Focused antenatal and emergency Obstetric care

1. FOCUSED ANTENATAL
AND EMERGECY
OBSTETRIC CARE
Pavemedicine.com

2. FOCUSED ANTENATAL CARE (FANC)

3. BACKGROUND
 Previously, ANC visits were noted to have
non-focused visits which were regular with
long waiting times and poor feedback to the
women.
 Also in Tanzania in July,2002, it was noted
that;
• despite the high attendance of pregnant
women to the antenatal clinics MMR and IMR
were high.
• only 44% of pregnant women would deliver in
health facilities.
• In the same year WHO produced a model for
new antenatal care

4. BACKGROUND…..
 The design aimed at reducing the time and resources
necessary for ANC by :
• limiting the number of visits
• clinical procedures
• follow up actions to those that have been proven to be
effective in promoting positive maternal and neonatal
outcomes.

5. DEFINITON
 FANC is providing goal oriented care that is timely
,friendly ,simple ,beneficial and safe to pregnant
women. To achieve a good outcome for the mother and
baby and prevent any complications that may occur in
pregnancy, labour, delivery and postpartum.

6. Purposes of FANC
 Promote and maintain the physical , mental and
social health of mother and baby by providing
education on nutrition ,rest ,sleep and personal
hygiene
 Detect and treat conditions associated with
complication whether medical, surgical or
obstetric
 Ensure the delivery of a full-term healthy baby
with minimal stress or injury to mother and baby
 Help and prepare the mother to breast feed
successfully, experience normal puerperium and
take good care of the child physically,
psychologically and socially

7. What is effective ANC?
 Care from a competent provider and continuity of
care
 Preparation for birth and potential complications
 Focused content of routine Antenatal visits
 Promoting health through provision of Tetanus
toxoid, micronutrients supplementation and positive
self care practices such as adequate nutrition, avoid
tobacco, and alcohol use ,safer sex etc.
 Detection and treatment of disease such as:
HIV/AIDS, syphilis, tuberculosis, hypertension and
diabetes
 Early detection and management of complications
 Counsel on HIV/AIDS

8. Elements of FANC
 Early detection and management of
disease/abnormality
 Focused ANC visits

9. Early detection and management
of disease/abnormality
 Counseling on health promotion
 Birth preparedness
 Complication readiness
 Individual Birth Plan
Methods used:
• History taking
• Physical Examination
• Laboratory Test

10. Focused ANC visits
 There should be at least 4 thorough,
comprehensive, personalized antenatal
visits, spread out during the entire
uncomplicated pregnancy (WHO 2002)
 The first visit-As soon as pregnancy is
detected.
 The second visit should be in the 20th
-24th week [5th -6th month]
 The third visit should be in 28th -32nd
week [7th -8th month ]
 The fourth visit should take place in the
36th week [9th month]

11. 1st ANC VISIT
 screen, detect and treat such condition as anemia,
syphilis and malaria.
 begin the individualized birth plan and immunization
schedule
 Counsel on ITN use -“Hati Punguzo”
 Issue Iron and Folic Acid whether Anemic or not.

12. 2nd, 3rd and 4th visits…
 To confirm life of fetus , detect the
existence of any abnormalities and
finalize the individual birth plan .
 These visits are aimed at detecting
and managing conditions such as
multiple gestation, pre-eclampsia,
anemia and to further develop the
individualized birth plan.
NOTE:
 The basic tool for FANC is the ANC
Card Designed to cut across all major
aspects of Antenatal care.

13. ANC CARDS
 SECTIONS ON THE CARD
• Personal information
• Past obstetric history
• Risk factor identification
• Danger signs
• Physical examination
• Laboratory investigation
• Immunization records
• Counseling on family planning

14. Health promotion
 Diet and nutrition
 Rest in pregnancy
 Personal hygiene
 Danger signs in pregnancy
 Birth preparedness
 Use of drugs and immunization in pregnancy
 Protection from malaria ( ITNs and other protective
measures)
 Prevention from STIs/ HIV
 Care of breasts and breast feeding
 Avoiding harmful habits

15. Birth Preparedness and
Individual Birth Plan
 Each woman must be assisted to develop an
Individual Birth Plan (I.B.P). The plan includes
• Preparations for place of birth.
• Identifying a skilled attendant at birth.
• Identifying someone to take care of her family in her absence.
• Collection of essential items necessary for clean birth such as three
pairs of gloves, one roll of cotton wool, razor blades, syringes, piece
of soap and a pair of ‘khanga’ or ‘kitenge’.
• Identifying a blood donor.
• Identifying transport/funds in case of emergence and labour.
• Identifying a decision making family member to accompany the
mother to the hospital.

16. EMERGENCY
OBSTETRIC CARE
(EmOC)

17. DEFINITION
 Emergency obstetric care (EmOC) refers
to a series of crucial life-saving functions,
ideally performed in a medical facility,
which can prevent the death of a woman
experiencing the start of complications
during pregnancy, delivery, or the post-partum
period
 Maternal Mortality is the death of woman
while pregnant or within 42 days of
termination of pregnancy, irrespective of
duration or site, from any cause related
to or aggreviated by pregnancy or its
management, but not from accidental
causes.

18. RATIONALE
 Majority of maternal death are due to Direct Obstetric Causes. E.g PPH,
sepsis, abortion etc.
 Indirect causes (illnesses aggravated by pregnancy) are on the increase.
E.g Malaria, TB, HIV/AIDS, Diabetes etc

19. Major causes of Maternal mortality as
stated by WHO/UNICEF/UNFPA
• Hemorrhage
• Prolonged/obstructed labour
• Postpartum sepsis
• Complication of abortion
• Pre-eclampsia/Eclampsia
• Ectopic pregnancy
• Ruptured uterus

20. Basic EmOC
 Basic EmoC functions: (six signal
functions)
 Administer parenteral ( intravenous or by
intramuscular injection)
 Administer parenteral anticonvulsants
 Administer parenteral oxytocics
 Perform mannual removal of placenta
 Perform removal of retained products of
conception
 Perform assisted vaginal delivery
( vacuum extraction,forceps)

21. EmOC…..
 Comprehensive EmOC: ( eight signal functions)
In addition to the basic EmOC functions, a comprehensive
EmOC facility provides:
 perform surgery
 perform blood transfusion

22. Evidence based interventions
to reduce maternal mortality
 Ensure skilled attendance during pregnancy, labour,
delivery and postpartum
 Access to quality emergency obstetric care (EmOC)
 Minimize the barriers to access EmOC

23. SKILLED ATTENDANT AT DELIVERY, BY REGION
SKILLED ATTENDANT AT DELIVERY, BY REGION
42%
53% 52%
75%
99% 98%
120
100
80
60
40
20
0
N.AMERICA EUROPE LATIN AMER./
CARIB.
ASIA OCENIA AFRICA
PERCENTAGE

24. Barriers to accessing EmOC
The three delays
 To seek care
 To access care
 To receive appropriate care

25. Phases of delay

26.  The first two "delays" (delay in deciding to seek
care and delay in reaching appropriate care) relate
directly to the issue of access to care,
encompassing factors in the family and the
community, including transportation. The third
"delay" (delay in receiving care at health facilities)
relates to factors in the health facility. Unless the
three delays are addressed, no safe motherhood
programme can succeed.

27. Process indicators
 In 1997 UNICEF/WHO/UNFPA
introduced 6 process indicators to
monitor obstetric services.
 The process indicators measures
activities that lead to the desired goal
of reduction in maternal death.
 Together the 6 P.I give indication as
whether the services are given in
sufficient quantity,and women who
most need them, are infact using
them.

28. Process Indicators and minimal
acceptable level
Indicator Minimal Acceptable
level
Facilities For every 500,000
people, 4 facilities that
provides basic EmOC
and one that offers
comprehensive EmOC
Number of all births in
EmOC facilities
At list 15%of all births
Met need All women with
complications receive
EmOC
Number of Caesarian
Between 5 and 15% of

29. Study done on availability, distribution
and use of emergency obstetric care in
northern Tanzania

30.  The objective of this study is to determine the
availability, distribution and quality of facilities
providing delivery, as services well as their use
by pregnant women.
 The study is a survey of all facilities providing
delivery services (n=129) in six districts in
northern Tanzania. The framework provided by
the UNICEF/UNFPA/WHO (UN) Guidelines is
applied. An attempt is made to answer the first
three questions in this audit outline: are there
enough emergency obstetric care (EmOC)
facilities? Are they well distributed? And are
enough women using them?

31. Results
 The results show that there is a very
low availability of basic emergency
obstetric care (BEmOC) units (1.6/500
000), and a relatively high availability
of comprehensive emergency obstetric
care (CEmOC) units (4.6/500 000),
both with large urban/rural variation.
 The percentage of expected deliveries
in EmOC facilities is 36%, compared
with the UN Guidelines minimum
accepted threshold of 15%.

32. Results …..
 Nevertheless, the distribution shows a
much higher utilization in urban
districts compared with rural,
indicating that mothers have to travel
long distances to receive adequate
services when in need of them.
 The paper also discusses the
provisional context of the services in
terms of level of facilities providing
them and their public/private mix
 Most facility deliveries are conducted
at CEmOC facilities

33. Results….
 Pregnant women tend to utilize the
services of voluntary agencies to a
greater degree than government
services in rural areas, while the
government services have a higher
burden of the workload in urban areas
 A majority (86%) of the deliveries
occurring in voluntary agency facilities
occur in a qualified EmOC facility.

34. Recommendations
 There is a large potential for quality improvement, in
particular at dispensary and health centre levels. We
argue that the main barrier to access to quality care is
not the mother's ignorance or their ability to get to a
facility, but the actual quality of care meeting them at
the facility.