©moh-drh/domc/nltp/ jhpiego focused antenatal care (fanc) 1 what is fanc? is health care given to a...

©MOH-DRH/DOMC/NLTP/JHPIEGO

Focused Antenatal care (FANC)11

What is FANC?Is health care given to a pregnant woman from conception to

the onset of labour.It is personalised care provided to a pregnant woman which

emphasises on the woman’s overall health, her preparation for childbirth and readiness for complications (emergency preparedness).

It is timely, friendly, simple and safe service to a pregnant woman.


AIM OF FANC22

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


The approach:

33

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

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


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

44

1ST VISIT: <16 WEEKS

2ND VISIT: 16-28 WEEKS

3RD VISIT: 28-32 WEEKS

4TH VISIT:32-40 WEEKS

NB: DEPENDING ON INDIVIDUAL NEED, SOME WOMEN WILL REQUIRE ADDITIONAL VISITS.

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Four comprehensive, personalized antenatal visits:


Objectives of Focused Antenatal Care

66

Early detection and treatment of problems Prevention of complications using safe, simple and

cost-effective interventionsBirth preparedness and complication readinessHealth promotion using health messages and

counselingProvision of care by a skilled attendant


Objective one: Early detection and treatment of Problems77

Service providers should identify existing medical, surgical or obstetric conditions during pregnancy. Such as:– Severe anaemia (Hb <7gm/dl)– Vaginal bleeding– Pre-eclampsia (increased BP, severe oedema)– STI’s, HIV/AIDS, TB and Malaria– Chronic diseases (diabetes, heart or kidney problems)– Decreased/absent foetal movement; – foetal malpresentation after 36 weeks


Why disease detection and not risk assessment?

88

Risk approach is not an efficient or effective strategy for maternal mortality reduction.

Every pregnancy is at risk!

–Risk factors cannot predict complications: (e.g. young age does not predict eclampsia).

–Research showed that the majority of women who experienced complications were considered low risk (90% of women considered to be high risk, gave birth without experiencing a complication).


Why disease detection and not risk assessment cont…..

99

Risk factors do not predict problems. Most high risk women deliver without problems and most women who develop life-threatening complications belong to the low risk group.

Every pregnant woman should be prepared for the possibility of complications.


Objective two: Prevention of complications

1010

The service provider should ensure prevention/protection of complications by providing:

Tetanus toxoid to prevent maternal and neonatal tetanusIron/folate supplementation to prevent anaemiaUse of IPT and ITNS to prevent malaria/ anaemiaEnsure environmental hygiene to prevent intestinal wormsPresumptive treatment of hookworm infection with

Mebendazole 500mg STAT anytime after the first trimester**Basic Maternal and Newborn Care: A Guide to Skilled

Providers, Page 3-58


Objective three: Birth preparedness and complications readiness

1111Service providers should discuss components of birth plan which include:

Is the EDD known?Has a facility been identified?Has a SBA/professional been identified?Has a means of Transport been identified?Are emergency Funds identified?Who is the custodian of the emergency funds?Has a Birth companion been identified?Are Items for clean safe birth and for the newborn been

identified?


Objective three cont…Complication Readiness1212

Knowledge of danger signs; what to do if they arise

Has a decision maker been identified?Has a Blood donor been identified?


Individual birth plan ensures that the client:

1313

Knows when her baby is dueIdentifies a skilled birth attendantIdentifies a health facility for delivery/emergency Can list danger signs in pregnancy and delivery and

knows what to do if they occurIdentifies a decision-maker in case of emergencyKnows how to get money in case of emergency Has a transport plan in case of emergencyHas a birth partner/companion for the birthHas collected the basic supplies for the birth


Danger signs in pregnancy Any vaginal bleeding in pregnancy( APH,

Abortion)Severe headache or blurred vision (high blood

pressure, eclampsia)Swelling on the face and hands (high blood pressure,

eclampsia)Convulsions or fits (high blood pressure, eclampsia)High fever ( infection)Drainage of liqourLaboured breathing ( pneumonia, heart problems,

severe anemia) Premature labour painsNoticed that the baby is moving less or not moving

at all (fetal distress, IUD ). 1414


Other danger signs in pregnancy 1515Feeling very weak or tired (anemia, severe disease, multiple

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


Danger signs in labour:

1616

Labour pains for more than 12 hrs (sun rise to sunset)Excessive bleedingRuptured membranes without labour for more than 12 hrsConvulsions during labourLoss of consciousnessCord, arm or leg prolapse


Danger signs in postpartum period (Mother):

1717Excessive bleedingFeverFoul smelling dischargeAbdominal cramps or painsPainful breasts or cracked nipplesMental disturbancesExtreme fatigueFacial or hand swellingHeadachesConvulsionsPainful calf muscles


Danger signs in postpartum period

1818Fast breathing(more than 60 breaths/minute)Slow breathing less than 30 breaths/minuteSevere chest in-drawingGruntingUmbilicus draining pus/redness extending to skinFloppy or stiffFever (temp 38 degrees celsius and aboveConvulsionsMore than 10 skin pustulesBleeding from stump/cut


Give advice on whom to call or where to go in case of the above

complications/emergencies.

1919


Objective four: Health promotion using health messages and counseling 2020

NutritionRest and hygieneSafer sexCare for common

discomforts Use of IPT and

ITNs/LLINs

Drug complianceFamily planning/

health timing and spacing of pregnancy

Early and exclusive Breastfeeding

Newborn care

Encourage dialogue on the following: Encourage dialogue on the following:


Maintain the woman’s health and survival through:

2121

Health education and counselling on:Danger signs in pregnancyAdequate nutrition and hydrationEarly and exclusive breastfeedingPrevention and treatment of sexually transmitted infections

(STIs) and worm infestationAvoidance of alcohol and tobaccoIndividual Birth Plan (IBP)Complication readiness plan


To come to postpartum clinic :Immediately,48hours, 2 weeks, at 6 weeks,6months and one year. To visit well baby clinic (MCH/FP Clinic) for immunizations Follow up for exposed babies to TB and HIV. To chose a postpartum family planning method:- LAM (exclusive breastfeeding)- Progesterone only pills- Condoms- Post partum IUCD- feeding options

2222


Teach mothers about the importance of immunizations: 2323

Inform her about the first-year immunization schedule to protect children from TB, polio, tetanus, diphtheria, pertussis, hepatitis B and measles.

Immunize baby with BCG, HBV, OPV birth dose before the mother leaves the health facility.

Ensure all babies delivered at home are taken to the health facility for immunization.


National guidelines for IPT

2424

IPT is an effective approach to preventing malaria in pregnant women by giving anti malarial drugs in treatment doses at defined intervals after quickening to clear a presumed burden of parasites

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

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

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


National guidelines for Tetanus toxoid

2525Dose of TT

When to give

1 At first contact or as early as possible in pregnancy

2 At least 4 wks after TT1

3 At least 6 months after TT2 or during subsequent pregnancy

4 At least 1 yr after TT3 or during subsequent pregnancy

5 At least 1 yr after TT4 or during subsequent pregnancy


Objective 5: Provision of Skilled Care at Birth

2626Currently only 41% of pregnant women receive skilled care at birth

By 2015, it is expected that three quarters of pregnant women should receive skilled care at birth

A skilled attendant offers services either at the health facility or within the community (domiciliary practice)

FANC provides an opportunity to increase skilled careBrainstorm strategies in your catchment area in support of

increased skilled care


During FANC visits, ensure that the following have been accomplished

2727Provide: Iron, folate , IPT*(SP is the currently

recommended) tetanus toxoid and Nevirapine if recommended

Counselling on: Danger signs Individual birth plan (IBP) Complication readiness Nutrition, breastfeeding, family

planning, safer sex, hygiene, etc. PMTCT Return dateANC Profile Most of the lab work should be done

during the first visit Sputum for AFB Urinalysis Hb, grouping and Rh factor VDRL/RPR Sickle cell, Stool and Hepatitis B (if indicated)

History taking: Current complaints/identify danger

signs Dietary history Tetanus vaccination status Reproductive history History of medical illness e.g. TB

Physical exam: Physical assessment of general health Swollen glands Genital inspection, including sexually

transmitted infections Check for blood pressure, edema and

proteinuria to rule out pre-eclampsia Check for anaemia Check baby’s growth

MANY MEN ARE UNCERTAIN ABOUT HOW THEY CAN CONTRIBUTE TO A WOMAN’S HEALTHY PREGNANCY

2828

The role of fathers in antenatal care


Service providers should educate fathers about antenatal care2929

Fathers should make sure that the woman:– has enough nutritious food to eat and that she has taken iron and folate

tablets. – is sleeping under a treated net and is able to get plenty of rest. – has had 2 doses of SP and tetanus toxoid.

Make sure that the couple has an individual birth plan.

Make sure that the couple know the danger signs in pregnancy and labour.


Adolescents and pregnancy3030In Kenya, 17-18% of all births are to women under the age

of 20 years*Pregnant youth are entitled to the same quality of care that

older women areResearch has shown that adolescents tend to delay seeking

care due to social and cultural practices and as such more attention should be directed to them

Services should be provided in an acceptable, non-judgmental manner, convenient and offer confidentiality to the adolescents.

Note: This will encourage the young women to return for continued antenatal services.

*KDHS 1998/2003


Reinforce counseling to the adolescents /youth on.. 3131

Peer influence Early ANC attendance Safer sex (ABCD)Drug abuseSTI, HIV/AIDS/TBFamily PlanningDangers of abortion


Before the woman leaves your clinic, STOP and ask her if she:

Has a supply of iron and folate tablets.Has taken her SP and has had her tetanus toxoid

injection.Knows the danger signs in pregnancy and child

birth.Knows her appointment for the next ANC visit

and SP dose.Has an individual birth plan.Has been screened for TBKnows the importance of using postpartum

family planning. 3232

3333

Integrated FANC ServicesIntegrated FANC Services

CCCCCC

PMTCTPMTCT

TBTBFANCFANC

STIsSTIs

LABLAB MALARIAMALARIA


What is Tuberculosis (TB)? 3434Tuberculosis is a chronic infectious disease caused by an organism

called mycobacterium tuberculosis, an acid fast rod shaped bacilli.– Over 90% of new TB cases and deaths occur in developing countries

TB is one of the leading infections causing of deaths among women of reproductive age

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


Factors leading to the increase in TB 3535

HIV epidemic PovertyOvercrowdingPoor nutrition Limited access to health servicesChronic diseases e.g. Diabetes,

carcinoma etcImmune suppressing therapy


Risk of TB infection

3636

The risk of one being infected with the TB bacillus depends on:Exposure to bacilliIntensity of exposureDuration of exposurePresence of undetected smear positive TBPresence of poorly treated previous TB


Types of Tuberculosis

3737Pulmonary Tuberculosis (PTB) is the most common and infectious type of TB.– It affects the lungs and causes 81% of all TB cases in Kenya

• Extra Pulmonary Tuberculosis (outside of the lungs) any organ of the body such as the kidney, bladder, ovaries, testes, eyes, bones or joints, intestines, skin or glands, and the meninges i.e. TB meningitis

– The most common extra pulmonary TB is TB of the glands also called TB lymphadenitis

– The most severe extra pulmonary TB is pleural effusion and meningitis.


Signs and Symptoms of Pulmonary Tuberculosis (PTB)3838

Persistent cough lasting for two or more weeks with or without blood stained sputum

Loss of body weightIntermittent feverExcessive night sweatsShortness of breathLoss of appetite Chest painExcessive tiredness and generally feeling unwell


Signs and symptoms of TB of the glands (TB lymphadenitis*) 3939

Slow and painless enlargement of the lymph nodes which then become matted and eventually discharge pus

The most common lymph nodes: cervical (neck) lymph nodes

Generalised lymph node enlargement is becoming common in HIV related TB

*Confirmed during head-to-toe examination


When does TB pass from the mother to the baby?4040

Pregnant women who are infected with TB can pass TB to the baby:

During pregnancy through the placenta barrier causing fetal death or infection (congenital TB is rare)

At birth when the baby inhales or ingests infected amniotic fluid or secretions

After delivery when the baby inhales droplet secretions if the mother is coughing-commonest


TB affects the health of a pregnant woman and her baby 4141

TB in a pregnant woman can lead to:Premature birth of the babyLow birth weight or small baby for datesDeath of baby in the uterusInfecting the baby with TBIncreased newborn deaths


Screening for TB

4242Ask every mother at every ANC/PNC visit the

following questions:

symptom YES

NO

1. Have you had a persistent cough with or without sputum for more than two weeks?

2. Have you experienced excessive sweating or fever at night?

3. Have you lost any weight?

4. Do you have any chest pain?

5. Have you been in contact with any one who has TB?

6. Do you have any swollen glands?(Confirm during physical examination)


Investigations4343

Smear positive TB cases are the most infectious both to the new born and other children in the household

These are diagnosed through sputum examinationSmear negative cases and Extra-pulmonary are diagnosed

through history, physical examination, radiography and histology


Why integration…TB/FANC

4444Since the onset of the HIV epidemic in the early

eighties in Kenya, the prevalence of TB has risen sharply

HIV increases the likelihood of developing tuberculosis

Pregnancy also increases the risk of developing TB TB is the major opportunistic infection in HIV and the

leading killer of PLWHAMore than 50% of TB clients in Kenya are also HIV

positiveAt least one out of eight of HIV+ pregnant women

could also have TB**USAID Bureau for Africa, 2000

4545

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

Ensures that women receive targeted care according to their needs with appropriate linkages and referral structures are in place

Involves the reorganization and re-orientation of health systems to ensure the delivery of a set of interventions or targeted package as part of the continuum of care

Involves integrated procurement of commodities

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Integration addresses structural , managerial and operational issues at all levels of the health system in order to:

Create effective coordination mechanisms between departments, programs and other stakeholders

Support integrated training and capacity planning, management and joint supervision

Harmonize efforts to support targeted service delivery


Intensified TB case finding in FANC4747

All pregnant women should be screened for TB

Pregnant women suspected to have TB should have their sputum collected and tested for TB

Pregnant women found to have TB should be referred to the TB clinic for treatment

NB: Negative Sputum result does not exclude TB!


Symptoms of TB ?4848

C (Coughing)W (Weight loss)F (Fever)N (Night sweats)G (enlarged

Glands)

—


Refer to Lab:

4949

If the pregnant woman has a cough for two weeks or more, explain that three specimens of her sputum must be collected to help confirm the presence or absence of TB

Explain that testing and treatment for TB is free


Collection of sputum specimen: laboratory 5050

Ask the pregnant woman to cough deeply to produce sputum in an open place

Ensure that nobody is standing nearby during the cough

Avoid contaminating the outside of the container with sputum

Ensure that an adequate amount of sputum is collected in the specimen pot


PTB confirmation is based on 3 sputum specimens collected within a 24-hour period5151

3 specimens are collected and examined by direct smear for acid fast bacilli (AFB)

“Spot” refers to a specimen obtained right there in the clinic

The process goes: SMS

SpotMorning plusSpot

#1 specimen at the lab, or “on the spot”

Provide container for next day home collection

#2 early morning the following day client brings to Lab

#3 specimen “spot” at the Lab right after she drops off the one from home


Refer to TB clinic:

5252

Explain that TB can be treated over a 6-8 month period and the drugs are safe to use during pregnancy and breastfeeding

If the sputum is positive – Send the woman to the TB clinic directly– Document the positive results in the register

If the sputum is negative, but the woman is symptomatic, send her to the TB clinic anyway– Note: Negative smear test for TB does NOT exclude TB– Explain that after delivery, barrier methods of family planning are necessary

as some TB drugs interfere with the absorption of hormonal contraceptives.


TB treatment

5353

If a pregnant woman is confirmed to have TB the treatment will last 6-8 months :

Intensive phase (2 months): – Ethambutol (E) , Rifampicin ( R ), Isoniazid (H) and Pyrazinamide (Z)

Continuation phase (4-6 months)*– Rifampicin (R) and Isoniazid (H) (4 months)– Ethambutol (E) and Isoniazid (H) (6 Months)

For pregnant women who are HIV+ and also have TB, the TB treatment should be continued and client referred to the CCC

All co-infected patients HIV and TB should be started on cotrimoxazole prophylaxis as it reduces mortality

*Which regimen are you using in your district


What is DOT5454

DOT: Directly Observed TreatmentInitial Phase: the first two months of TB treatment should

be administered under direct observation of either a health worker in the facility or a member of the household or community

If client is too sick or observed treatment not possible the client should be admitted to hospital

Continuation phase: the client collects a supply four weekly for daily self administration at home.


What can be done to support TB control5555

Adhere to the national TB control program guidelines for case detection, definition and management.

Provide health education for the community. Encourage symptomatic women to come for TB testing and

treatment.Provide counseling support so that they will complete their

treatment.Develop a system for supervising community health workers

assisting health care providers to track and monitor treatment compliance.

Keep accurate records.


Follow-up visits:

5656

At each subsequent FANC visit the HCW inquires about TB treatment progress, looks for TB clinic information and documents, updates in the register

Continue follow-up into the post natal period


At the post partum visit

5757

Ask the postpartum mother if contact invitation has been initiated

Ask if newborn and others have been assessed and treated for TB

Is she still taking medications?Document information in recordExplain that barrier methods of family planning are

necessary as some TB drugs interfere with the absorption of hormonal contraceptives


TB and the newborn5858If a mother has TB and has started treatment 2 months or more

before the due date, she should have 2 sputum smear tests done before the birth.

If she is sputum smear negative just before delivery then she is non-infectious and the infant does not need prophylaxis and BCG is given at birth

If she is sputum smear positive then the newborn must receive daily isoniazid (5mg/kg) for 3 months and if the mothers sputum is negative and mantoux test is non reactive (<5mm) then isoniazid should be stopped and BCG given (3 days after prophylaxis treatment has stopped)


TB and newborn/child care

5959

If the Mantoux test is reactive (>5mm) after 3 months on Isoniazid, then Isoniazid should be continued for another 3 months

Breast feeding women on INH should also include diet rich in Vitamin B6

Any other child under five years old living in the same household must also be given isoniazid prophylaxis if mother is smear positive and child does not have active TB INH given for 6 months


Integrated care model for pregnant woman6060

Integrated FANC Clinic

PMTCT/ other interventions e.g. MIP

Laboratory TB ClinicReferral 2

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PMTCT/ other interventions e.g. MIP

Laboratory TB ClinicReferral 2

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Interacting drug

TB Drug Effect of interaction Management recommendation

Streptomycin In pregnancy it causes deafness to the unborn baby

Avoid in pregnancy

Nevirapine Rifampicin Lowers blood levels of Nevirapine

Refer to/Consult CCC

Drug Interactions


Caution

6262

If a client is on Anti-TB drugs, anti-convulsants and/or antiretrovirals, the interactions between these drugs and hormonal contraceptives may lower the effectiveness of the latter. Barrier methods are preferred


Treatment:

6363

The following drug regimens are used in Kenya:

1. For new TB case(Previously untreated):- 2RHZE/4RH

2. For retreatment TB cases- 3RHZE/5RHE

NB: R – Rifampicin

H – Isoniazid

Z – Pyrazinamide

E - Ethambutol


THANK YOU!

6464

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