Maternal Care Package

i
Maternal Care Package

A Guide to
Field Healthcare Workers
Family Health Bureau

Ministry of Health
2011
ii
1st Edition
October 2011
ISBN : 978-955-1503-07-9
Draft adaptation and writing by:

Dr. Nilmini Hemachandra
Consultant Community Physician
National Programme Manager Maternal Care
Family Health Bureau,
Ministry of Health
Sri Lanka
Printed by:
New Karunadhara Press,
97, Maligakanda Road,
Colombo 10
Published by:
Ministry of Health
Sri Lanka
Sponsored by:
World Health Organization
Sri Lanka
iii
RESOURCE PERSONS
Resource Persons:
Dr.Deepthi Perera
Dr.C. de Silva
Dr.Nilmini Hemachandra
Dr.Dammica Rowel
Dr.Kapila Jayaratne
Dr.Nethanjalee Mapitigama
Dr.Loshan Moonasinghe
Dr.Nirosha Lansakara
Dr.Udaya Usgodaarachchi
Dr.Sarath Amarasekara
Dr.Sarath Samarathunga
Dr.Gamini Perera
Dr.Hemantha Perera
Prof. Hemantha Senanayake
Prof.Harsha Seneviratne
Prof.Chandrika Wijeratne
Dr.Lakshman Senanayake
Dr.Athula Kaluarachchi
Dr.Sujatha Samarakoon
Dr.Renuka Jayatissa
Dr.Anoma Jayathilaka
Dr.Deepika Attygalle
Dr.Nishamanie Karawita
Dr.Nilani Fernando
Dr.Daya Wattearachchi
Dr.Badrika Gunawardena
Dr.Lalitha Ratnayake
Dr.Sapumal Danapala
Dr.Sarath Warusavithana
Dr.Priyankara Jayawardena
Dr.Uditha Bulugahapitiya
Dr. Prasad Katulanda
Dr.Rabindra Abeysinghe
Dr.Sudath Pieris
Dr. S de Alwis
Mrs. D. Ubeywarna
Dr.Hasitha Aluthge
Dr.Dumithra Kahangamage
Dr. Shanika Senanayake
Mrs.K.A. Sunethra
Mrs.Nalika Weeraratne
Editing
Dr. Anoma Jayathilake
Dr. Dhammica Rowel
Dr. Shanika Senanayake
Director /Family Health Bureau

Deputy Director /Family Health Bureau
Consultant Community Physician / FHB
Consultant Community Physician/ FHB
Consultant Community physician/ FHB
Consultant Community physician/ FHB
Consultant community Physician/ FHB
Consultant Community Physician/ FHB
Consultant Community Dental Surgeon/ FHB
Consultant Obstetrician and Gynaecologist / SLCOG
Consultant Obstetrician and Gynaecologist/ SLCOG
Prof.of Obstetrics and Gynaecology,Faculty of Medicine, Colombo
Prof.of Obstetrics and Gynaecology,Faculty of Medicine,Colombo
Prof.of Reprodutive Health, Faculty of Medicine, Colombo
Consultant Obstetrician and Gynaecologist
Consultant Obstetrician and Gynaecologist, Faculty of Medicine-Colombo
Consulatnt Venereologist, NSACP
Nutritionist, MRI
National Professional Officer,World Health Organization
Nutrition Specialist, UNICEF
National Health officer, UNICEF
Deputy RDHS Kandy
Medical Officer /Maternal and Child Health Rathnapura
Medical Officer of Health- Piliyandala
Medical Officer of Health - Piliyandala
Consultant Community Physician - Central Province
Medical Officer of Maternal and Child health Matara
Consultant Physician Castle Street Hospital for Women
Consultant Endocrinologist
Consultant Physician,NHSL
Consultant Community Physician, Anti Malaria Campaign
Consultant Epidemiologist, Epidemiology Unit, Ministry of Health
Director, National Respiratory and Chest Disease Control Programme
Director/Nursing (PHS)
MOH, Deraniyagala
MOH ,Padukka
Medical Officer Family Health Bureau
PHNS ,Thihagoda MOH area
PHNS, Pelmadulla MOH area
National Professional Officer, WHO

Consultant Community Physician, FHB
Consultant Community Physician, FHB
Medical Officer, FHB
iv
CONTENT
Preface
Acknowledgement
List of Abbreviations
1. Introduction
2. Basic principles of maternal and newborn health interventions
3. Maternal care models in Sri Lanka
4. Antenatal care at the clinic
5. Management of risk conditions at field level
6. Domiciliary care for low risk pregnancies
7. Domiciliary care for high risk pregnancies
8. Developing a birth and emergency plan
9. Antenatal classes
10. Clinical procedures for antenatal care
10.1 Anthropometric assessment of pregnant women
10.2 Measuring blood pressure at the clinic setting
10.3 Obstetric examination
10.4 Fetal movement chart or kick count chart
10.5 Urine testing at the clinic setting
10.6 Antenatal screening for syphilis: Guidelines for sample collection,
storage and transportation
10.7 Estimating Haemoglobin levels using a colour scale
11. Nutrition during pregnancy and lactation
12. Common discomforts during pregnancy
13. National guidelines for prevention and control of maternal anaemia
14. Management of high blood pressure during pregnancy at field level
15. Guidelines on immunization against tetanus
16. Guideline on screening and management of diabetes mellitus during
pregnancy in the field /non specialized institutions
17. Prevention of mother to child transmission of HIV infection (PMTCT)
18. Elimination of congenital syphilis (ECS)
19. Syndromic management of sexually transmitted infections during pregnancy
20. National guidelines for prevention and management of Malaria in pregnancy
21. Management of Tuberculosis during pregnancy
22. Postnatal Care
23. Postnatal Clinic
24. Family planning after delivery
25. Screening for postpartum depression
26. Management information system of maternal care
27. Surveillance on maternal morbidity and mortality
28. Supervision of maternal care services
29 Planning of domiciliary care for pregnant and partum women
List of References
vi
vii
ix
xi
01
07
13
19
41
46
54
65
68
71
75
76
80
81
83
84
85
91
100
106
107
110
114
127
135
145
147
155
170
172
173
175
176
191
213
215
vii
PREFACE
Pregnancy is the most wonderful physiological phenomenon which is responsible for the existence of
mankind within the universe, though it creates a high risk environment for a womans life. With
development of the discipline of obstetrics and the health systems, the threat to life has been
minimized and the world has achieved a lot in maternal and child health.
Sri Lanka, although a developing country, has been able to achieve remarkable health indices such as
low maternal mortality rate, infant mortality rate, under five mortality rate, higher level of life
expectancy due to the tireless efforts of many stakeholders over the last few decades. The foundation
for these achievements are the policy of free education and free health services for the entire nation,
commitment by all levels of medical and other related professional personnel and the existence of a
strong preventive and curative health infrastructure.
Provision of comprehensive maternal, family planning, and child care services through a wellorganized structure at institutional and community level, implementation of evidence based
interventions integrated as packages, use of professionally trained health personnel at the community
level from the inception of the national MCH/FP programme are the major contributors for the
success.
Although our targets in most aspect of the MCH has been achieved, still some gaps can be
identified in certain areas such as postnatal care, quality of care and geographical disparity in some
indices. Further, some indices such as IMR, MMR, Low birth weight rate have shown slow decline
during the past decade.
To overcome these gaps and challenges, we need to focus more on targeted interventions, equitable
service provision and quality of care. Therefore, this guide was developed by a group of experts in
the relevant fields considering existing maternal care model and intervention packages, evidence
based interventions, recommendations given by the external review of the Maternal and Newborn
care programme (2007), National Maternal Mortality Reviews, MCH reviews and the felt need of the
relevant experts for the betterment of the maternal care programme in the country.
We strongly recommend this book as a guide for the health workers who provide maternal and
newborn care in the country and as a hand book for medical, nursing and midwifery students.
Dr. Ajith Mendis

Director General of Health Services
Ministry of Health
Sri Lanka.
Dr. Deepthi Perera

Director/ Maternal and Child Health
Ministry of Health
Sri Lanka.
viii
ix
ACKNOWLEDGEMENT
This guide is an outcome of the efforts of many people. Dr. L. Siyambalagoda, Deputy Director
General (Public Health Services), Dr. Deepthi Perera, Director/ Maternal and Child Health, Family
Health Bureau and Dr. Chitramalee de Silva, Deputy Director/ Maternal and Child Health, Family
Health Bureau guided us to develop this guide providing their fullest support and guidance.
Dr. Sarath Amarasekara (president /2010), Dr.Ananda Ranathunga, (President/2011), and other
members of the Sri Lanka College of Obstetricians and Gynaecologists provided us with their
technical expertise and cooperation during the development of this guide and pilot testing of the
revised maternal care model. Our gratitude is conveyed to SLCOG.
We would like to appreciate the contribution of Consultant Community Physicians at the Family
Health Bureau with their technical expertise in their fields and constructive criticism. We would
acknowledge all the Medical Officers (Maternal and Child Health), Medical Officers of Health,
Public Health Nursing Sisters, Supervising Public Health Midwives and Public Health Midwives
who contributed for the development of this guide in various ways.
We would like to appreciate the contribution of the Public Health teams of Ratnapura and Kandy
districts for the pilot testing of the maternal care package and their contribution to fine tune this. We
would like to acknowledge and appreciate the contribution of Dr. Anoma Jayathilake as a public
health specialist in the field of maternal care for the success of this endures.
Financial support received from UNICEF for consultative meetings during the process of
development of this package is highly appreciated. Our sincere gratitude is conveyed to the World
Health Organization Country Office for the guidance and financial support received, for pilot testing
scaling up and printing of this document in all three languages.

National Programme manager Maternal care
Ministry of Health,
Sri Lanka.
xi
LIST OF ABBREVIATIONS
AIDS
Acquired Immune Deficiency Syndrome
MOMCH Medical Officer-Maternal & Child

Health
MSD
Medical Supplies Division
MTCT
Mother To Child Transmission
NCD
Non Communicable Disease
NICU
Neonatal Intensive Care Unit
NMMR
National Maternal Mortality Review
NSACP
National STD/AIDS Control
Program
OCP
Oral contraceptive Pills
OGTT
Oral Glucose Tolerance Test
AMC
ANC
APH
ART
BF
BMI
Anti Malaria Campaign

Antenatal Care
Antepartum Haemorrhage
Anti retro viral treatment
Breast Feeding
Body Mass Index
BP
CEmOC
CHDR
Blood Pressure
Comprehensive Emergency Obstetric
Care
Child Health Development Record
CS
CSB
DMMR
EBF
ECCD
EDD
EmOC
Congenital Syphilis
Corn Soya Blend
District Maternal Mortality Review
Exclusive Breast Feeding
Early Childhood Care & Development
Expected Date of Delivery
Emergency Obstetric Care
PHI
PHM
PHNS
PID
PIH
PLHIV
PMTCT
EPI
FHB
FHS
FM
GBV
GDM
Hb
HEO
HIV
IUD
IUGR
IVF
JMO
Expanded Programme of Immunization

Fetal Heart Sounds
Fetal Movements
Gender Based Violence
Gestational Diabetes Mellitus
Haemoglobin
Health Education Officer
Human Immunodeficiency Syndrome
Intra Uterine Device
Intra Uterine Growth Retardation
In Vitro Fertilization
Judicial Medical Officer
POA
PPBS
PPH
RDHS
SCBU
SFH
SMI
SPHM
STD
TB
TT
USS
VDRL
JVP
KCC
LRM
LRT
LSCS
MO
MO/STD
MOH
Jugular Venous Pressure

Kick Count Chart
Last Regular Menstruation
Ligation and Resection of Tubes
Lower Segment Cesarean Section
Medical Officer
Medical Officer/STD clinic
Medical Officer of Health
PDHS
xii
Provincial Director of Health

Services
Public Health Inspector
Public Health Midwife
Public Health Nursing Sister
Pelvic Inflammatory Disease
Pregnancy Induced Hypertension
People Living with HIV
Prevention of Mother To Child
Transmission of HIV
Period of Amenorrhoea
Post Prandial Blood Sugar
Postpartum Haemorrhage
Regional Director of Health services
Special Baby Care Unit
Symphysio- Fundal height
School Medical Inspection
Supervising Public Health Midwife
Sexually Transmitted Diseases
Tuberculosis
Tetanus Toxoid
Ultra Sound Scan
Venereal Disease Reference
Laboratory
xiii
Maternal Care Package A Guide to Field Healthcare Workers
Chapter 01
INTRODUCTION
Development of maternal care services in Sri Lanka

The history of health care systems in Sri Lanka is extended to kings era. The documentary evidence
says that there were several hospitals for indigenous medicine and maternity homes for child birth
existed during the reign of the Sinhalese kings as early as 340-368 AD. The expectant mothers were
made to move into these homes in the ninth month of pregnancy and stay there till child birth. Most
mothers delivered in the few maternity homes that were available or in their homes under the care of
experienced birth attendants.
Around the 15th century, a systematized network of Ayurvedhic treatment centers and hospitals
throughout the country was established and Ayurvedhic Physicians were trained to work in these
treatment centers. This resulted in gradual diffusion of health care within the country. The
documentary evidence in the history of ancient Ceylon stated that separate hospitals existed for
women under the Ayurvedic System of Medicine where deliveries have been conducted.
Sri Lanka came under the colonial rule in1505 and was successively under the Dutch, Portuguese
and the British till achieving independence in 1948. During this period, the Western System of
medicine was introduced and hospitals were built to provide medical care. In 1859, a separate Civil
Medical Department was established and public health became a function of this department.
The first organized effort towards care of the childbearing woman was made in 1879 with the
opening of the De Soysa Lying- in- Home now known as the De Soysa Hospital for Women. This
was built by a philanthropist (Sir Charles Henry De Soysa) to provide a home for lying-in-mothers as
well as to provide out-patient care to mothers and children. This was probably the first maternity
hospital to be established in Asia and soon afterwards the first training school for midwives was
opened at this maternity hospital in 1881. In 1887, Legislation for registration of midwives was
introduced which made it mandatory for all midwives to be registered prior to practicing midwifery.
This was a great step taken towards development of maternal care services since it enhanced the
quality of midwifery services provided in Sri Lanka.
In 1902, a maternal and child health department was created with in the Colombo Municipality
following an investigation into the high rate of infant mortality within the Municipality. In 1906, a
system of field maternal services commenced within the Colombo Municipality with the
appointment of six midwives. This was followed by the appointment of two health visitors in 1913.
The MCH services were thereafter gradually expanded.
The first antenatal clinic was started at the De Soysa Lying-in-home in 1921 following the
commencement of Antenatal Clinics in Boston, USA in 1911, Sydney in 1912 and Edinburgh in
1915.
The need for developing the preventive and promotive services was recognized by the government as
early as 1920. In the mid 1920s steps were taken to introduce a Health Unit System which could
provide a comprehensive health care service (institutional and domiciliary) to mothers and children.
1
This scheme was to provide domiciliary as well as clinic based services to mothers during pregnancy
and postpartum period and, trained assistance at delivery by encouraging mothers to deliver in
medical institutions or provide trained assistance in the case of home deliveries. The first Health Unit
was established in 1926 at Kalutara and trained Public Health staff (Public Health Midwives and
Nurses) were appointed to provide the necessary services. This scheme was thereafter extended to
other areas and by 1936, eight Health Units were established within the country.
Until 1926, the midwives functioned only in the hospitals and their training was only hospital based.
With the establishment of the Health Unit System, the Midwives were given one month field training
in public health midwifery and appointed to the Health Units as Public Health Midwives. After 1938,
the PHMs training was more systematized with the use of appropriate circular and the field training
was extended to six months.
Training of Public Health Nurses (PHNs) commenced in 1928 and consisted of six months training
in midwifery and six months in public health. Since 1980, training in the public health for nurses
conducted at the National Institute of Health Sciences (NIHS) was extended to one year, after which
a Diploma in Public Health Nursing was awarded. This category is now designated as Public Health
Nursing Sisters.
Formal training for Medical Officers of Health commenced in 1936 and is of one months duration.
This facilitated the effective implementation of the Health Unit System.
The control measures adopted following the Malaria epidemic of 1935, led to further expansion of
the Health Unit System. The maternal and child health infrastructure, which originated with the
Health Unit Systems, was linked to the expanding malaria control programme and the medical
officers recruited for malaria control provided MCH services at the health centres in addition to their
normal malaria control activities.
The Government policy in the early 1930s enunciated the need for diffusion of health services
throughout the country. After the granting of Universal Franchise in 1931, there was political
demand for expansion of health services in rural areas. A large number of maternity homes, rural
hospitals and cottage hospitals were constructed and the staff in these medical institutions was
trained in care of the mother and child. The number of Health Units, which was eight in1936,
increased to ninety-one by 1950. Currently there are more than 300 Health Units in the country.
The government provided health care free of charge making health services accessible to the poorest
segments of the population. The introduction of the free education system in 1941 led to an increase
in literacy, which helped in increasing the level of health consciousness and greater utilization of
health facilities.
The number of medical institutions with facilities for delivery increased from 141 in 1941 to 521 in
2000. Also the number of health centres increased from 600 in1948 to about 3200 in 2000.
Similarly availability of trained health man power has shown a marked increase since 1940s.
Trained midwives increased from 347 in 1941 to 8741 in 2009 and the Public Health Nurses (now
called Public Health Nursing Sisters) increased from 41 in 1948 to 254 in 2009.
Since independence in 1948, a more concerted effort was made to provide a comprehensive service
to mothers and children throughout the country. The MCH services were extended to the rural areas
in an effort to make the service availability more equitable. The second maternity hospital in
Colombo (Castle Street Maternity Hospital) with accommodation for 144 patients was opened in
2
1950. Thereafter, an increasing number of maternity beds and specialist services were provided to
the Provincial and Base Hospitals with blood transfusion facilities extended to these hospitals.
The policies of Sri Lanka in the early years after independence reflected little concern over the high
growth rate (31 per 1000) that prevailed during that period. The first organized effort for introducing
family planning was made in 1953 with the founding of the Family Planning Association (FPA) of
Ceylon. The activities of the Association were focused on family welfare with a view to reducing
maternal mortality, infant mortality and malnutrition and were mainly centered within and around
Colombo. The work done by the Association was recognized when the government provided a
financial grant in 1954.
Realizing the importance of family planning, in 1958 the government entered into a bilateral
agreement with the Royal Government of Sweden to study communitys attitude toward family
planning and its acceptance by the people. Under this agreement, training programmes for doctors,
nurses and midwives were started and two pilot projects were conducted in community family
planning. The results of this project were encouraging. In the pilot areas, the crude birth rate showed
a promising decline and an increase in positive attitudes towards family planning was seen within the
community. The activities of the Swedish project during 1958 1965 period demonstrated that
family planning can be successfully integrated into the MCH services without any great increase in
personnel or expenditure.
Based on the above experiences, the government accepted family planning as national policy in 1965
and decided to integrate family planning services with the already well-established Maternal and
Child Health services provided through the Ministry of Health. This procedure was adventurous
since the personnel and the infrastructure of an already wellorganized system could be made use of
without any additional cost and also family planning could be introduced as an integral part of the
maternal health package offered by the system. Considering its national importance, a separate
division, the Family Planning Bureau which was later re-designated as Maternal and Child Health
Bureau was set up in 1968 within the Ministry with an Assistant Director MCH responsible for
implementation of the programme throughout the country. This Bureau was given the task to plan,
operate, supervise and evaluate the family planning programme within the country.
The period 1966 to 1968 could be regarded as an introductory phase where establishment of family
planning clinics, training of relevant health personnel and administrative strengthening of the
Ministry of Health laid the foundation for the expected expansion and intensification of the
programme.
In 1970, the government made a positive statement towards family planning. It stated that though
family planning would not be a solution to the economic ills of the country, nevertheless family
planning facilities should be made available on a more intensified scale. In the national five year
plan of 1971, family planning received due importance and a statement was made emphasizing that
family planning should be made available to all groups and not be confined to the privileged section
of society. This provided the necessary political endorsement and support from the government for
family planning, though some groups still resisted the idea.
In 1972, 100 pilot projects were started, one in each MOH area to try out a coordinated approach to
maternal care, family planning, child care including nutrition and immunization, health education
etc. Based on the experience gained, the MCH/FP programme received a new dimension with a more
comprehensive approach towards the family. The Bureau was re-designated the Family Health
3
Bureau in 1973 and the programme was named Family Health so that this would provide a more
comprehensive service to the mother and child. Thereafter maternal and child health services
received greater emphasis and were given priority in the overall health development plan. This led to
more concerted effort to strengthen the service infrastructure to provide an efficient family health
service through out the country. The government sought the assistance of International Organization
to financially support the implementation of services within the country.
The Family Health Bureau was made the central organization of the Ministry of Health responsible
for planning, promoting, coordinating, monitoring and evaluating family health activities. Following
a revision of the MCH information system in1985, the Family Health Bureau was entrusted the task
of collecting, processing and analyzing MCH data from the Health Units
Maternal death investigations were conducted from the early 1950 s, but were actively implemented
in the mid 1980s when instructions were given to investigate and report all maternal deaths
occurring in the medical institutions and in the field (community) including those in the plantation
sector. These were thereafter reviewed at the district and national levels by the respective health
authorities. Any corrective measures needed to overcome problems and constraints were taken to
prevent such deaths in the future. This system was further strengthened in 1989 when maternal
deaths were made a notifiable event and clear guidelines on the procedure for investigation were
issued to all hospitals and health units.
Since the International Conference on Population and Development in Cario in 1994, the concept of
reproductive health has been introduced which addresses reproductive health issues of the
adolescents, young adults, married couples, and women even after menopause thus providing a life
cycle approach to family health care. Some of the reproductive health issues that have received
emphasis in the programme are RH problems in the adolescents, early identification of reproductive
health organ malignancies, prevention of reproductive tract infections including sexually transmitted
diseases / HIV-AIDS, concept of womens empowerment and male involvement in RH activities.
Services in respect of sexually transmitted diseases and HIV/AIDS are provided through the National
STD Control Programme (NSACP). The Family Health Bureau in collaboration with the National
Cancer Control Programme (NCCP) has introduced in 1995 a screening programme for reproductive
organ malignancies and certain other conditions. Under this programme Well Womens Clinics
have been established in all Health Unit areas conducted by trained medical officers. Women over 35
years of age could be screened for such as hypertension, diabetes, breast malignancies and cervical
cancers. If any abnormality is detected clients are referred to the health care system for necessary
management. The PHM of the area is responsible for follow up of cases in the field and provides
necessary advice and guidance thereafter.
Tenth anniversary of Safe motherhood concept which was held in Sri Lanka in 1997 was an appraisal
of maternal health program in Sri Lanka.
Institutional Framework for Providing Maternal Care

Maternal, child health and family planning services are provided through the well-developed health
infrastructure of the Ministry of Health, which has grown steadily over the past few decades. The
services are provided through a net of work of Medical Institutions comprising major hospitals with
specialist services (Teaching, Provincial and Base hospitals), Divisional Hospitals, and central
4
dispensaries and Maternity homes. The institutional network is closely linked to a system of Health
Units, which are primarily responsible for providing preventive and promotive health care to the
community.
Since 1989, the countrys administration was decentralized with devolution of administrative powers
to the Provincial Councils. Each province has a Provincial Director of Health Services (PDHS) who
is responsible for total health care within the province. He is supported by a Regional Director of
Health Services (RDHS) who is in charge of a Health District. RDHS is supported by a team
comprising a Medical Officer MCH (MO.MCH), Regional Epidemiologist (RE), Regional
Supervising Public Health Nursing Officer (RSPHNO), 2-3 Health Education Officers, a Statistical
Survey Officer (SSO) and a Programme Planning Officer (PPO). Each Health District is further subdivided into Health Divisions (7-15) consisting of Health Units and a network of medical institutions
of different categories.
The Health Units have a clearly defined area, which is congruent with the administrative divisions
of the country. It is managed by a Medical Officer of Health (MOH). He is supported by a team of
public health personnel comprising of one or two Public Health Nursing Sisters (PHNS), Supervising
Public Health Inspector (SPHI), few Supervising Public Health Midwives (SPHM), 20 25 Public
Health Midwives (PHM s) and 5-6 Public Health Inspectors (PHI).
Public Health Midwife area (PHM areas) is the smallest working unit in the government health
system. The PHM is the front line health worker for providing domiciliary MCH/FP services in the
community. Each PHM has a well defined area consisting of a population ranging from 2000-4000.
Though systematic home visits, the Public Health Midwife provides care to pregnant women, infants
and pre-school children and family planning services to couples in the reproductive age within her
area. In case of necessity, she provides trained assistance during home deliveries when called by the
community. She also provides necessary education and advice to adolescents on RH where needed
and educates women on the importance of screening for reproductive organ malignancies thus
motivating them to attend the well women clinics for necessary check up. She also assists at the
area MCH/FP clinics, which are conducted fortnightly, linking the community with the institutional
health system. Her activities are supported by a system of record keeping which enables her tot plan
and monitor her routine activities. Her work is regularly supervised by the Supervising Public Health
Midwife, Public Health Nursing sister and the MOH of the area.
Higher Level Health Institutions; Teaching Hospitals, Provincial General Hospitals, District General
Hospitals and Base Hospitals provide specialized care for obstetric including Comprehensive
Emergency Obstetric and Neonatal Care (CEmONC) and other specialties. Currently there are 72
hospitals within the country belonging to this category giving a ratio of 1 per 275,000 population.
Almost 80 percent of institutional deliveries occur in these hospitals.
Intermediate Level Health Institutions; Divisional Hospitals manned by qualified medical graduates
(MBBS) and provide a wide range of services including in-patient and out -patient care. These
institutions are capable of providing basic EmONC services. Currently there are 455 Divisional
Hospitals and 525 Primary care units within the country where almost 20 percent of institutional
deliveries take place.
Primary Level Institutions manned by qualified medical graduates (MBBS) or Registered/ Assistant
Medical Practitioners. These are the central dispensaries and Maternity Homes (CD & MH) where
facilities for only uncomplicated deliveries are available.
5
The private sector, which includes private hospitals/nursing homes and general medical practitioners
also provide maternal care services of a varying degree. Although data is not available, it is known
that a considerable proportion of patients obtain maternal care from the private sector.
Service delivery and Achievements

The Government of Sri Lanka is committed to providing a comprehensive system of health care to its
people. Maternal and Child health and Family Planning form an important component of the
prevailing health care system and are an integral part of the Primary Health Care strategy.
Maternal care is provided free of charge to all pregnant women during antenatal, intranatal and
postnatal periods through the health care system. The use of skilled attendance during pregnancy and
labour has greatly increased over the past five decades.
Studies has shown that more than 99 percent of pregnancy women had received antenatal care during
pregnancy and almost 99 percent received trained assistance at delivery (DHS-2006/2007).
Antenatal care is provided at MCH clinics conducted in health centers both in the field and in
medical institutions. These clinics are usually conducted once a fortnight. In addition, domiciliary
care is provided by Public Health Midwives through routine home visiting. Pregnant women are
registered for antenatal care early and Pregnancy record is maintained to facilitate proper follow
up. Since the early 1990s, a home based Pregnancy Record was introduced which is kept and
carried by the mother so that vital information regarding the pregnancy is made available to the
attending doctors and the health staff at any facility she visits. High risk mothers are identified and
special attention is given throughout pregnancy and delivery. An organized system of referral exists
for cases that need special care and attention.
The number of mothers receiving trained care during delivery has more than doubled since 1948.
Only 48 percent of mothers had received trained assistance at delivery (i.e. delivered either in an
institution or under supervision of a qualified midwife) during the late 1940s. Currently almost 99
percent of deliveries receive trained assistance with approximately 99 percent taking place in
medical institutions (95 percent in Government institutions and 4 percent in the private hospitals).
Of the total deliveries in the government institutions almost 80% take place in larger hospitals where
Comprehensive Emergency Obstetric Care is available. This has resulted in overcrowding of
maternity wards in the larger hospitals. One of the main reasons for this overcrowding is the peoples
preference to have their confinement in larger hospitals with better facilities rather than going to their
area hospital.
Births in government medical institutions have increased steadily during the past four decades. Easy
access to institutional care and regular contact with the PHM appears to have influenced their
decision in favour of institutional deliveries.
After delivery the mother and child are followed at home by the area PHM with necessary post
partum care (including advice and guidance) being provided during these visits. Routine statistics
reveal that approximately 80 percent of women receive post natal care at least once during the first
ten days after delivery (Annual Family Health Report, 2007-FHB)
Chapter 02
BASIC PRINCIPLES OF MATERNAL AND NEWBORN HEALTH

INTERVENTIONS
Maternal and Newborn health interventions are treatments, technologies, and key family practices
that prevent or treat Maternal and Newborn illness and reduce deaths in mothers and children (WHO
2010).
These interventions are not only reducing mortality and morbidity in the mother and newborn but
also ensure quality of life. There are simple low-cost interventions for the prevention and treatment
of all the most common causes of maternal and newborn, morbidity and mortality. An effective
maternal and newborn health programme must focus on achieving a high level of coverage with such
interventions that have the greatest potential to reduce maternal and newborn mortality and
morbidity in the country.
Principles of delivering interventions

The continuum of care for the mother and child includes the life stages from adolescent, pre
pregnancy, pregnancy, through birth, the newborn period, infancy and childhood. Interventions
should be targeted at all of these stages in order to maximize impact.
The continuum of care across the health system includes the levels at which interventions are
delivered: home and community, first-level health facilities (field clinics and medical institutions up
to Divisional Hospitals) and referral facilities (hospitals with specialist facilities). Interventions
should be delivered at each of these levels where relevant. Facility-based interventions should be
balanced with those in the home and community, since the prevention and management of maternal
and newborn illness and deaths begins in the home. Continuums of care throughout the lifecycle and
across the health system are a useful way of delivering an intervention.
Programmatic Pathway to improve health status
IMPLEMENTATION
OF ACTIVITIES
Advocacy for health
IMPROVED
Human, material and

financial resource
mobilization
Availability and
access to health
care
Human resource
capacity development
Quality of care
Demand for care
Communication with
families & communities
Knowledge of
families
and communities
Health system
development
Monitoring and supervision
INCREASED
POPULATIONBASED
COVERAGE
of key effective
interventions
IMPROVED
SURVIVAL
AND HEALTH
Mortality,
Morbidity,
fertility, and
Nutritional
status
Other determinants
Pregnancy care
Interventions at home/ COMMUNITY level
Information and counseling on self-care at home, nutrition, safer sex, HIV, breast feeding, family
planning, healthy life style including harmful effects of smoking and alcohol use, and use of
insecticide treated bed nets
Birth planning, advice on labour, danger signs and emergency preparedness
Support for compliance with preventive treatments
Support for woman living with HIV/AIDS
Assessment of signs of domestic violence and referral
Educate and support for compliance with preventive treatment
Pregnancy care at FIRST LEVEL FACILITY

All of the above plus
Confirmation of pregnancy
Monitoring of progress of pregnancy and assessment of maternal and fetal well-being including
nutritional status
Detection of problems complicating pregnancy ( eg: anaemia, hypertensive disorders, bleeding,
mal-presentations, multiple pregnancy)
Responds to other reported needs
Tetanus immunization
Anaemia prevention and control ( iron and folic acid supplementation and worm treatment) and
nutrition counselling
Syphilis testing and treatment of syphilis ( woman and her partner)
Treatment of mild to moderate pregnancy complications (mild to moderate anaemia urinary
tract infection, vaginal infection)
Post abortion care and family planning
Pre- referral treatment of severe complications (pre-eclampsia, eclampsia, bleeding, infection and
complicated abortion)
Antibiotics for premature rupture of the membranes
Support for women living with violence and HIV
Situational
HIV testing and counseling, prevention of mother to child transmission of HIV (PMTCT) by
antiretroviral including antiretroviral therapy (ART), infant feeding counseling, mode of delivery
advice
Antimalarial intermittent preventive treatment (IPT) and promotion of insecticide treated nets
(ITN)
Deworming
Assessment of female genital mutilation
Treatment of mild to moderate opportunistic infections
Treatment of simple malarial cases
Interventions at REFERRAL FACILITIES

Treatment of severe pregnancy complications (anaemia, severe pre eclampsia, eclampsia,
bleeding , infection , other medical complications)
Treatment of abortion complications
Management of mal- presentations, multiple pregnancy
Corticosteroids for preterm labour
9
Situational
Treatment of severe HIV infection
Treatment of complicated malaria
Child birth care

Companion of choice to support the woman during delivery

Support for care for the rest of the family
Support for transport
Promote and support for skilled care at birth and institutional delivery
Child birth care at FIRST LEVEL FACILITY

Care during labour and delivery
Diagnosis of labour
Monitoring progress of labour , maternal and fetal wellbeing with partogragh
Companion of choice to support the woman
Infection prevention
Supportive care and pain relief
Detection of problems and treatment of complications (e.g. malpresentation, prolonged and/ or
obstructed labour, hypertension, bleeding and infection)
Delivery and immediate care of the new born baby
Active management of third stage of labour
Immediate postpartum care of mother
Monitoring and assessment of maternal well being
Prevention and detection of complications (e.g. hypertension , infections, bleeding, anaemia)
Treatment of abnormalities and complications ( e.g. prolonged labour, vacuum extraction, breech
presentation, episiotomy, repair of genital tears, manual removal of placenta)
Pre- referral management of serious complications( e.g. obstructed labour, fetal distress, preterm
labour, severe peri- and postpartum haemorrhage )
Counseling and Support for the family if maternal and perinatal death
Counselling for family planning including insertion of IUDs, LRTs
Immediate newborn care
Skin to skin care
Thermal care
Hygienic cord care
Newborn resuscitation if required
Early initiation of breast feeding
Rooming in
Recognition of danger signs and prompt treatment
Identification and initial management of newborn complications and appropriate referral
Special care for small babies including Kangaroo Mother Care
Exclusive breast feeding
BCG immunization
Prevention of mother to child transmission of HIV (guidance and support for chosen infant
feeding option)
Situational
Vitamin A administration for mother
HIV testing and counseling
Prevention of mother to- child transmission of HIV by mode of delivery, guidance and support
for chosen infant feeding option
Care for HIV positive women/ ART
10
Child birth care at REFFERRAL FACILITY

Treatment of severe complications in child birth and in the immediate postpartum period,
including caesarean section, blood transfusion and hysterectomy
Induction and augmentation of labour
Management of other obstetric complications
Management of severe newborn complications
Postpartum care
Information and counseling on selfcare at home, nutrition, safer sex, breast feeding, family
planning/ birth spacing, healthy lifestyle including harmful effects of smoking and alcohol use
Support for rest and less work load
Support for exclusive breast feeding
Safe disposal/ washing of pads
Assessment of maternal wellbeing including maternal nutrition
Malaria prevention and management of malaria
Support for complications with prevention measures and treatments (infections, bleeding,
anaemia, UTI, RTI, wound infections, breast feeding problems)
Family planning / birth spacing
Recognition of danger signs, including blues/ depression
Awareness of signs of domestic and sexual violence and referral
Support for women living with HIV/ AIDS including ART
Reporting birth and death (vital registration)
Use of insecticide treated bed nets
Postpartum care at FIRST LEVEL FACILITY

Prevention and detection of complications (e.g. infections, bleeding, anaemia)
Anaemia prevention and control ( iron and folic acid supplementation)
Provision of contraceptive methods
Treatment of some problems(e.g. mild to moderate anaemia, mild puerperal depression, mastitis)
Pre referral treatment of severe complications (e.g. severe postpartum bleeding , puerperal
sepsis)
Vit. A mega dose suplementation
Recording and reporting
Situational
Antiretroviral treatment (ART)
Treatment of uncomplicated malaria
Postpartum care at REFFERRAL FACILITY

Treatment of all complications
Severe anaemia
Severe postpartum bleeding
Severe postpartum infections
Severe postpartum depression
Tubal ligation and vasectomy
Situational
Treatment of complicated malaria
11
New born care

Promotion and support for:
Exclusive breast feeding
Thermal protection
Infection prevention : general hygiene, hand washing , cord care and safe disposal of babys
faeces
Care of a small baby without breathing and feeding problems: frequent breast feeding , skin to
skin contact
Prevention of indoor air pollution
New born stimulation and play
Recognition of danger signals, problems, illness and timely care- seeking
Support for routine care and follow up visits
Birth registration
Promotion, protection and support for exclusive breast feeding
Monitoring and assessment of wellbeing and response to maternal concerns
Care of preterm/ low birth weight without breathing problems: support for breast- milk feeding,
Kangaroo mother care, skin to skin care
Situational
Promotion and provision of insecticide treated bed nets

Adherence to ARV for PMTCT
Interventions at FIRST LEVEL HEALTH FACILITY

Rooming in
Eye infection prophylaxis
Immunization
Additional follow up for at risk babies
Treatment of local infections (skin , cord, eye, mouth)
Identification , initial management and referral of a new born with any sign of severe illness ,
injury or malformation
Recording and reporting
Situational
ARV regimens for PMTCT including ART
Support for safer infant feeding options
Interventions at REFFERRAL FACILITY

Management of a new born with severe problems: general care of a sick newborn and specific care for:
Preterm babies with breathing problem or unable to feed orally (includes provision of KMC)
Severe infection
Severe birth asphyxia
Other: severe jaundice, malformations
Presumptive treatment of congenital syphilis
12
Chapter 03
MATERNAL CARE MODEL IN SRI LANKA

Antenatal care model currently used in Sri Lanka is the traditional multi-visit model; once a
month up to 28weeks, fortnightly during 28-36weeks and weekly thereafter. The domiciliary
care also follows the same model. Pregnant women are simultaneously receiving maternal
care services at multiple settings eg. Field clinic, hospital clinic, specialized care unit, and
some even visits to obstetricians in the private sector. Therefore, altogether pregnant woman
received 12-18 clinic visits and 8-10 home visits during antenatal period as more than 90% of
women registered for antenatal care before 12 weeks. Postnatal care model consists of two
home visits during 1st 10 days, one visit between 11-28 days, and one visit around 42 days
(altogether 4 visits). This model also includes a postnatal clinic visit at 4-6 weeks. However,
in contrast to antenatal clinic and domiciliary care coverage which is almost universal, only
80% of women receive at least one postnatal home visit. Postnatal clinic care is not well
established in the country.
Though Sri Lanka has achieved effective service coverage in MCH/FP, the quality of service
delivery needs further improvement in order to attain further reductions of maternal mortality
and morbidity. Therefore, an external review of Maternal and New born Health in Sri Lanka
was conducted in 2007 to identify the gaps in existing service delivery system. This review
has identified the need to streamline the provision of maternal care and bring it into line with
evidence based interventions with the objective of improving the quality of care and
preventing the duplication of the services. Further, recommendations of National Maternal
Mortality Reviews and District Maternal and Child Health Reviews also pointed out the need
for revision to streamline the services and to address the gaps in service provision.
Meanwhile, need of strengthening the integration of elimination of congenital syphilis (ECS)
and prevention of mother to child transmission of HIV (PMTCT) programmes into maternal
care programme was highlighted.
Therefore, Family Health Bureau in collaboration with Sri Lanka College of Obstetricians,
and Gynecologists, WHO and UNICEF revised the existing service provision model of
antenatal and postnatal care. Series of consultative meetings were held with the relevant
stakeholders and reviewed available models in the world including WHO Antenatal care
randomized trial and NICE guidelines. After considering the existing health policies and
health care system in the country, achievements and gaps, ability of packaging evidence
based interventions, client and service providers satisfaction, development in transport and
communication, cost effectiveness and expectation of the public, the following model was
developed to deliver evidence based interventions to reduce maternal and child mortality and
mortality.
13
Proposed Maternal Care Model

Domiciliary and clinic care
Pre pregnancy care
Early Registration of Pregnant Mother

(preferably 6-8weeks) either at clinic/home By
PHM
If registered at home Refer to field ANC
At Field Clinic/
MO /MOH/RMO
Booking visit (clinic visit 1) 6-8 weeks
Risk assessment
Low Risk Pregnancy
Provide Basic
antenatal care
Field Clinic/ MO/

MOH/RMO
Shared care/ Out

reach clinic/ field
clinic
Field Clinic/
MO/MOH/RMO
Field Clinic/
MO/MOH/RMO
Clinic Visit- 2
Risk uncertain
Refer to specialized
care to clarify the risk
12-14weeks
Home visit 1 (612 weeks)

High Risk Pregnancy
Refer to Specialized
care
Antenatal class I
1st Trimester
Clinic Visit -3
18-20 weeks
Home visit 2
22-24 weeks
Clinic Visit -4
weeks
22- 24 weeks
Antenatal class II
2nd Trimester
Clinic Visit 5
26-28 weeks
Antenatal class III
Field Clinic/
MO/MOH/RMO
Clinic Visit 6
32-34 weeks
14
3rd Trimester
Field Clinic/
MO/MOH/RM
Clinic Visit -7
36 weeks
Home visit 3
36 -38 weeks
KCC chart
Field Clinic/
MO/MOH/RMO
Clinic Visit -8
38 weeks
Clinic Visit -9
40 weeks
Field Clinic/
MO/MOH/RM
If no pains admit for
inward review
Delivery at an Institution
Immediate postnatal care

Postnatal screening of mother & baby
PHM
Postnatal home visit 1 (0-5 days)
PHM
Postnatal home visit 2 (5-10days)
PHM
Postnatal home visit 3 (14-21days)
MO/MOH
Apply EPDS
screening tool
Postnatal clinic visit (4-5wks)

PHM
Postnatal home visit (6-7wks)
Baby
Mother
Well women
services
Family
planning
services
Infant care
15
16
Antenatal Care
17
18
Chapter 04
ANTENATAL CARE
All eligible couples should be registered in the eligible couple register (H 526) by the area
PHM. All the women who are getting pregnant are assumed to have pre-pregnancy care
(Rubella immunization, preconception folic acid supplementation, screening for medical
condition and nutritional assessment and if required necessary family planning services).
During pre pregnant care, couples should be educated regarding pregnancy symptoms and
importance of early initiation of antenatal care. They should be educated when to and how to
inform PHM once they get pregnant. These services should be provided through womens
health program and family planning program. In Sri Lanka, antenatal care provides through
clinic care and domiciliary care.
The main objective of antenatal care is to monitor the health of the pregnant mother as well
as the health and development of the fetus. Antenatal care helps to screen for possible adverse
conditions during pregnancy and to predict problems with pregnancy, labour or birth.
Therefore, they can be either prevented, or manage efficiently. It also helps to initiate a plan
for continuing care during pregnancy and post partum period.
Antenatal care consists of:
1. Assessment: Maternal risk factors, Ongoing assessment of maternal and fetal wellbeing and screening for maternal complications
2. Care provision
3. Health promotion
Antenatal care at the clinic

Following the registration at the clinic or at home, pregnant mother should receive the clinic
antenatal care as early as possible, preferably around 6-8 weeks of gestation. The officers
who provide antenatal care should follow the General Circular No. 01-25/2004 issued by the
Director General of Health Services on 14th September 2004 on antenatal care Each antenatal
clinic visit should be objective. All findings of the clinic antenatal care should be entered on
the Pregnancy Record (H512 A and B) by the officer who performs the examination.
Designation of the officer who performs the obstetric examination should enter in the
relevant cage in both H 512 A & B. The services which should be provided at each clinic
visits are mentioned below.
Booking Visit 6-8 weeks

Objectives of the visit
1.
2.
3.
4.
5.
6.
7.
To provisional establishment of pregnancy (either clinically/ with laboratory testing)

To assess medical and obstetric risk factors and take necessary actions
To assess the psychological/nutritional status and take necessary actions
To provide necessary care and health promotion
Screening for anaemia, syphilis and testing for blood group and Rh
Check for dental conditions and appropriate referral
Examination of heart to identify heart diseases
19
When mother is registered at the clinic, PHM should visit her home within 12 weeks of
POA as described in the section on domiciliary care.
During booking Visit/First visit all pregnant mothers must be seen by a medical officer
(MOH/AMOH/MO)
If MOH/MO is not available in the first visit, the closest clinic date should be given to the
mother for the next visit. A medical officer should examine all the pregnant women.
a) Obtain information on:
Personal history
Name
Age (date of birth)
Address and telephone number
Marital status and duration
History of consanguinity
Educational level: primary, secondary, university
Economic resources: employed? (Salaried work or short-term?)
Type of occupation of mother and husband
Substance abuse: alcohol or drugs ( husband & wife)
Domestic Violence
Availability of a responsible person at home in an emergency
Mode of transport in an emergency
Closest EMOC facilities the distance/ transport facility
Medical history (Past and present)

Specific diseases and conditions: tuberculosis, heart disease, chronic renal/hepatic
disease, epilepsy, diabetes mellitus, hypertension, psychiatric illnesses and any
chronic diseases
STIs
HIV status, if known to be positive please follow the guidelines (page 114) without
entering into the pregnancy record.
Other specific conditions depending on prevalence in area (for example, hepatitis,
malaria, Thalaseamia)
Other diseases; past or chronic; allergy(-ies)
Operations other than caesarean sections (heart/ lung surgeries)
Past blood transfusions, Rhesus (D) antibodies
Current use of medicines specify
Period of infertility: when? duration, cause(s), specialized treatment taken for
difficulties in conceiving eg. Ovulation induction, IVF etc.
Family History
Diabetes mellitus
Hypertension/ PIH
Twins
Congenital abnormalities
20
History of present pregnancy

Date of last menstrual period (LMP)
Certainty of dates (by regularity, cycle length, accuracy of recall and other
relevant information)
Habits: smoking/chewing tobacco, alcohol, drugs (frequency and quantity)
Any other concerns with regards to pregnancy (pain, vaginal bleeding, and
excessive vomiting other: specify)
History of malaria attacks- when was the last attack
Any other discomforts
Contraceptive history
Method use
When it was started
When it was stopped
Method failure or not
Obstetric history (review all the available records, diagnostic cards, clinic records etc.)
Number of previous pregnancies.
Date (month, year) and outcome of each event (live birth, stillbirth, abortion, ectopic,
hydatidiform mole). Specify (validate) preterm births and type of abortion, if
applicable and possible.
Birth weight (if known)
Sex of the child
Periods of exclusive breast-feeding: For how long?
Did she have any feeding difficulties in previous pregnancies?
Special maternal complications and events in previous pregnancies; specify which
pregnancy (- ies), validate by records (if possible):
Recurrent early abortion, induced abortion and any associated complications

Thrombosis, embolus
Hypertension, pre-eclampsia or eclampsia
Gestational diabetes
Placenta praevia/ APH
Liver disease/fatty liver
Breech or transverse presentation
Obstructed labour, including dystocia
Third-degree tears
Retained placenta
Post partum haemorrhage
Puerperal sepsis
Anesthetic complications
Obstetrical interventions
Cervical cerclage (Shirodkar Suturing)

Caesarean section (indication, if known)
Forceps or vacuum extraction
21
Manual/instrumental help in vaginal breech delivery

Manual removal of the placenta.
Dilatation and evacuation (D&E) or dilatation and curettage (D&C)
Special perinatal (fetal, newborn) complications and events in previous pregnancies

specify which pregnancy(- ies), validate by records (if possible):
Twins or higher order multiples
Low birth weight: <2500 g/ 2500-2000g / 1999- 1500g/ <1500g
Intrauterine growth retardation (if validated)
Rhesus-antibody affection (erythroblastosis, hydrops)
Malformed or chromosomally abnormal child
Macrosomic (>3500g) newborn
resuscitation or other treatment of newborn (SCBU and NICU admissions)/
ventilation
perinatal, intrapartum, neonatal or infant death (also: later death)
Feeding problems
b) Perform clinical examination
Record weight (Kg) and height (metres) (page 71)
Calculate BMI using BMI chart/cycle (page 71)and record it in pregnancy
record
Check for signs of severe anaemia: pale complexion, fingernails, conjunctiva,
oral mucosa and shortness of breath
Look for edema (ankles, fingers, face and abdoman)
Do a general examination: Look for thyroid diseases, dental hygiene,
deformities spinal/pelvic, icterus, cyanosis, clubbing
Measure blood pressure and record (Page 75)
Auscultate heart and chest: Heart sounds, murmurs and abnormal breathing
sounds
Perform obstetric examination (page 76)
Perform breast examination if needs (lumps, nipple problems)
c) Perform following tests
Urine: Check for glucose (Benedicts test) and protein (coagulation test) or if
available use urine test strips for protein and sugar (page 81)
VDRL testing as a screening test of Syphilis ( page 83)
Blood group and Rh (Should be done through government sector)
Check Haemoglobin at first visit using colour scale/ any other method (page
84)
(Discuss with the nearest hospital with laboratory facilities to test Hb. This will be more
accurate method than colour scale)
If there are risk factors (BMI above 25kg/m2, previous baby weighing
3.5kg or above, previous gestational diabetes, first degree relative with
diabetes) do PPBS, if the value is more than 120mg/dl, refer for OGTT in
a specialized unit
22
d) Implement the following interventions

o If any risk is identified, act according to the guidelines (page 41)
o If woman is on treatment for diabetes, hypertension, epilepsy, psychiatric disease or
any other disease refer them to the relevant clinics for continuous treatment
o Mothers without high risk conditions should be offered basic antenatal care
o Folic acid (5mg daily) supplementation
o Nutritional supplementation (2 packets of Triposha/CSB for all mothers)
o Ask to seek medical advise if having vaginal bleeding, severe vomiting or abdominal
pain or any other concerns
e) Discuss and understand:
Give the pregnant woman an opportunity to discuss issues and ask questions: time for free
communication
On whom to communicate or where to go in case of bleeding, abdominal pain and any
other emergency, or when in need of other advice (page 65)
On issues related to sexual relationship and activities
Nutrition during pregnancy (page 85)
Minor ailments and their management during early pregnancy (page 91)
Advise the woman to participate with the husband or any other care giver for
antenatal classes where they can learn how to deal with a pregnancy (page)
f)
Schedule next appointment:

Plan second clinic visit at 12-14 weeks of POA. State the date and time
Confirm the date for antenatal classes
This should be written in the pregnancy record (512A) and in the clinics appointment book if
available.
g) Maintain complete records
Complete clinic records.
Complete the Pregnancy record.
Give the record to mother and advice her to bring it with her to all appointments with
any health services.
.
23
Second Clinic Visit- 12-14 weeks

1.
2.
3.
4.
5.
6.
7.
8.
To assess the progression of pregnancy

To assess the risk conditions and take necessary actions
To see the results of the tests and take necessary actions
Tetanus toxoid immunization
To give Antihelminthic treatment
To start micronutrient supplementation (Iron, folic acid, Vit C and calcium lactate)
To discuss the birth and emergency plan

Personal/ social history
Note any changes since first visit.

Domestic difficulties: disharmony, violence etc
Change of home environment
Change of duty station or occupation of wife or husband
Medical history
Review relevant issues of medical history as recorded at first visit.

Note intercurrent diseases, injuries, or other conditions since first visit.
Review intake of medicines, other than folic acid
Folic acid intake: check compliance.
Note other medical consultations, hospitalization or sick-leave since last visit.
Obstetric history
Review relevant issues of obstetric history as recorded at first visit.
Present pregnancy
Record symptoms and events since first visit: e.g. pain, bleeding, vaginal discharge,
signs and symptoms of severe anaemia
Other specific symptoms or events.
Note abnormal changes in body features or physical capacity (e.g. peripheral swelling,
shortness of breath with mild exertion) observed by the woman herself, by her
partner, or other family members.
Review, discuss and record the results of all screening tests undertaken
b) Perform physical examination
Weigh the mother and plot the weight gain in the chart (page 73), Look for deviations
of the expected weight gain
24
Measure blood pressure and record. Respond accordingly (page 75)

Look for other alarming signs of disease: gross oedema of feet, facial oedema, pallor,
jaundice (icterus), cyanosis, shortness of breathing with mild exertion
Perform abdominal examination- compare the fundal height with POA , look for
abdominal masses (page 76)
c) Perform the following tests:
Repeat Hb% if signs and symptoms of severe anaemia are detected on examination
Check urine for protein using coagulation test
d) Assess for referral
Reassess whether the woman can still follow the basic component of the antenatal
care based on evidence since first visit and observations at present visit.
Any new symptoms of recent onset: refer as required (page 41).
If complain of bleeding per vagina: refer for evaluation
e) Implement the following interventions:
Tetanus toxoid immunization (page 107).

Start iron folate supplementation with Vit C and calcium supplementation (page
100) if mother does not have vomiting or loss of appetite. Advice not to take iron
and calcium together (iron at night and calcium in the morning before/after meal.)
Malaria prophylaxis to be decided by MOH according guidelines issued by AMC
(page 145)
Nutritional supplementation (Triposha/CSB 2 packets )
Ask to seek medical advice if having vaginal bleeding or abdominal pain or any
other symptom
If risk conditions are identified, refer them to the specialized care
f) Advice, questions and answers, and scheduling the next appointment
Create an opportunity to discuss issues and ask questions

Offer verbal information supported by antenatal classes and written information
(booklets, leaflets etc.)
Give advice on whom to call or where to go in case of bleeding, abdominal pain or
any other emergency, or when in need of other advice. This should be confirmed in
writing (e.g. on the pregnancy record) as at first visit (page 65)
Discuss and write down the birth plan
Schedule the third visit at 18-20 weeks either at field clinic or at specialist clinic
depending on the local policy.
Advice to write down the date of quickening
Confirm the date for antenatal class II

Complete clinic records and pregnancy record. Give the record to mother and advise her to
bring it with her to all appointments with any health services.
25
Visit 3 (18-20 weeks)

This visit may be either at field clinic or at specialist clinic or at out reach clinic.
Objectives of this visit in a field clinic
1.
2.
3.
4.
5.

For primies, to give second dose of tetanus Toxoid
To Examine the heart to identity abnormalities
Objectives of the visit in a specialist clinic

1.
2.
3.
4.
To confirm dates and placental position

To serve as a booking visit for delivery

Personal history
Note any changes since last visit.
Domestic difficulties : disharmony, violence etc.
Medical history
Review relevant issues of medical history as recorded at last visit.

Note intercurrent diseases, injuries, or other conditions since last visit.
Review intake of medicines, other than ironfolate and calcium
Ironfolate, Vit C and calcium: check compliance.
Check compliance with other advice given during last visit
Obstetric history
Review relevant issues of obstetric history as recorded at last visit.
Present pregnancy
Record symptoms and events since last visit: e.g. pain, bleeding, vaginal discharge,
signs and symptoms of severe anaemia
Note abnormal changes in body features or physical capacity (e.g. peripheral
swelling, shortness of breath with mild exertion), observed by the woman herself, by
her partner, or other family members.
Fetal movements: whether felt or not. Note the date of first recognition in pregnancy
record.
Review, discuss and record the results of all tests undertaken.
26
Weigh the mother and plot the weight gain in the chart look for deviations of the
expected rise
(page 73)
Look for generalized oedema and pallor.
Recheck heart and lungs and listen for heart sounds, murmurs and abnormal breathing
sounds
Measure SFH and record (page 76).
Other alarming signs of disease: gross oedema of feet, facial oedema, pallor, jaundice
(icterus), cyanosis, shortness of breathing with mild exertion
Repeat Hb % if signs and symptoms of anaemia are detected on examination or on

treatment for anaemia
Check urine for protein using coagulation test
care, based on evidence since last visit and observations at present visit.
If complain bleeding per vagina: refer for evaluation
For primies give second dose of Tetanus toxoid immunization (page 107).
Give malaria prophylaxis if needed (page 145)
Continue micronutrient supplementation
Give nutrition supplementation
Give an opportunity to discuss issues and ask questions

(booklets, leaflets etc.)
writing (e.g. on the antenatal card), as at second visit
Discuss the birth plan and make changes if any.
Schedule the forth visit at 22-24 weeks

Complete Pregnancy record. Give the record to mother and advise her to bring it with
her to all appointments with any health services.
27
Clinic Visit 4 (22-24 weeks)

1. To assess the progression of pregnancy
2. To screen for risk factors and take necessary actions
3. To provide necessary care and health promotion
Personal history
Note any changes since last visit
Medical history

Review intake of medicines, other than iron folate, Vit C and calcium
Obstetric history
Present pregnancy
Look for symptoms and events since last visit: e.g. pain, bleeding, vaginal discharge
(amniotic fluid?), signs and symptoms of severe anaemia.
Review, discuss and record the results of all screening tests undertaken.
Weigh the mother and plot the weight gain in the chart, look for deviations of the
expected rise- consider macrosomia and IUGR, if suspect, refer (page 73)
Measure SFH , record, interpret and take necessary action if any deviation from
expected (page 76).
28
Ask about FM and listen for FHS and record.

Other alarming signs of disease : gross oedema of feet, facial oedema, pallor,
Check urine for proteinuria

If complain bleeding per vagina, refer for evaluation.
Suspicion of fetal growth retardation ( uterine height values below expected or
indicative of poor growth as evidenced by the chart curve): refer
If uterine height (SFH) is above expected: refer for evaluation.
Suspicion of twins: Refer for confirmation and plan for delivery.
Give malaria prophylaxis if needed (page 145)


writing (e.g. on the antenatal card), as at last visit (page 65).
Schedule the fifth visit at 26-28 weeks

Complete Pregnancy record. Give the record the mother and advise her to bring it
with her to all appointments with any health services
29

1
2
3
4
5

To screen for risk factors and take necessary actions
To screen for gestational diabetes
To screen for anaemia

Personal history
Medical history

Review intake of medicines, other than iron folate, Vit C and calcium
Obstetric history
Present pregnancy
Look for symptoms and events since last visit: e.g. pain, bleeding, vaginal discharge,
signs and symptoms of severe anaemia.
Review, discuss and record the results of all screening tests undertaken.
expected rise- consider macrosomia and IUGR, if suspect refer (page 73)
30
expected (page 76).
Ask about FM and listen for FHS and record.
Other alarming signs of disease : gross oedema of feet, facial oedema, pallor,
Check urine for proteinuria all mothers

Screen all pregnant women for anaemia
All pregnant mothers should screen for GDM using PPBS (cut off 120mg/dl). For
further details see page 110)
If complain bleeding per vagina : Refer for evaluation
Suspicion of fetal growth retardation ( uterine height values below expected or
If SFH is above the expected: refer for evaluation
Give malaria prophylaxis if needed


writing (e.g. on the antenatal card), as at last visit (page 65).
Schedule the sixth visit at 32 - 34 weeks
Confirm the date for antenatal class III

with her to all appointments with any health services
31

1.
2.
3.
4.
5.
6.
7.
8.

Review the SFH chart and weight gain chart to ascertain the fetal growth
To look out for signs of PIH, IUGR, macrosomia, polyhydroamnios
To ascertain the lie and presentation
To reevaluate the birth plan
To examine the heart to detect any abnormalities

Personal history
Medical history

Review intake of medicines, other than ironfolate, Vit C and calcium
Obstetric history
Present pregnancy
Look for symptoms and events since last visit: e.g. abdominal or back pain (preterm
labour?), bleeding, vaginal discharge (amniotic fluid?), signs and symptoms of
severe anaemia.
Any other specific symptoms or events.
Ask for fetal movements
32
expected rise- consider macrosomia and IUGR, if suspect refer (page 73)
Recheck heart and lungs and listen for heart sounds, murmurs and abnormal
breathing sounds
Measure SFH, record, interpret and take necessary action if any deviation from
expected (page 76)
Ask about FM and listen for FHS and record
Look for Lie and Presentation.
(icterus), cyanosis, shortness of breathing with mild exertion

If complain bleeding per vagina or vaginal discharge: refer for evaluation
Suspicion of fetal growth retardation (uterine height values below expected or
If SFH is above expected: refer for evaluation
If transverse lie or breech presentation: refer for evaluation
Give malaria prophylaxis if needed (page145)


Offer verbal/ written information supported by antenatal classes
Give advice on measures to be taken in case of pain, dribbling and bleeding (page 65)
Reconfirm the written information on whom to call and where to go in case of
emergency (page 65).
33
Plans to ensure transport is available in case of an emergency (page 65).

Provide recommendations on breast feeding, family planning and post partum care.
Schedule the seventh visit at 36 weeks

with her to all appointments any health services.
Clinic Visit 7 (36 weeks)

1.
2.
3.
4.
5.
6.
7.
8.

Review the SFH chart and weight gain chart to ascertain the fetal growth
To ascertain the lie and presentation
To introduce kick count chart
To look out for signs of PIH, IUGR
To reevaluate the birth plan

Personal history
Medical history

Review medications other than ironfolate, Vit C and calcium
Obstetric history
34
Present pregnancy
severe anaemia.
Ask for reduced fetal movements
expected rise- consider macrosomia and IUGR, if suspect refer
Measure blood pressure and record. Respond accordingly
Look for generalized oedema (especially facial) and pallor.
expected.
Check for presentation and fetal lie (head, breech, transverse) and record
Other alarming signs of disease: gross oedema of feet, facial oedema, pallor,
jaundice (icterus), cyanosis,shortness of breathing with mild exertion

Any new symptoms of recent onset: refer as required .
If complained of bleeding per vagina or vaginal discharge, refer for evaluation.
If SFH is above the expected : refer for evaluation.
Suspicion of breech presentation or abnormal lie: Refer for specialized care

35

Introduce the kick count charts (KCC) and give clear guidance to maintain the
chart (page 80)

Re-emphasis the signs and symptoms of labour
Re-confirm the written information on whom to call and where to go in case of
emergency
Plans to ensure transport is available in case of an emergency.
If experience of reduced fetal movement, advice mother to get admit to the hospital
immediately.
Provide recommendations on breast feeding, family planning and postpartum care
(page 172).
Schedule the eight visit at 38 weeks

with her to all appointments with any health services.

1.
2.
3.
4.
5.

Re-evaluate presentation/ lie/ PIH/ SFH/ weight chart/ KCC
To reevaluate the birth and emergency plan

Personal history
Domestic difficulties: disharmony, violence etc.
Medical history

Review intake of medicines, other than iron, folate , calcium
36
Obstetric history
Present pregnancy
severe anaemia.
expected rise- consider macrosomia and IUGR, if suspect refer
Measure blood pressure and record. Respond accordingly
Look for generalized oedema and pallor
expected .
(icterus), cyanosis,shortness of breathing with mild exertion:

Any new symptoms of recent onset: refer as required.
If SFH above the expected ; refer for evaluation.
Suspicion of breech presentation or abnormal lie: Refer for specialized care

37

Explain the signs and symptoms of labour and advice to get admitted to a hospital if
she experience any
Give advice on measures to be taken in case of labour.
If no labour pains by 40 weeks ask her to get admitted to a specialized unit for
assessment.
If experience of reduced fetal movement, advice mother to get admit to the hospital
immediately
emergency
Ensure the plans to ensure transport, to whom accompany with her, money and items
to be taken
Provide recommendations on breast feeding, family planning and postpartum care
Schedule the eighth visit at 40 weeks and explain her delivery may occur before the
next clinic visit


1. To ensure that the mother reaches the place of delivery in time
2. To assess the risk conditions and take necessary actions
3. To provide necessary care and health promotion
Personal history
Medical history

Review intake of medicines, other than ironfolate Vit C and calcium
38
Obstetric history
Present pregnancy
Record symptoms and events since last visit: e.g. abdominal or back pain, bleeding,
vaginal discharge (amniotic fluid?), signs and symptoms of severe anaemia.
Weigh the mother and plot the weight gain in the chart. Check the total weight gain.
Measure blood pressure and record .Respond accordingly
Measure SFH and record.
(icterus), cyanosis,shortness of breathing with mild exertion:

Refer to the hospital where delivery is planned to be taken place for assessment.

Ask her to get admit to the hospital for an indoor assessment

Give advice on danger signals (reduced fetal movements, bleeding PV, headache,
shortness of breathing, severe chest pain, rapture of membranes and high fever)
Give advice on measures to be taken in case of labour
emergency or ant other need.
Plans to ensure transport is available in case of an emergency.
39
Provide recommendations on breast feeding, family planning and post partum care.
Ask her to go to the nearest hospital if labour signs and symptoms occurred, or if no
labour pain after 40 weeks, ask her to go to specialized care unit.
Advice to continue iron, folic acid, Vit C and calcium lactate for 6 months after
delivery.
Emphasis on following:
To inform the area PHM as soon as the mother came home after delivery
To attend the postpartum clinic after 4 weeks of delivery
To continue micronutrients for 6 months after delivery

Danger signals during pregnancy

Advise to go to the hospital immediately, day or night, without
waiting if any of the following signs:
Vaginal bleeding
Convulsions
Severe headaches with blurred vision
Fever and too weak to get out of the bed.
Severe abdominal pain/ epigastric pain /RHC pain
Fast or difficult breathing
Reduced fetal movements
She should go to the hospital as soon as possible if any of the following
signs:
Fever
Abdominal pain
Feels ill
Swelling of fingers, face, legs
Dating Scan
Confirmation of dates is essential for early identification of IUGR. USS is the
most reliable method of confirmation of dates. However the parameters used
are depend on the POA.
11- 14 weeks of POA Crown rump length
16- 20 weeks of POA Head circumference
40
Chapter 5
MANAGEMENT OF RISK CONDITIONS AT FIELD LEVEL
Note:
When a high risk pregnant woman receives her antenatal care from a specialized unit
in a hospital, she should receive domiciliary care from the PHM. If she wish she can
attend to the field clinics also.
When pregnant women are not receiving micronutrients or food supplementations

from the hospital clinic, they should be supplied from the field clinic.
If high risk mothers are not receiving the specialized care, they should receive
adequate care from the field clinic.
If pregnant women have any problem they can attend to the field clinic disregarding
the clinic appointment or risk condition
All the high risk pregnant women should attend to the antenatal classes with their
husbands
Risk Condition
Action to be taken
Past Obstetric History

Previous stillbirth (antenatal or intrapartum)
or neonatal loss or malformed babies
Refer at first visit

Act according to the consultant Obstetricians
instructions.
Arrange targeted home visits by PHM
Pay special attention for kick count chart after 36
weeks.
History of 2 or more consecutive first

trimester miscarriages
Refer at first visit.

Depending on the cause, MOH/ consultant
Obstetricians can decide whether to continue as a
risk mother or not
Need to do a proper screening including genetic
screening, thrombophilic screening at the specialized
care unit
History of preterm delivery before 37weeks, Refer at first visit.

or second trimester miscarriage
Act according to the Consultant Obstetricians
instructions.
Arrange targeted home visits by PHM
41
History of PIH, eclampsia/ pre-eclampsia
Refer at first visit.

If there is a history of PIH only, no need to refer
special care. Closely monitor the BP
If there is H/O of pre eclampsia/Eclampsia, refer at
the 1st visit for specialized care.
Need close/ regular monitoring of BP
If abnormally detected in BP, refer immediately
History of APH
If it is due to placenta previa, refer to specialized

care at 18-20wks for scan to ascertain the position of
the placenta as there is a risk of recurrence.
Placental abruption: there is a possibility of
recurrence. Refer at 1st visit.
Correct the anaemia if detected.
Ascertain blood group and Rh.
History of retained placenta
Correct aneamia if detected

Check Blood group and Rh.
Refer to consultant Obstetricians at 36 weeks for
assessment.
Plan for delivery in a CEmOC facility
History of postpartum haemorrhage
Correct aneamia if detected

Check Blood group and Rh.
Refer to consultant Obstetricians at 36 weeks for
assessment.
Plan for delivery in a CEmOC facility
History of cesarean section/ Myomectomy
All the women with history of LSCS or

myomectomy should have a scan at 18-20 weeks to
detect placental localization.
Refer to specialized unit for this and to get
specialized advice regarding delivery.
Need to be admit to an institution with CEmOC
facilities by 38weeks
If she gets pain need to admit to the hospital in
fasting state
History of surgery on reproductive tract

Refer for specialist care at first visit for a scan. Act
(removal of septum, cone biopsy, large loop according to the consultant obstetricians instructions
excision of transformational zones
(LLETZ),
History of a birth with birth weight < 2500g
Refer for specialist care at first visit.
History of a birth with weight > 3500g
Do a PBBS and if the result is > 120mg/dl refer to

specialist clinic for OGTT.
42

instructions.
History of IUGR
Refer for specialist care at first visit. They will need

accurate dating scan before 14 weeks and regular
USS with growth charts.
instructions.
History of Feeding difficulties/ breast

surgery
MOH should identify reasons and plan for

appropriate interventions at last trimester
Present pregnancy
Age less than 20yrs
If less than 18 years refer to specialized care.

18-20yrs MOH / MO who provide antenatal care
should monitor closely.
Advanced maternal age (Age >35yrs)
Need more close monitoring by MOH as more prone

to Hypertension, Diabetes Mellitus etc
Refer necessary cases such as sub fertile mothers,
elderly primies, NCD complicating pregnancies to
specialized care
Height < 145cm
Refer to a specialist unit at last trimester for an

assessment. To be delivered in a CEmOC facility
BMI < 18.5kg/m2
MOH should manage according to the given

guidelines.
MOH should monitor the intra uterine growth of
the fetus using SFH and maternal weight gain
BMI 25 -29.9kg/ m2
MOH should monitor the intra uterine growth of

the fetus using SFH and maternal weight gain.
BMI 30kg/ m2
MOH should thoroughly screen for Hypertension,

PIH, Diabetes mellitus.
Refer to specialist unit for OGTT.
Closely monitor the weight gain and SFH to detect
Macrosomia and polyhydroamnios
Ascertain the lie after 36weeks
Manage according to instruction given.
Primigravida
MOH should manage her at his field clinic if there

are no other risk factors.
During third trimester look for lie, presentation and
head engagement.
43
Parity (5 or more)
Refer to specialist care at first visit.

Correct anaeamia if her Hb level is < 11g/dl.
Need special counseling for Family Planning.
Try to identify social problems if any
Plan delivery at CEmOC facility
Multiple pregnancy
If suspected, refer as early as possible to specialized

care
Diastolic blood pressure more than

90mmHg
Admit to a nearest hospital for monitoring for 24

hours, if BP persists above 90mm Hg, transfer to
CEMOC facility (refer management guidelines of
PIH in the field).
Diastolic > 110mmHg or systolic 160

mmHg or more
admit urgently to the nearest hospital manage

according to guidelines and transfer immediately to
a CEmOC facility
Vaginal bleeding (any time)
Admit to the nearest hospital for assessment and

management
If need, refer to a specialist unit
Maternal jaundice
Admit to the nearest hospital to transfer specialized

unit immediately.
Severe maternal anaemia (Hb% <7g/dl)
Need to admit to a specialized care unit for

investigation and correction.
Maternal malaria
Admit to nearest hospital medical unit (manage

according to AMC guideline)
Maternal Syphilis
Refer to STD clinic, as early as possible,

Confidentiality should be strictly assured.
Maternal HIV
Refer to STD clinic, as early as possible,

Confidentiality should be strictly assured.
Uncertain dates/ irregular periods
Need to refer specialized unit to ascertain the dates

before 20 weeks. (USS is accurate for dating only
before 20 weeks.)
Intra Uterine Growth Retardation (IUGR)
Refer to specialized care. They will need accurate

dating and regular USS with growth charts. Need to
plan for delivery at a CEmOC facility. POA of
delivery also need to decide based on the specialist
opinion
44
Mal-presentations and abnormal lie after

34 weeks
Refer to a specialized unit.
Other risk conditions

Diabetes Mellitus/ Liver disease and renal
diseases
Refer to a consultant Obstetrician. He/she will

manage the pregnant woman with other relevant
specialists.
Rheumatic and congenital heart disease
If there is a suspicion of having a murmur, refer to

cardiologist for confirmation and diagnosis. After
that refer to a consultant Obstetrician. He/she will
manage the case with other relevant specialists.
Diagnosed cases need to refer to consultant
Obstetrician for combined care with a cardiologist.
Epilepsy

manage the case with other relevant specialists
(neurologist/ physician)
Mental disorders

(psychiatrist/ MO mental health)
Asthma

(general or chest physician)
Rh Negative mother
Refer to a consultant Obstetrician.

Send a blood sample to the blood bank with special
referral form for screening antibodies.
Sub fertility ( inability to conceive

irrespective of regular unprotected
intercourse for 2 or more years)
Refer for specialized care
Social problems
Unmarried mothers/ widows (single
mothers), geographically marginalized and
other social factors
Ensure social support (MOH/PHM) Social service

officer, Grama Niladhari, Samurdhi officer etc.
Targeted and more frequent home visits by PHM
Link with social security programs
45
Chapter 06
DOMICILIARY CARE FOR LOW RISK PREGNANCIES

Domiciliary care for pregnant women is provided by the area PHM. At the time of
registration as an eligible couple, PHM should give the screening questionnaire for newly
married couples and help them to fill it. Then she should go through the questionnaire and
with further clarifications try to identify the risk conditions if available. After that she should
refer the couple to MOH clinic for further screening by a medical officer and should give the
dates for sensitization classes. PHM should make aware the couple regarding the importance
of early commencement of antenatal care and pre pregnancy folic acid supplementation. She
also should inform them how to inform PHM once the wife gets pregnant.
When a woman gets pregnant, PHM should register her ideally by 6-8 weeks. PHM should
make aware the community regarding the importance of early registration as a pregnant
woman and the means of communicating with her. PHM can register the pregnant women
either at home or in the clinic. It is better to register at home as PHM gets an opportunity to
assess the socioeconomic condition, home environment and to meet the other members of the
family during early pregnancy. This is an opportunity to educate the family members
regarding pregnancy and other relevant topics.
Home visit 1 (6 -12 weeks)

Objectives:
1. To assess the condition of the pregnant woman including socioeconomic status
2. To develop a rapport and linkage with the pregnant woman and the family
3. To educate the pregnant woman and the family regarding the maternal care
When the pregnant woman is registered at the home, that visit can be considered as the first
home visit. When the pregnant woman is registered at the clinic, PHM should visit her before
12 weeks of POA. During this visit PHM should:
a) Assess the condition of the pregnant woman (physical, mental, social and
environmental)
Obtain information on:
Personal history :
-
Name
Age /date of birth
Address and telephone number
Marital status- duration and history of subfertility
History of consanguinity
Pre pregnancy care: Eligible couple registration
46
Rubella Immunization
Intake of folic acid
Attend to a pre pregnancy care programme/not
Thalasseamia test if relevant
Planned/ unplanned pregnancy
Socio- economic status:

-
Housing: type, size, number of occupants

Sanitary conditions: type of toilet, source of water
Lighting: Electricity or other sources of lighting
Cooking facilities- gas, electricity, firewood
Tobacco use (smoking or chewing habit) or use of other harmful substances
Alcohol use
Gender Based Violence
Environment: Prone to dengue and accidents, cleanliness etc
Domestic air pollution: smoke inhalation (tobacco smoking, smoke from the
hearth, mosquito coils etc.)
Educational level: primary, secondary, university or higher education
Economic resources: employed (salaried work or short-term)
Type of work and position: both pregnant woman and husband
Occupation: distance to travel, harmful occupational exposures, maternity
benefits, work load
Nuclear or extended family
Relationship with in-laws
Family support and social support
Availability of a responsible person at home
Mode of transport at an emergency
Closest EMOC facilities: distance / transport facilities
Home gardening, iodized salt, eating habits, Myths, House hold food security
Leisure activities
Religious activities
Medical history
-
Specific diseases and conditions: tuberculosis, heart disease, chronic renal

disease, epilepsy, diabetes mellitus, hypertension, asthma, psychiatric illness
STIs/ HIV status: if known
Other specific conditions depending on prevalence in the area: hepatitis,
malaria, thalaseamia
Allergies: food or drug
Operations other than caesarean sections: heart surgeries, surgeries for
gynaecolgical conditions
Blood transfusions: Rhesus (D) antibodies
Current use of medicines: specify
Period(s) of infertility: Duration, cause(s) treatments etc
47
History of present pregnancy

-
Date of commencement of last menstrual period (LMP)

Certainty of dates: by regularity, accuracy of recall and other relevant
information
Any unexpected event: pain, vaginal bleeding, other- specify
History of malaria attacks
Contraceptive history: method used, when it was started, when it was stopped,
method failure or not
Family history (blood relatives)

-
Diabetes Mellitus, Hypertension, Twins, Congenital abnormalities
Obstetric history
Previous pregnancies (Review all the available records, diagnosis cards, clinic records)
-
Number of previous pregnancies

Date (month, year), place of delivery and outcome of each event (live birth,
stillbirth, abortion, ectopic, hydatidiform mole) - Specify and validate with
available documents
Preterm births and types of abortion: If applicable and possible
Birth weight (if known)
Sex and age of the living children
Special maternal complications and events in previous pregnancies (specify which

pregnancy/ ies validate by records (if possible):
-
Recurrent early abortion

Induced abortion and any associated complications
Gestational diabetes
Hypertension, pre-eclampsia or eclampsia
Placental abruption
Placenta praevia
Breech or transverse presentation
Obstructed labour, including dystocia
Third-degree tears
Excessive bleeding (antepartum or postpartum)
Puerperal sepsis
Obstetrical interventions:
-
Caesarean section (indication, if known)

Forceps or vacuum extraction
Manual/instrumental help in vaginal breech delivery
Manual removal of the placenta
48
Special perinatal (fetal, newborn) complications and events in previous pregnancies

specify which pregnancy/- ies, validate by records (if possible):
-
Twins
Higher order multiples
Low birth weight: <2500 g
Malformed or chromosomally abnormal child
Macrosomic (>3500g) newborn
Resuscitation or other treatment of newborn
Perinatal, neonatal or infant death (also: later death)
IUGR
Rhesus antibody affection (Erythro blastosis, hydrops fetalis)
SCBU or NICU admissions
b) Perform physical examination )

-
Assess the personnel hygiene

Check for signs of severe anaemia: pale complexion in fingernails,
conjunctiva, oral mucosa, tip of tongue and shortness of breath.
Look for oedema- ankles, fingers, face, and abdomen
Do a general examination: Look for thyroid diseases, dental hygiene,
deformities (spine, pelvic and limbs), icterus, clubbing, cyanosis
Breast examination: masses, changes in the skin, nipple
Abdominal examination masses, tenderness, palpable uterus (compare with
the POA)
c) Investigations
-
Check urine for glucose and/or proteins if indicated (PIH, hypertension, renal
disease, diabetes)
d) Referral for antenatal care

-
Determine the expected date of delivery based on LMP and all other relevant
information. Use 280-day rule (LRMP + 280 days). Some women will refer to
the date of the first missed period when asked about LMP, which may lead to
miscalculation of term by four weeks.
Eg. Last LRMP: 23rd March 2010 EDD 30th December 2010
Give an appointment for antenatal clinic care

-
If new risk factors identified refer to ANC as early as possible (when 1st home
visit after first clinic visit).
Give advice on safe sex. Emphasize the risk of acquiring or transmitting HIV
or STIs.
49
Advise women to stop the use of tobacco (both smoking and chewing),
alcohol and other harmful substances. Advice to avoid passive smoking.
Advice on management of abdominal pain, urinary tract infections and minor
discomforts during pregnancy, personal hygiene, physical and mental rest and
sleep.
Advice on how to prevent infectious diseases. (use cool boiled water, hard
washing etc).
Advice all the family members on family support needed during pregnancy.
Advice to increase fluid intake, how to prepare a balanced nutritious diet.
Explain the signs and symptoms and actions to be taken in the case of ectopic
pregnancy or an abortion.
Give advice on whom to call or where to go in case of bleeding, abdominal
pain and any other emergency, or when in need of other advice.
Emphasis the need of continuation of treatment for medical conditions.
Give advice on how to contact PHM in an emergency (mobile numbers, place
of the office and residence).
Request the woman to record when she notes the first fetal movement.
Discuss with the woman and the family regarding the importance of
maintaining the good mental status during pregnancy.
Discuss with the woman and the husband (or a family member) on the
importance of attending antenatal clinics and antenatal classes. So that they
can be involved in the activities and can learn how to support the woman
through her pregnancy.
Introduce the relevant reading material (guide to pregnant mothers, five
booklets on breast feeding, booklets on ECCD) to the pregnant woman and the
family.
Schedule next appointment:

-
Give them a date for first antenatal class

Make arrangements for the second home visit, at (or close to) 22 -24 weeks:
state date and hour. This should be written in the pregnancy record (H512) A
and B.
Give a date for the first antenatal clinic visit if she has not gone yet.
Ask her to come to the clinic or inform PHM if there is any problem.
Inform her the dates of the clinic sessions and the dates and place of weighing
(children) in the village where she can meet the PHM.
h) Maintain complete records

-
Complete 512 A, B and the diary

Issue properly filled a H512 (pregnancy record) to the mother and explain her
and family importance of it and how to self assess the weight gain using
weight gain chart and growth of the fetus using SFH chart
Advise her to bring pregnancy record with her to all appointments she may
have with any health services
50
Home visit 2 (22 -24 weeks)

Objectives:
1.
2.
3.
4.
Ask:
-
To access the progression of the pregnancy

To help the pregnant woman and the family to deal with the pregnancy
To advice the family regarding birth plan and emergency plan
To help the family to prepare for the delivery and newborn
For any complains

Whether she feels fetal movements, if she feels, record first date of quickening and see
whether it is compatible with her POA
About her mental wellbeing ( happiness, support from the family members)
About the diet, intake of vitamins, worm treatment and immunization ( Tetanus toxoid)
About the rest, sleep, daily activities done at home
For any physical discomforts: Headache, dysuria, vaginal discharges, any discharges from
the nipples, breast pain, vomiting and morning sickness
About the family support ( from the husband and other family members)
About sexual activities
About the plans for delivery and emergency (hospital/ transport/ money/arrangements to
care for the home and other children if any)
Whether all the investigations are done (Grouping and Rh, Hb, VDRL, PPBS)
Whether she has attended for the referrals
Examination:
-
Assess the personnel hygiene

Observe any behavioural changes
Check for signs of severe anaemia: pale complexion in fingernails, conjunctiva, oral
mucosa, tip of tongue and shortness of breath
Look for thyroid diseases, Dental hygiene, icterus, clubbing, cyanosis
Look for oedema: ankles, fingers, face, abdomen
Abdominal examination : feel for fundus , fundal height, fetal movements, fetal heart
sounds
Check urine for sugar and protein: If needed (women with renal disease, hypertension,
diabetes)
Interventions and actions:

-
Educate mother and care givers regarding danger signals during pregnancy
(antepartum haemorrhage, severe abdominal pain, severe headache), importance of
clinic visits, proper nutrition, monitoring of weight gain, working and mental wellbeing during pregnancy, items to be taken to the hospital for the delivery, ECCD, rest
and sleeping
51
Referrals should be done if needed- anaemia, severe headache, difficulty in breathing,

other difficulties
Emphasis the need of continuation of treatment for medical conditions
Check for compliance on taking micronutrients, food supplementation and medical
advice given in the clinic
Discuss with the family: place of delivery, actions to be taken in an emergency,
arrangement for transport
Give a date for third home visit
Confirm the attendance for antenatal class II
Give date and place for third antenatal class
Make records in 512 A, B , and in the diary
Home visit 3 (34- 36 weeks)

Objectives
1. To ensure the birth plan and preparedness for the hospitalization and delivery
2. To help the family to welcome the new member
3. To ensure breast feeding, ECCD activities and family planning
Ask:
-
For any complains, physical discomforts

Whether she feels fetal movements, and teach her how to maintain a kick count chart
About the support from the family
Check the compliance on taking micronutrients, food supplementation and medical
advice given in the clinic
Advice and check to prepare the essential items for both mother and baby during
hospitalization including transport
Ask about the present illnesses, changes in the vulva, oedema and headache, varicose
veins, dysuria, difficulty in breathing
Ask about the advices given in the clinics and see whether she is complying
Examination:
- Assess personnel hygiene
- Observe for any behavioural changes
- Check for signs of severe anaemia: pale complexion in fingernails, conjunctiva, oral
mucosa, tip of tongue and shortness of breath.
- Look for oedema: ankles, fingers, face, abdomen
- Examine abdomen and assess the fundal height compare with POA, check the lie and
presentation
- Listen to fetal heart sounds
- Check urine for sugar and protein- If needed (women with renal disease,
hypertension, diabetes)
52
Interventions and actions:

-
Educate and reconfirm what mother and care givers knew regarding signs of labour
Ensure that all the items need for delivery and hospitalization are ready
Aware the mother regarding vaginal examination, lithotomy position, pain

management, delivery on to abdomen (skin to skin contact with the baby),
importance of cooperation at the labour room, breathing exercises
Educate mother and the family members about the labour, breast feeding, family
planning, early childhood care development, obstetric emergencies: reduced fetal
movements, antepartum haemorrhage, dribbling, severe headache, abdominal pain,
and actions to be taken if she experience any of those, new born care, post partum
micronutrient supplementation, EDD and signs of labour
Discuss with the family: actions to be taken during an emergency, transport

arrangements in an emergency, care for other children while mother is in hospital,
family and social support after delivery
Discuss the breast feeding: including first feed, exclusive breast feeding, attachment,
positioning etc. and ensure that she has read the booklets on breast feeding
Infection control: importance of limiting visitors, handling of baby, hand washing
Advice to prepare the home environment to welcome the newborn
Services from the hospital: start breast feeding within the first hour of delivery and
exclusive breast feeding, BCG immunization, Vit. A mega dose, birth registration,
pregnancy record to be returned, CHDR, neonatal examination by a MO
Method to inform the PHM after delivery: telephone, messenger
Refer to an appropriate health facility if needed
Record the findings in the 512 A,B and complete the diary
If needed, complete LRT consent form
If they change the residence after delivery, ask them to inform the area PHM in the
new residence for postnatal care
53
Chapter 7
DOMICILIARY CARE FOR HIGH RISK PREGNANCIES

Please note all the high risk pregnant women should receive the routine domiciliary care described in the previous chapter.
Risk condition
Frequency of
home visits
Ask
Examine
Remarks
After 28 weeks
PHM should
provide
domiciliary care
every 4 weeks
Ask about fetal

movement
Routine examination
and focus more on FHS
from 20 weeks
Make aware on conditions which can cause still births

E.g. Gestational DM, Placenta abruption , cord round
the neck etc
Past Obstetric History

Previous still birth
(antenatal or
intrapartum) or
neonatal loss or
congenitally
malformed babies
Inquire about the

other risk conditions
eg. GDM, PIH
Ascertain that blood sugar levels checked.

Educate on danger signals
Ask pregnant woman:
to be more vigilant about fetal movements
to pay special attention to KCC after 36 weeks
to get admit as early as possible if she experience
reduced fetal movements
to get admit to hospital as early as possible if she gets a
severe abdominal pain, bleeding per vagina.
Reassure that it will not happened in consequent
pregnancies
Plan for delivery and emergency
Refer to post-partum clinic for neonatal examination
after delivery
54
History of 2 or more
consecutive first
trimester abortions
History of preterm
delivery before 37
weeks, or second
trimester miscarriage
During first
trimester, provide
domiciliary care
in every 4 weeks.
After that if no
risk conditions
identified, routine
antenatal
domiciliary care
Inquire about vaginal

bleeding , abdominal
pain
After 28 weeks
PHM should
provide
domiciliary care
once in 4 weeks
Inquire about lower

abdominal pain or
vaginal bleeding
Routine examination
Ask her to get admit as early as possible if she

experience abdominal pain or bleeding per vagina
See the compliance of medication and instructions given
by antenatal clinic/ specialized care units
If the reasons for the

abortions are other
medical condition,
act according to the
advice given.
Routine examination
and focus more on FHS
from 28 weeks
Ask her to avoid heavy work and get adequate rest

Ensure the family support for domestic work
Ask her to get admit as early as possible if she gets
lower abdominal pain or blood stained vaginal discharge
or per vaginal bleeding
Ask to prepare all the things need for the delivery
See the compliance of medication and instructions given
by antenatal clinic/ specialized care units
History of PHI
eclampsia/
preeclampsia
If high blood
pressure is not
detected in this
pregnancy,
Routine three
home visits are
adequate.
Ask about headache,

visual disturbances,
chest pain , shortness
of breath and
epigastric pain
Measure BP if possible
Check urine for albumin
during home visits.
Educate family members on signs and symptoms pre

eclampsia
Ask her to get admit if she experience any of those
symptoms
Ask her to check blood pressure at least once a month
and maintain the records.
Refer to a doctor if BP is high or if albumin is present in
urine or any sign of pre eclampsia
55
History of APH
History of retained
placenta or history
of postpartum
haemorrhage
Routine three
home visits are
adequate.
Routine three
home visits are
adequate.
History of caesarean
After 28 weeks,
section/ myomectomy domiciliary care
should be given
every 4 weeks
Ask about vaginal

bleeding and
abdominal pain
See whether USS has

done to confirm the
placental site
Ask about shortness

of breath while
moderate exercise
(features of anaemia)
See whether the reports

If anaemic, act according to the guidelines given.
of blood grouping and
Rh and Hb are available See the compliance on ironfolate and nutrition advice.
Ask for symptoms of

anaemia
Look for signs of

anaemia
Help her and the family to decide on place of delivery

(place with CEMOC facilities)
See whether the reports

of blood grouping and
Rh and Hb are available
Examine for scar

tenderness
Ask her to get admit if she experience abdominal pain,

vaginal bleeding and scar tenderness
See whether the USS is

done to confirm the
placental site
If so ask her to go to the hospital fasting due to

possibility of emergency section
Ask for abdominal

pain, vaginal
bleeding, pain in the
scar
Educate her to take nutritious iron rich diet.

Ask her to get admit as early as possible in case of
vaginal bleeding or abdominal pain.
Examine for signs of

aneamia
Look whether the Hb

and blood grouping and
Rh reports are available
See the compliance on ironfolate and nutrition advice
Help her and family to decide on place of delivery

(place with CEmOC facilities)
See the compliance on ironfolate and nutrition advice
History of surgery on
reproductive tract
(removal of septum,
cone biopsy, large
loop excision of
transformational
zones)
Monthly home
visits from the
registration
Ask for abdominal

pain or vaginal
bleeding
Examine for tenderness

in the abdomen
See whether intrauterine
pregnancy is confirmed
56
Ask mother to get admit as early as possible if she

experience severe abdominal pain during first trimester
Advice to get a scan done to confirm intrauterine
pregnancy
Check the compliance on medical advice given in the
specialized care unit
Birth with birth

weight <2500g
Monthly home
visits
Measure SFH
Ask her to take balanced nutritious diet
Check maternal weight

gain
Advise on adequate rest.
Check for FHS
Birth weight > 3500g
History of IUGR
Routine home
visits are
adequate, if there
is no additional
complication
Monthly home
visits
Inquire about the

Gestational DM
Ask for other risk

conditions (PIH)
Ask for chronic
diseases and
frequently occurring
conditions
Feeding difficulties/
history of breast
surgery
Refer to the clinic if SFH is less than POA
Measure SFH
Refer to the clinic if SFH is more than POA for USS

gain
Check whether screening for GDM has done
Check for FHS
Ask for fetal

movements
Ensure the family support on domestic work
Help mother to decide on place of delivery( with

CEMOC facilities)
Check urine for glucose

during home visit
Kick count chart after 36 weeks
Measure SFH
Reassure mother
Identify nutritional problems and intervene

gain
Ensure family support and adequate rest at home
Check for FHS
Monthly visits
during last
trimester
Inquire about the type of household work engaged in

Refer to the clinic if SFH is less than POA
Advice on breast feeding technique , how to express

breast milk and importance of breast feeding
57
Present pregnancy
Age less than 20
years
If she is less than

18 years monthly
home visits
See whether she has

gone to a specialized
unit
Ensure the antenatal clinic care

Ensure the help from the family or neighbours
Discuss the care during postnatal period
Discus about postpartum family planning
Discuss about Breast Feeding
Advanced maternal
age (Age> 35 years)
Height< 145cm
BMI <18.5kg/m2
If mother is more
than 40 years and
a primi need
monthly home
visits. For others
routine three
visits are
adequate
Ask for risk

conditions
(hypertension,
diabetes Mellitus)
Ask for fetal
movements
Check for SFH, FHS
Explain her about the risk of chromosomal

abnormalities, first trimester miscarriages associate with
the age
Ask her to be more vigilant on fetal movements after 36
weeks
Check whether
screening for GDM has
done
Ask her to admit as early as possible if she experience

reduced fetal movements
Routine three
visits are
adequate
See whether she has

gone for pelvic
assessment to a
specialized unit during
the third trimester
Explain her and family members about the process of

labour
Monthly home
visits until the
weight gain is
adequate
according to BMI
Check whether mother

is taking balanced
nutritious diet
Ask her to take a balanced nutritious diet
Help her to decide on place of delivery with CEmOC

facilities
Help her to decide the place of delivery with CEmOC

facilities.
Assess the level of physical activity and if she is

carrying out heavy work, discuss with her how to reduce
that kind of work.
Ensure the help of the family and adequate rest
58
BMI > 30kg/m2
Monthly home
visits
Ask for other risk

conditions such as
Hypertension, PIH,
GDM
Check whether
screening for GDM has
done
Measure SFH
Refer to the clinic if SFH>POA

Advice on dietary habits- low fat/ carbohydrates
Explain the risks of obesity/ overweight
Ask her to check blood pressure regularly
Look for lie and

presentation after 36
weeks
Primigravida
Routine three
visits are
adequate
Check for lie

presentation and head
engagement after 32
weeks
Educate on labour , labour pains, environment of the

labour room
Ensure the family support
Advise on the items to be taken to the hospital.
Educate on breast feeding and BF techniques
Parity (5 or more)
Monthly visits
Ask about the social

problems (GBV,
poverty, low
educational level)
Check whether the Hb

report is available
Ask her to get admit as soon as possible even with slight

lower abdominal pain closer to delivery
Help the her decide the place of delivery with EMOC
facilities
Ask about the

symptoms of anaemia
Discuss about the family planning method

Ensure the family support and arrangements for other
children
Multiple pregnancy
Monthly up to
second trimester
and two weekly
during third
trimester
Ask about the

vomiting and other
symptoms of
pregnancy during
first trimester
Check whether the Hb

report is available
Ask about the
Explain her about risk of having preterm labour and ask

to get admit as early as possible if she experiences any
lower abdominal pain close to term.
Check whether mother

has gone to a specialized Explain her about risk of PIH associated with multiple
unit
pregnancies and asked to BP checked regularly
59
Ask her to go to a specialized unit in case of an
symptoms of anaemia
emergency
Ask about other risk

conditions (PIH)
Advice on technique of breast feeding both babies

simultaneously
Advice on family planning methods
Advice on how to care twins
Emphasis on family support which is very much needed
after delivery
Diastolic BP more
than 90mmhg
Every two weeks

after detecting
high blood
pressure
Ask about severe

headache , visual
disturbances, chest
pain and shortness of
breath
Ask about fetal
movements
Check urine for
albumin
Refer to a medical officer if BP is high or if urine for

albumin is positive
Ask her to be fasting while getting admit to hospital in
case of emergency
Check the compliance

on antihypertensives and Help her to decide on place of delivery with C EmOC
the advice given at the
facilities
clinic
Educate the family members regarding danger signals
Check FHS
and the actions to be taken in an emergency
Uncertain dates /
irregular periods
Once the dates

are corrected,
routine three
home visits are
adequate
Ask about previously Check whether she has

used family planning gone for dating scan
method method used,
when did it stop, how
long she has used it,)
Refer for a dating scan before 20 weeks of POA
Intra uterine growth

retardation
Home visits
should be done
every two weeks
once IUGR is
detected
Ask for fetal

movements
Check whether dating

scan is done
Refer to specialized clinic for accurate dating and

regular USS with growth charts
Measure SFH
Ask mother to be more vigilant on fetal movements
Check FHS
Ensure the adequate rest
Check the maternal

weight gain
Ensure that the advice given by the clinics is followed.
60
Ask mother to be more vigilant on date of quickening
Mal-presentation and
abnormal lie after 34
weeks
Home visits every

2 weeks
Reassure mother
Refer to specialized unit
Vaginal bleeding (any

time)
Ask mother to get admit to hospital as early as possible
Maternal jaundice
Ask mother to get admit to hospital as early as possible
Maternal anaemia
(Hb 7- 11g/dl)
Monthly home
visits until the Hb
level is normal
Severe maternal
Two weekly
anaemia (Hb < 7 g/dl) home visits until
the Hb levels
normal
Maternal malaria
Maternal syphilis
Two weekly
home visits until
the condition
resolved
Monthly home
visits
Ask about the

Check whether warm
symptoms of anaemia treatment are taken
Ask mother to get Hb checked until the levels normal
Ask about the

symptoms of anaemia on advice given
Refer to a specialized unit for correction
Educate on taking iron rich diet

Check the compliance of
Educate on side effects of iron therapy
iron therapy
Give advice on micronutrients and diet
Check the use of bed

nets/ insecticide
impregnated bed nets
on malaria prophylaxis
treatment
Ask about symptoms Check the compliance
of other STIs (vaginal on the drugs given
discharge, itching of
vulva)
61
Give advice on micronutrients and diet
Refer to nearest hospital medical unit

Advise to use insecticide impregnated bed nets
Ensure the malaria prophylaxis treatment
Refer to the STD clinic as early as possible

Check the compliance on advice given
Educate on safe sex practices
Advice to get her partner screened for syphilis
Ensure the confidentiality of the information.
Maternal HIV
Monthly home
visits
Ask about symptoms

of other STIs(vaginal
discharge, itching of
vulva)
Check the compliance of Refer to the STD clinic

drugs given.
Advice to get her partner screened
Check the compliance on advice and treatment given
Explain the mother the risk of transmitting the HIV
infection to the baby is very low when mother is on
treatment for HIV
Discuss on Breast feeding
Refer to the MOH for further information
Other risk conditions

Diabetes Mellitus
Home visits in
every two weeks
Ask for fetal

movements
Check urine for sugar
Manage as decided by VOG and relevant specialists
Check for FHS
Educate mother and family members on diet
Monitor maternal
weight gain
Ask mother to mark kick count chart after 36 weeks
Measure SFH
Ask mother to get admit as early as possible if she

experience reduced fetal movements

with medical advice
Educate mother and family members on co- infections

eg:UTI, fungal infections
Help to plan the delivery in a CEmOC facility
Liver disease and

renal disease
Home visits in
every two weeks
Look for oedema (facial, Manage as decided by VOG and relevant specialists
finger, and abdomen)
Educate mother and family members on diet
Look for jaundice,
Delivery in a CEmOC facility
itching, clubbing etc.
Check urine for proteins
Monitor maternal
weight gain
62
Rheumatic and
congenital heart
diseases
Home visits in
every two weeks
Ask for shortness of

breath with exertion
eg. Climbing stairs
Look for features of

heart disease( ankle
odema, elevated JVP)
Advice to restrict work as advised by cardiologist/ VOG

Discuss about Family Planning
Delivery in a CEmOC facility
Ask for dyspnoea on

lying down
Ask whether she need
two or more pillows
for sleeping
Epilepsy
Mental disorders
Monthly home
visits
Monthly home
visits
Ask for the details of

last attack
Look for drug

compliance and places
that can endanger life in
the home environment
eg: unprotected wells ,
floor level fire places
Advice family members on what to do during an

epileptic attack, to take necessary precautions
Check compliance of
drugs
Educate on family members on the disease and advice

on family support
Explain the family members on importance of

compliance on drugs
Ask family members to seek medical advice in case of a

behavioural change of the mother
Explain that drugs can be used even during breast
feeding and not harmful for the baby
Explain family members that mental disorders can be
aggravated during post-partum period and to be more
cautious
Educate family members on postpartum psychological
disorders
63

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i

Family Health Bureau

Draft adaptation and writing by:

Director /Family Health Bureau

National Professional Officer, WHO

Dr. Ajith Mendis

Dr. Deepthi Perera

Dr. Nilmini Hemachandra

Acquired Immune Deficiency Syndrome

MOMCH Medical Officer-Maternal & Child

Anti Malaria Campaign

Expanded Programme of Immunization

Jugular Venous Pressure

Provincial Director of Health

Maternal Care Package A Guide to Field Healthcare Workers

Development of maternal care services in Sri Lanka

Maternal Care Package A Guide to Field Healthcare Workers

Maternal Care Package A Guide to Field Healthcare Workers

Maternal Care Package A Guide to Field Healthcare Workers

Institutional Framework for Providing Maternal Care

Maternal Care Package A Guide to Field Healthcare Workers

Maternal Care Package A Guide to Field Healthcare Workers

Service delivery and Achievements

Maternal Care Package A Guide to Field Healthcare Workers

BASIC PRINCIPLES OF MATERNAL AND NEWBORN HEALTH

Principles of delivering interventions

Maternal Care Package A Guide to Field Healthcare Workers

Programmatic Pathway to improve health status

Human, material and

Maternal Care Package A Guide to Field Healthcare Workers

Pregnancy care at FIRST LEVEL FACILITY

Interventions at REFERRAL FACILITIES

Maternal Care Package A Guide to Field Healthcare Workers

Child birth care

Companion of choice to support the woman during delivery

Child birth care at FIRST LEVEL FACILITY

Maternal Care Package A Guide to Field Healthcare Workers

Child birth care at REFFERRAL FACILITY

Postpartum care at FIRST LEVEL FACILITY

Postpartum care at REFFERRAL FACILITY

Maternal Care Package A Guide to Field Healthcare Workers

New born care

Promotion and provision of insecticide treated bed nets

Interventions at FIRST LEVEL HEALTH FACILITY

Interventions at REFFERRAL FACILITY

Maternal Care Package A Guide to Field Healthcare Workers

MATERNAL CARE MODEL IN SRI LANKA

Maternal Care Package A Guide to Field Healthcare Workers

Proposed Maternal Care Model

Early Registration of Pregnant Mother

Booking visit (clinic visit 1) 6-8 weeks

Field Clinic/ MO/

Shared care/ Out

Home visit 1 (612 weeks)