Day 3 Review DME 11 - Midwives Revision

Day 4 - Goal Oriented Antenatal Care | Nurses Revision Uganda

DAY 3 📅 Nov 13 (Wed)

🤰 Goal-Oriented Antenatal Care

DME 111: ANC (8 Contacts Minimum)

8-Contact Schedule & Trimester Goals
History, Examination & Investigations
Health Promotion & Birth Preparedness

⚠️ REMEMBER: GOAL-ORIENTED not FANC! 8 contacts minimum for uncomplicated pregnancy!

🎯 KEY POINT: Every visit = BP, Urine, Weight, SFH, FHR. Address problems ALWAYS!

"Quality ANC is the foundation of safe motherhood. Every contact counts!"

"Before I formed you in the womb I knew you." - Jeremiah 1:5

1. GOAL-ORIENTED ANTENATAL CARE - OVERVIEW

📚 Definition:

Goal-Oriented ANC is a structured approach with minimum 8 contacts in uncomplicated pregnancy, with specific goals for each trimester and contact timing.

⚠️ CRITICAL CHANGE: Uganda MOH moved from FANC (4 visits) to GOAL-ORIENTED 8 contacts in 2022 for better maternal-fetal outcomes!

🎯 The 8-Contact Mnemonic:

🧠 MNEMONIC: "EVERY PREGNANT WOMAN NEEDS PROPER CARE"
Early booking ≤12 weeks (Contact 1)
Pregnancy assessment 13-20 weeks (Contact 2)
Week 21-28 monitoring (Contact 3)
Nearing term 30 weeks (Contact 4)
Preparation 34 weeks (Contact 5)
Confirm readiness 36 weeks (Contact 6)
Ready for labor 38 weeks (Contact 7)
Check at 40 weeks (Contact 8)
→ 41+ weeks: REFER IMMEDIATELY!

💡 EXAM ALERT: Know the timing AND goals of each contact. They ask: "What are the goals of second trimester contacts?"

2. FIRST CONTACT - FIRST TRIMESTER (≤12 WEEKS)

🎯 Primary Goals:

Confirm pregnancy and estimate gestational age
Comprehensive risk assessment
Health education and birth planning
Initiate preventive interventions
Involve male partner

📋 History Taking - The "LNMP-OMS-TSD" Framework:

📝 MNEMONIC: COMPREHENSIVE FIRST VISIT HISTORY
LNMP & estimated due date
Nulliparous/Multiparous status
Menstrual history (regularity)
Prior contraceptive use
Obstetric history (GTPAL)
Medical & Surgical history
STI/HIV/TB screening
Tobacco/Alcohol/Drugs
Social support & IPV screening
Dietary habits & nutrition

🔍 Examination Components:

General exam: Vitals (BP, pulse, temp, RR)
ABDOMINAL: SFH measurement (not much in 1st trimester!)
SPECIFIC: Vulva exam (speculum if indicated)
NUTRITIONAL: Height, weight, MUAC

🧪 Laboratory Investigations:

Test	Purpose	Action if Abnormal
Hb/CBC	Screen for anemia	Start FeSO4, treat if Hb <11g/dL
Blood Group & RhD	Identify Rh negative mothers	Rh prophylaxis at 28 weeks
HIV Test	eMTCT program	Start ART, partner testing
Syphilis (RPR)	Prevent congenital syphilis	Treat mother & partner (Benzathine Penicillin)
Hepatitis B	Vertical transmission risk	Vaccinate newborn at birth
Urine (Albumin, Glucose)	Screen for infection, PIH, DM	Culture if ASB suspected
Malaria RDT	endemic	Treat per guidelines, give LLIN

🌍 UGANDA CONTEXT: Malaria RDT is critical! Uganda has high malaria endemicity. Give LLIN at first contact, IPTp starts at 13 weeks!

💊 Interventions at First Contact:

Tetanus/Diphtheria vaccine (Td): 2 doses minimum (Td1 & Td2, 4 weeks apart)
Haematinics: FeSO4 60mg + Folic acid 400mcg daily
Mebendazole: 500mg stat (after 1st trimester)
LLIN: Insecticide-treated net
IPTp: NOT given in 1st trimester! Starts at 13 weeks

3. SECOND TRIMESTER CONTACTS (13-28 WEEKS)

🎯 Trimester Goals:

Respond to abnormal lab results
Provide preventive measures (Td, IPTp)
Exclude multiple pregnancy & fetal abnormalities
Promote nutrition & wellbeing
Assess for PIH danger signs
Rule out anemia

📅 Contact 2: 13-20 Weeks

🎯 MNEMONIC: "FEELING BETTER - TIME FOR SCANS"
Fetal movements first felt (16-20 weeks)
Education on PIH symptoms
Early ultrasound scan (best at 20 weeks)
Lab results reviewed
IPTp dose #1 (at 16 weeks)
Nutritional assessment
Growth assessment started

Birth plan discussion begins
Encourage male involvement
Td2 vaccine given (if 4 weeks from Td1)
Test urine for albumin
Encourage rest & exercise
Routine vitals (BP, weight, SFH)

📅 Contact 3: 21-28 Weeks

Quickening confirmed: Fetal movements recorded
Anatomy scan: Rule out anomalies before 24 weeks
IPTp dose #2: At least 4 weeks from dose #1
Hb check at 26 weeks: Identify anemia early
BP monitoring: PIH usually appears after 20 weeks!
Mebendazole: Give if not given earlier (500mg stat)

⚠️ DIPLOMA LEVEL EXAM TIP: PIH screening intensifies after 20 weeks! BP ≥140/90 mmHg = URGENT action!

🔍 Special Focus - ULTRASOUND SCAN:

🕒 TIMING IS CRITICAL: Anatomy scan BEST at 20 weeks but MUST be before 24 weeks for anomalies detection! After 24 weeks, termination is legally restricted in Uganda.

Ultrasound objectives:

Confirm gestational age
Detect multiple pregnancy
Identify fetal anomalies
Locate placenta (RULE OUT PREVIA!)
Assess amniotic fluid

🌍 UGANDA CONTEXT: Many women book late! If booking after 20 weeks, COMBINE all preceding goals - do full labs, Td, IPTp, ultrasound ASAP!

4. THIRD TRIMESTER CONTACTS (29-40 WEEKS)

🎯 Trimester Goals:

Monitor fetal growth (SFH plotting)
Exclude anemia (Hb at 36 weeks)
Assess for PIH signs at every visit
Review & finalize birth preparedness plan
Exclude abnormal presentation/lie
Prepare for postpartum care & FP

🧠 MNEMONIC: "CHECK FETUS GROWTH WEEKLY"
Check BP & urine (EVERY VISIT!)
Hemoglobin at 36 weeks
Evaluate fetal lie & presentation
Check SFH growth pattern
Kick count education (fetal movement)
Finalize birth plan
Educate on labor signs
Test for HIV (repeat at 36 weeks per guidelines)
Urine culture if ASB suspected (34 weeks)
Steroids if preterm risk (hospital level)
Give IPTp #3 & #4 (if applicable)
Review danger signs
Offer cervical cancer screening info
Week 41 = REFER urgently!
Td3 if due (total 3 doses minimum)
Hospital bag check

📅 Contacts 4-8 Schedule:

Contact	Timing	Key Actions	Critical Labs
4	30 weeks	Check growth, BP, urine	Urine albumin
5	34 weeks	ASB screening, birth plan review	Midstream gram stain
6	36 weeks	Hb check, HIV retest, lie check	Hb, HIV test
7	38 weeks	Final preparedness check	Urinalysis
8	40 weeks	Assess for labor signs	BP, urine

🚨 CRITICAL RULE: If not delivered by 41 weeks, refer IMMEDIATELY for postdates management!

5. DANGER SIGNS IN PREGNANCY - THE "MUST REFER" LIST

🔴 Danger Signs to Teach at EVERY Contact:

🚨 MNEMONIC: "BAD OBSTETRIC SIGNS"
Bleeding PV (any amount!)
Abdominal pain/severe back pain
Dizziness/fainting
Oedema (face, hands, feet)
Blurred vision/severe headache
Swelling of fingers (can't remove ring)
Temperature (fever >38°C)
Expelled fluid (suspect PROM)
Tense uterus (constant contraction)
Reduced/no fetal movement (<10 kicks/day)
Inability to breathe (SOB at rest)
Convulsions/fits
Sudden swelling (severe preeclampsia)

→ ANY of these = REFER IMMEDIATELY!

6. BIRTH & EMERGENCY PREPAREDNESS PLAN (BEPP)

🎯 The 5 Pillars of BEPP - "The 5 W's & 1 H":

🏥 MNEMONIC: "WHERE WHO WILL GO WITH WHAT WHEN HOW"
WHERE will you deliver? (Facility name & location)
WHO will accompany you? (Support person/husband)
WILL you have transport? (Vehicle/driver/ambulance number)
Go WITH what? (Birth items: mama kit, clothes, food, money)
WHEN will you go? (As soon as labor starts/danger signs)
HOW much money? (Save for transport, drugs, emergencies)

+ BONUS: Identify compatible blood donor!

📋 Items for Birth Kit:

🔹 Mama kit (sterile gloves, cord ties, razor blade)
🔹 Clean clothes for mother & baby
🔹 Food & water for labor
🔹 Transport money (to & from facility)
🔹 Emergency fund (for drugs, complications)
🔹 ANC card & records
🔹 Warm clothing for newborn

🌍 UGANDA CONTEXT: In rural areas, emphasize saving money in "VSLA groups" or mobile money for emergency transport. Many maternal deaths are due to lack of transport funds!

7. SPECIAL PREVENTIVE INTERVENTIONS

7A. Intermittent Preventive Treatment for Malaria (IPTp):

Start: 13 weeks gestation (2nd trimester)
Drug: Sulfadoxine-Pyrimethamine (SP) 3 tablets
Schedule: At least 4 weeks apart
Minimum: 3 doses (13w, 21w, 29w)
Maximum: Monthly until delivery (up to 8 doses)
Contraindication: HIV+ on Cotrimoxazole (Dapsone instead)

🦟 MNEMONIC: "SP PREVENTS MALARIA"
Start at 13 weeks
Pills = 3 tablets SP
Pregnant women only
Repeat every 4+ weeks
Even if on LLIN
Vital to prevent anemia
Effective for placental malaria
Never skip doses (minimum 3!)
Take under DOT if possible

7B. Tetanus/Diphtheria (Td) Vaccination:

Dose	Timing	Protection	Uganda Schedule
Td1	First contact	0% (initiates series)	Give even if previous TTT
Td2	4 weeks after Td1	80% for 3 years	Must be during pregnancy
Td3	6 months after Td2	95% for 5 years	Give if time permits
Td4 & Td5	1-year intervals	Lifetime protection	Lifetime protection after 5 doses

⚠️ EXAM CRITICAL: Minimum 2 doses (Td1 & Td2) during pregnancy to protect newborn from neonatal tetanus!

7C. Deworming:

Mebendazole 500mg stat
Timing: After 1st trimester (13+ weeks)
Benefit: Reduces anemia from hookworm
Repeat: In 3rd trimester if community prevalence high

8. FANC vs GOAL-ORIENTED ANC - THE KEY DIFFERENCES

Feature	OLD FANC	NEW GOAL-ORIENTED
Total Visits	Minimum 4 visits	Minimum 8 contacts
Focus	Risk-based approach	Universal coverage + goals
First Visit	Up to 16 weeks	≤12 weeks (emphasize early booking)
Partner Involvement	Encouraged	Mandatory documentation
Birth Preparedness	General discussion	Detailed 5W1H plan documented
IPTp Doses	Minimum 2	Minimum 3 (monthly possible)
HIV Retest	Not routine	At 36 weeks per guidelines
ASB Screening	Not routine	At 34 weeks (gram stain)

📊 EXAM STRATEGY: Always specify "Goal-oriented ANC with 8 contacts" in answers! Examiners want to see you know the update!

9. RISK FACTORS REQUIRING MORE THAN 8 CONTACTS

High-Risk Conditions = Increased Surveillance:

⚠️ MNEMONIC: "HIGH RISK PREGNANCY NEEDS MORE CARE"
HIV positive (viral load monitoring)
Insulin-dependent diabetes
GH (Gestational Hypertension/Pre-eclampsia)
History of previous CS

Rh negative (antibody titers)
Infections (STIs, TB)
Sickle cell disease
Known fetal anomalies

Previous obstetric complications (PPH, inversion)
Recurrent APH
Elderly primigravida (>35 years)
Grand multiparity (≥5 births)
Non-cephalic presentation after 36 weeks
Anemia (Hb <8g/dL)
No fetal growth (IUGR)
Cholestasis, cardiac disease
Young mother (<18 years)

🚨 EXAM RULE: High-risk pregnancy = at least 12 contacts and more frequent monitoring!

🎯 Documentation - The ANC Card:

Tick all completed tasks: Labs, immunizations, interventions
Plot SFH: On graph from 24 weeks
Record danger signs taught: Mother signs to confirm understanding
Birth preparedness plan: Document the 5W1H details
Next appointment: Write date and what will be done
Partner involvement: Document if partner attended

🌍 UGANDA CONTEXT: Use the MOH ANC card (2022 version) with 8 contact columns. Old cards had only 4! Check facility has updated stationery.

10. THE "GOLDEN RULES" OF ANC

✨ MNEMONIC: "EVERY VISIT IS A LIFE-SAVING VISIT"
Educate on danger signs (every contact)
Vitals: BP, weight, SFH, FHR (every contact)
Examine abdomen (lie, presentation)
Review birth plan (third trimester)
Yield to problems - address all concerns

Vaccinate (Td as per schedule)
Investigate appropriately (labs per contact)
Supplement (FeSO4 & Folic acid daily)
Itch? Screen for STIs, hepatitis
Treat complications or REFER!

Involve partner (male engagement)
Save money (birth preparedness)
Advocate for facility delivery
Link to postpartum FP
Intervene for IPTp, deworming
Follow up on appointments
Encourage LLIN use every night
Visit 8 times minimum
Insist on early booking
Screen for IPV & support
Identify high-risk cases early
Transfer to hospital when needed!

💡 MASTER TIP: In exam questions, always mention: "According to Uganda's Goal-Oriented ANC guidelines (2022)..." Shows you're up-to-date!

LIKELY EXAM QUESTIONS FOR DAY 4

1. FILL-IN-THE-BLANK (2 marks)

According to Uganda's current guidelines, the minimum number of ANC contacts for an uncomplicated pregnancy is ______ and the first contact should be before ______ weeks.

ANSWER: 8 contacts, ≤12 weeks

2. MULTIPLE CHOICE (3 marks)

A 24-year-old woman at 22 weeks gestation comes for ANC. Which intervention is MOST appropriate at this contact?
A) Give IPTp #1
B) Perform anatomy ultrasound scan ⭐ CORRECT
C) Check Hb at 36 weeks
D) Repeat HIV test

EXPLANATION: 22 weeks is in the 21-28 week contact window - anatomy scan must be done BEFORE 24 weeks!

3. SHORT ANSWER (5 marks)

Outline the 5W1H components of a birth and emergency preparedness plan that should be documented during ANC.

ANSWER GUIDE: 1 mark for each W and H
• WHERE to deliver (facility)
• WHO to accompany
• WILL transport be available
• WHAT items to bring
• WHEN to go (signs)
• HOW much money needed
+ 1 mark for blood donor

4. PRACTICAL SCENARIO (10 marks)

A primigravida books at 14 weeks gestation at your HC III. Outline your management plan according to Goal-Oriented ANC guidelines.

ANSWER:
1. Document contact 1 & 2 combined (2 marks)
• Full history (LNMP, obstetric, medical)
• Physical exam (BP, weight, SFH, FHR)
• All baseline labs (Hb, HIV, Syphilis, Blood group, Urine)

2. Interventions (3 marks)
• Td1, FeSO4/Folic acid started
• Give LLIN
• Book for anatomy scan (20 weeks)

3. Health education (3 marks)
• Danger signs
• Birth preparedness
• Nutrition

4. Follow-up (2 marks)
• Next appointment 21-28 weeks
• IPTp #1 at 16 weeks
• Emphasize importance of completing all contacts

5. TRUE/FALSE (2 marks each)

a) IPTp should be started at the first ANC contact, regardless of gestational age.
b) HIV-positive pregnant women require at least 12 ANC contacts.
c) The anatomy scan can be done anytime before 28 weeks.

ANSWERS:
a) FALSE - Starts at 13 weeks (2nd trimester)
b) TRUE - High-risk = increased surveillance
c) FALSE - Must be before 24 weeks for anomalies detection

6. LIST QUESTION (8 marks)

List four investigations that must be done at first ANC contact and four that are done specifically in third trimester.

ANSWER:
First Contact: Hb, HIV, Syphilis, Blood group, Urine, Hepatitis B (any 4)
Third Trimester: Hb at 36w, HIV retest at 36w, ASB screen at 34w, Urine albumen (each visit)
MARKING: 1 mark per correct answer

📊 STATISTICS: ANC questions appear in 100% of midwifery exams! Goal-oriented protocols are the new focus. Master the contact schedule and interventions!

📚 DAY 4 SUMMARY: THE 8-CONTACT MODEL

🎯 The 8 Contacts in One Glance:

Contact	Timing	The "Must Do" Action
1	≤12 weeks	Confirm pregnancy, baseline labs, Td1, FeSO4
2	13-20 weeks	IPTp #1, anatomy scan (20w), Td2
3	21-28 weeks	IPTp #2, Hb at 26w, quickening confirmed
4	30 weeks	Growth check, BP monitoring, PIH watch
5	34 weeks	ASB screening, birth plan review, IPTp #3
6	36 weeks	Hb check, HIV retest, lie/presentation check
7	38 weeks	Final preparedness, Td3 if needed
8	40 weeks	Assess for labor, refer if 41 weeks

🎯 The 5 Non-Negotiables at EVERY Visit:

BP measurement - PIH can develop anytime
Urine testing - Proteinuria = danger sign
Weight & SFH - Detect FGR/macrosomia
Fetal Heart Rate - Confirm fetal wellbeing
Address problems - No concern is too small

🎯 The 3 Lifesaving Interventions:

IPTp: Prevents placental malaria & maternal anemia
Td: Prevents neonatal tetanus
FeSO4/Folic acid: Prevents maternal anemia & neural tube defects

⚠️ FINAL EXAM TIP: When asked about ANC, always state: "According to Uganda's Goal-Oriented ANC guidelines with 8 contacts minimum..." This shows current knowledge and gets full marks!

"Every ANC contact is an opportunity to save two lives. Be thorough, be compassionate, and remember - the mother is your partner in care!"

"I will praise You, for I am fearfully and wonderfully made." - Psalm 139:14