The antenatal contact: a skills session

Key messages to land

1. At least eight contacts; the first by 12 weeks.
2. BP at every contact; 140/90 or more after 20 weeks needs a urine protein check.
3. Iron 30 to 60 mg and folic acid 0.4 mg daily for everyone; 120 mg iron daily for anaemia.
4. IPTp-SP from 13 weeks, at least a month apart, at least three doses, where malaria is endemic in Africa.
5. Severe pre-eclampsia: magnesium sulfate loading dose, lower BP of 160/110 or more, transfer. Never leave her alone.
6. Every woman leaves knowing the danger signs and her birth plan.

Running the pre-eclampsia drill

• Make it real: start a timer when the "woman" arrives. Most groups take too long to find and draw up the drug the first time.
• Check the arithmetic: 4 g IV of 20% solution, then 10 g of 50% solution, 5 g in each buttock. Ask: how many mL is 5 g of 50%? (10 mL.)
• Ask who checks the breathing rate, reflexes and urine before any repeat dose, and where the calcium gluconate is.
• If your facility stocks a different antihypertensive, practise with that one.

Common misunderstandings

"Swollen feet mean pre-eclampsia"

Oedema of the feet is not a reliable sign. Measure BP and check protein.

"Folic acid 5 mg is better"

For routine antenatal use WHO recommends 0.4 mg; high doses may stop SP working for malaria prevention.

"Weekly iron treats anaemia"

Weekly iron is a preventive option only. Anaemia needs 120 mg elemental iron daily.

"Four visits is enough"

WHO now recommends at least eight contacts because more contacts mean fewer perinatal deaths.

"Give diazepam for fits"

Magnesium sulfate is the recommended anticonvulsant for eclampsia and severe pre-eclampsia.

Adapting the session

For community health workers, replace the magnesium sulfate drill with a danger-signs role-play and a referral exercise, and focus on supplements, birth planning and follow-up of missed contacts. Where malaria is not endemic, drop IPTp and spend the time on the birth and emergency plan.

Case 1: Case 1: The preventive package

Mrs F is 18 weeks pregnant with her second baby. She lives in an area of high malaria transmission where hookworm is common and diets are low in calcium. Hb today 114 g/L. She had one tetanus vaccine dose as a teenager. She has not had IPTp yet.

1. What does she need today?
   Answer: Daily iron 30 to 60 mg with folic acid 0.4 mg; calcium 1.5 to 2.0 g a day in three doses with meals, several hours apart from iron; first dose of IPTp-SP (she is past 13 weeks); one dose of tetanus toxoid-containing vaccine; deworming (after the first trimester, endemic area); a bed net; a birth and emergency plan.
2. When is her next IPTp dose?
   Answer: At her next scheduled contact (20 weeks if she is seen then, or 26 weeks), provided at least one month has passed since the last dose. Aim for at least three doses.

Case 2: Case 2: The pre-eclampsia drill

Mrs G, 35 weeks, is brought in with a severe headache and pain under the ribs on the right. BP 168/114, repeated 166/112. Urine protein 3+. She is alert. The hospital is 90 minutes away by ambulance.

1. Classify and give the first steps.
   Answer: Severe pre-eclampsia. Give the magnesium sulfate loading dose (4 g of 20% IV over 5 minutes, then 10 g of 50% deep IM, 5 g in each buttock with lidocaine). Lower BP with the antihypertensive your facility uses (for example oral nifedipine immediate-release, repeated after 30 minutes if needed). IV line, catheter if possible, and arrange urgent transfer.
2. What goes with her in the ambulance?
   Answer: A health worker who stays with her, calcium gluconate 1 g (10 mL of 10%) and a syringe, the next magnesium sulfate dose if transfer will be long, and a referral note with BP readings, times and doses given.

Case 3: Case 3: Two women with anaemia

Mrs H is 14 weeks pregnant with Hb 96 g/L; she has some palmar pallor and no breathlessness. Mrs I is 30 weeks pregnant with Hb 64 g/L; she is breathless when she walks and her breathing rate at rest is 32 per minute.

1. Classify each woman.
   Answer: Mrs H: first trimester, Hb 96 g/L, moderate anaemia (70 to 99 g/L). Mrs I: Hb below 70 g/L with fast breathing, severe anaemia.
2. What do you do for each?
   Answer: Mrs H: elemental iron 120 mg daily with folic acid 0.4 mg until Hb is 110 g/L or more, malaria test and treat where endemic, deworm after the first trimester if indicated, reassess in 4 to 6 weeks. Mrs I: refer urgently; start double-dose iron; she must plan to give birth in a facility with blood transfusion.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. When should the first antenatal contact take place?
   1. Up to 12 weeks
   2. At 16 weeks
   3. At 20 weeks
   4. When she feels the baby move
2. What is the minimum number of antenatal contacts WHO recommends?
   1. Four
   2. Six
   3. Eight
   4. Twelve
3. What daily folic acid dose goes with routine antenatal iron?
   1. 0.4 mg
   2. 1 mg
   3. 5 mg
   4. 10 mg
4. IPTp-SP doses should be given at least how far apart?
   1. 1 week
   2. 2 weeks
   3. 1 month
   4. 3 months
5. Which is a reliable sign of pre-eclampsia?
   1. Swollen feet
   2. BP 140/90 or more with proteinuria after 20 weeks
   3. Weight gain
   4. Back pain
6. What is the IM loading dose of magnesium sulfate that follows the 4 g IV dose?
   1. 2 g in one buttock
   2. 5 g in each buttock (10 g in all) of 50% solution
   3. 10 g in each buttock
   4. 1 g every hour
7. Before a repeat magnesium sulfate dose, which must be present?
   1. Breathing at least 16 per minute, knee reflexes, urine at least 30 mL per hour
   2. BP below 140/90
   3. A normal fetal heart
   4. Hb over 100 g/L
8. In the second trimester, anaemia is Hb below:
   1. 100 g/L
   2. 105 g/L
   3. 110 g/L
   4. 120 g/L
9. What daily elemental iron dose treats anaemia in pregnancy?
   1. 30 mg
   2. 60 mg
   3. 120 mg
   4. 300 mg
10. Which is a danger sign that means "go to the facility at once"?
    1. Heartburn
    2. Leg cramps
    3. Severe headache with blurred vision
    4. Constipation

Answer key

1. A. The WHO model starts with a contact in the first trimester, up to 12 weeks.
2. C. At least eight contacts.
3. A. 400 micrograms (0.4 mg) daily, which also avoids interfering with SP.
4. C. At least one month apart, starting from 13 weeks.
5. B. Oedema of the feet is not reliable; raised BP with proteinuria after 20 weeks is.
6. B. 10 g of 50% solution: 5 g deep IM in each buttock.
7. A. If any is missing, delay or withhold the dose; calcium gluconate is the antidote.
8. B. 105 g/L in the second trimester; 110 g/L in the first and third.
9. C. 120 mg daily until Hb is 110 g/L or more, then back to the preventive dose.
10. C. Also vaginal bleeding, convulsions, fever with weakness, severe abdominal pain, fast or difficult breathing.