthens. -With the next contraction, repeat controlled cord traction with counter-traction.
As the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery. If the membranes tear, gently examine the upper vagina and cervix wearing highlevel disinfected or sterile gloves and use sponge forceps to remove any pieces of membrane that are present. Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placental fragments. If you can feel the placenta or placental fragments in the vagina, remove by hand (wear sterile or high-level disinfected gloves; wrap sterile gauze around fingers). If uterine inversion occurs, try to immediately replace the uterus. If failure, refer. If the cord is pulled off, manual removal of the placenta may be necessary.I

# UTERINE MASSAGE
Immediately massage the fundus of the uterus through the woman's abdomen until the uterus is contracted. Repeat uterine massage every 15 minutes for the first 2 hours. Ensure that the uterus does not become relaxed (soft) after you stop uterine massage.

# Please, see the illustrations of placental delivery on next pages.
Note Never apply cord traction (pull) without applying counter-traction (push) above the pubic bone with the other hand. 

# Diagnosis
A careful speculum examination, if available, may be performed, but only by an experienced person because of the risk of sudden haemorrhage.
Per vaginal examination is contraindicated but may be performed cautiously by an experienced person to confirm the diagnosis, once the woman is in hospital and ready for caesarean section.

# Differential diagnosis
- Bleeding after intercourse in woman with ectopia of the cervix due to pregnancy.
- A careful speculum examination may be performed to diagnose other causes of bleeding such as cervicitis or trauma. The presence of these conditions, however, does not rule out placenta praevia.

# Treatment
Heavy and continuous bleeding: caesarean delivery irrespective of foetal maturity. Light or intermittent bleeding with foetus alive but premature: rest, transfer for careful management (see below)
The pregnancy may continue and lead to delivery at term (type 1 and 2 may even allow vaginal delivery) or require emergency caesarean because of bleeding.

# Management
Refer the pregnant woman if she presents (see page119):
-heavy or recurrent bleeding -lower abdominal pain or contractions Careful management (which means observation) if: -the haemorrhage is not heavy and persistent -the foetus is not showing signs of distress: normal heart rate, good movements -the pregnancy is less than 37 weeks -the pregnant woman is confined to strict bed rest for three days after the bleeding stops.
Vaginal bleeding p | 187

# ABRUPTIO PLACENTAE Definition
Total or partial detachment of a normally situated placenta from the wall of the uterus before the foetus is delivered. See next page.

# Risk factors

# Diagnosis
Difficult, especially if the haemorrhage is concealed.

# Risks for the foetus
Intrauterine or perinatal death

# Risks for the mother
Haemorrhagic shock Coagulopathy (clotting failure) Maternal death

# Treatment
Caesarean section as soon as possible, except if vaginal delivery is imminent with fully dilated cervix, ruptured membranes, engaged presentation.

# Management
Refer the pregnant woman (see page 119). 

# VAGINAL DISCHARGE

# Candida albicans: fungus
The main source of infection is the gastrointestinal tract, but sexual transmission may occur. In the majority of women candidiasis is asymptomatic. The symptomatic disease is associated with an increase in the number of yeasts present in the vagina (predisposing factors: pregnancy, antimicrobial therapy, oral contraceptives, immunosuppression, AIDS, glycosuria).

# Vulvovaginal candidiasis:
-Pruritus vulvae and vaginal discharge (whitish, odourless, curd-like plaques adhering to the vagina)
-Possible erythema and/or oedema of the vulva and vagina Risks for the foetus:
-Muco-cutaneous candidiasis, due to transmission during delivery -Rare but fatal disseminated pulmonary candidiasis, due to rising infection during pregnancy Treatment Nystatin 100 000 IU intravaginally, daily for 14 days or Fluconazole 150 mg orally as a single dose

# Trichomonas vaginalis: parasite
Trichomoniasis is a sexually transmitted disease.
In men: -mostly asymptomatic; occasionally urethritis
In women: -yellow-green, frothy discharge, not malodorous -pruritus vulvae -dysuria -dyspareunia

# Treatment
Metronidazole: 2 g orally as a single dose if treatment is imperative during the first trimester, but may also be given during the second and third trimesters of pregnancy or 400 or 500 mg orally, twice daily for 7 days, after first trimester.

# p | 190

# Bacterial vaginosis
Changes in the vaginal bacterial flora: lactobacilli are no longer predominant and Gardnerella vaginalis or Mycoplasma hominis increase.
It is not clear whether this is a sexually transmitted disease.
Women present a homogeneous white vaginal discharge with a fishy smell, but 50% of cases are asymptomatic.
Risks for the foetus and the mother:
-late abortion -premature rupture of membranes -prematurity -chorioamnionitis -postpartum endometritis Treatment Metronidazole: 200 or 250 mg orally, 3 times daily for 7 days, after the first trimester or 2 g orally as a single dose if treatment is imperative during the first trimester, but may also be given during the second and third trimesters of pregnancy.

# Vaginal discharge p | 191
Vitamin A is essential for maintaining normal health and physiology, and for growth and development. During pregnancy there is a greater need for vitamin A for both the mother and the foetus. Although the increase in requirement during pregnancy is relatively small, in countries where vitamin A deficiency (VAD) is endemic, women often experience deficiency symptoms such as night blindness, xerophthalmia and Bitot's spots.
Severe vitamin A deficiency and overload are both teratogenic in animals and associated with adverse reproductive outcomes. Although similar outcomes in human populations are not documented, the possibility of risk must be considered. WHO currently recommends that the relatively small additional need for vitamin A during pregnancy should be met through diet (see annex III.B) or a supplement not exceeding 10 000 IU daily throughout pregnancy.

# Maternal supplementation during pregnancy
(Either during the first 60 days following conception when there is a teratogenic risk or after the first 60 days following conception, for women whose habitual intakes are above the RDA 20 or below the RDA)
For fertile women, independent of their vitamin A status, 10 000 IU (3 000 g RE 21 ) is the maximum daily supplement to be recommended at any time during pregnancy.
Where VAD is endemic among children under school age and maternal diets are low in vitamin A, health benefits are expected for the mother and her developing foetus with little risk of detriment to either, from :
- either a daily supplement not exceeding 10 000 IU vitamin A (3 000 g RE) at any time during pregnancy;
- or a weekly supplement not exceeding 25 000 IU vitamin A (8 500 g RE).
In this regard: -a single dose > 25 000 IU is not advisable, particularly between day 15 and day 60 following conception (day 0); -beyond 60 days after conception, the advisability of providing a single dose of > 25 000 IU is uncertain; any risk for non-teratogenic developmental toxicity is likely to diminish as pregnancy advances. In the case of a pregnant woman who may be reached only once during pregnancy, health workers should balance possible benefits from improved vitamin A status against potential risk of adverse consequences from receiving a supplement.
Where habitual vitamin A intakes exceed at least three times the RDA (about 8000 IU or 2 400 g RE), there is no demonstrated benefit from taking a supplement. On the contrary, the potential risk of adverse effects increases with higher intakes -above about 10 000 IU -if supplements are routinely ingested.
WHO, UNICEF and the International Vitamin A Consultative Group (IVACG) recommend that, in areas of VAD endemicity, high doses of supplemental vitamin A (200 000 IU) be given to breastfeeding women during the infertile postpartum period lasting 4 to 6 weeks. 

# VITAMIN A DEFICIENCY