FOCUSED ANTENATAL CARE

FOCUSED ANTENATAL CARE
MALARIA IN PREGNANCY
PREVENTION OF MOTHER-TO-CHILD TRANSMISSION
TUBERCULOSIS
ORIENTATION PACKAGE FOR SERVICE PROVIDERS
4TH EDITION 2007
TABLE OF CONTENTS
FOREWARD
ACKNOWLEDGEMENT
TABLE OF CONTENTS
ACRONYMS
ORIENTATION PACKAGE
OVERVIEW OF MATERNAL MORTALITY
FOCUSED ANTENATAL CARE
TUBERCULOSIS IN PREGNANCY
MALARIA IN PREGNANCY
MALARIA CASE MANAGEMENT
ANAEMIA IN PREGNANCY
VITAMIN A
PREVENTING MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV
QUALITY ANTENATAL CARE
INFECTION PREVENTION
GROUP WORK
LIST OF ANNEXES

PREVENTING MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV
HIV positive mothers can transmit the virus to the baby during pregnancy (5-10%), labour and delivery (10-20%) and breastfeeding (5-20%).
Without intervention, 1 out of 3 children born to HIV positive mothers will get the virus. This can be reduced by half with simple interventions.

Four pillars of WHO recommendations to reduce MTCT:

• Family planning services to reduce unintended pregnancies in HIV positive women
• Preventing HIV infection in women through the ABCD (Abstain, Be faithful, Condoms and dual protection)
• Identifying pregnant HIV positive women, preventing MTCT and, providing ARVs to mother and child
• Care and support of those living with HIV/AIDS

Risk factors for MTCT:
Viral factors:

• Clinical stage (New and advanced infection)
• Low maternal CD4 count
• High viral load (in the blood and genital trat)

Maternal factors:

• Unprotected sex with multiple partners
• Substance abuse
• Smoking
• STIs and other co-infections
• Vitamin A deficiency
• Mothers not taking ARVs
• Unprotected sex with an infected partner
• HIV infection during pregnancy
• Malaria infection in pregnant women

Obstetric factors:

• Invasive fetal monitoring
• Duration of membrane rapture
• Routine episiotomy
• Placental disruption
• Vaginal delivery

Infant factors:

• Breastfeeding
• Preterm delivery
• Neonatal birth injuries
• Vigorous naso-gasric tube suction

BEST PRACTICES DURING FANC

• Treat clients with dignity and privacy
• Good interpersonal/communication skills
• Clean, safe service delivery points with well-organised client flow
• Consistency in service provision
• Provider self-assessment – identify clinic problems, solutions and monitoring progress
• Thorough history taking and physical examination
• Offer HIV testing to every pregnant woman
• HIV testing should be voluntary

*PMTCT should be integrated in the FANC clinic

CARE OF HIV POSITIVE WOMEN IN THE FANC

1. Identify and treat other infections
2. Nutritional counseling and supplements
3. Monitor the HIV infection
4. Discuss infant feeding, other infections, danger signs, condom use and contraception
5. Stock Nevirapine in the ANC clinic
6. Give AZT from 28 weeks
7. HIV positive women should deliver in a health facility where they will get ARVs during labour and, the baby too, after delivery
8. The mother should take Nevirapine at the onset of labour
9. Monitor labour using a partogram
10. Only perform episiotomy if necessary
11. Avoid artificial rapture of membranes
12. Perform C-section before onset of labour and rapture of membranes
13. Avoid invasive vaginal delivery
14. Give the baby Nevirapine within 72 hours of birth
15. Informed choice: discuss the options and let the woman decide
16. Exclusive breastfeeding: Mixed feeding, mastitis and cracked nipples increase MTCT of HIV
17. Breastfeed exclusively for six months
18. Teach good breastfeeding technique to prevent cracked nipples and and mastitis
19. Use formula if it is available, affordable, safe and acceptable to the mother, and safe water is available
20. Formula is not as good as breast milk but it is a safe alternative
21. Refer HIV positive women for care, treatment and support to enhance followup

CHANGING FROM BREASTFEEDING AFTER 6 MONTHS
If replacement feeding is not available and the mother is HIV positive or of unknown sero-status, continue breastfeeding and give complementary feeds but regularly assess mother and child
Stop breastfeeding once a nutritionally adequate and safe diet can be given without breast milk

INTEGRATION

• Integrating comprehensive PMTCT of HIV into MCH programs significantly reduce the number of HIV infected infants and promotes better health for children, mothers and their families
• In clinical settings PMTCT is integrated with MCH/FP and Maternity services

CARE AND SUPPORT

• Prevent and treat opportunistic infections
• Good nutrition
• Social support
• Antiretroviral therapy
• Plan for children’s care when parents fall sick or die
• Avoid re-infection during pregnancy

WHAT YOU CAN DO TO PREVENT MTCT

• Discourage discrimination against HIV positive people
• Encourage antenatal care and HIV testing for all pregnant women
• Encourage women to deliver in health facilities that have PMTCT services
• Discuss infant feeding options
• Discuss family planning (dual method) to prevent unplanned pregnancy

WE HAVE THE TOOLS TO PREVENT MTCT. DO WE HAVE THE WILL TO USE THEM?

IMPROVING COMMUNICATION
1. Two-way communication: listen to them as well
2. Involve clients in decision making
3. Teach clients to recognize danger signs in pregnancy and seek help

DOCUMENT PATIENT REFERRALS WITHIN OR OUTSIDE THE CLINIC FOR APPROPRIATE SERVICES

ESTABLISH REFERRAL CHANNELS WITH OTHER FACILITIES/SERVICE PROVIDERS

ADHERE TO UNIVERSAL INFECTION CONTROL MEASURES:

1. Wash your hands
2. Decontaminate clinical areas and equipment – including the examination couch
3. Disinfect/sterilize your equipment and instruments
4. Use disposable supplies e.g gloves, syringes, needles and pipettes
5. Dispose waste properly

FAILING TO PLAN CONTRIBUTES TO MATERNAL MORTALITY

 (Adapted from the "FOCUSED ANTENATAL CARE" orientation package for service providers - 4th Edition 2007; a publication of the Ministry of Health - Kenya)