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Antenatal Care Module: 9. General Assessment of the Pregnant Woman

Study Session 9  General Assessment of the Pregnant Woman

Introduction

This study session shows you how to conduct a general assessment of the pregnant woman’s health status during an antenatal visit. You should make all of these assessments every time you see her for antenatal care. For each assessment, we first describe the signs and symptoms that indicate the pregnant woman is in good health. Then we describe the warning signs and symptoms that may indicate health problems that may lead to a serious complication of pregnancy, including anaemia, diabetes, poor nutrition, iodine deficiency, hypertension, fever, infection, lung and kidney problems.

Later in this module, you will learn about the most serious complications of pregnancy in more detail — HIV infection in Study Session 16; premature rupture of the fetal membranes in Study Session 17; anaemia, malaria and urinary tract infections in Study Session 18; hypertension, pre-eclampsia and eclampsia in Study Session 19; and bleeding in early and late pregnancy in Study Sessions 20 and 21.

Learning Outcomes for Study Session 9

When you have studied this session, you should be able to:

9.1  Define and use correctly all of the key words printed in bold. (SAQ 9.1)

9.2  Know how to assess a pregnant woman for pallor, nutritional status, pulse rate, blood pressure, temperature, shortness of breath, and sugar in the urine. (SAQs 9.2 and 9.3)

9.3  Identify the healthy signs and symptoms of pregnancy and the possible warning signs and symptoms of pregnancy complications, based on these assessments. (SAQs 9.2 and 9.3)

9.1  Checking for symptoms of poor nutrition or lack of iodine

When you begin an antenatal visit, one of the first things you should ask the pregnant woman is if she has any symptoms that suggest poor nutrition or lack of iodine in her diet. This is very important, because poor maternal nutrition is associated with poor pregnancy outcomes like a small baby, and the child may be short in stature. The questions you ask her should aim to find out if she has any of the following warning symptoms (i.e. things she notices herself):

Warning symptoms

  • Not wanting to eat
  • Not gaining weight
  • Weakness and general ill-health
  • Sores, rashes, or other skin problems
  • Sore or bleeding gums
  • Stomach problems or diarrhoea
  • Burning or numbness of the feet.

The effects of iodine deficiency are:

A woman with goitre
Figure 9.1  Goitre may be a warning sign of lack of iodine in the diet.
  • Goitre (swelling in the front of the neck caused by iodine deficiency; Figure 9.1)
  • Short children
  • Children with deafness
  • Children with cretinism, a disability that affects thinking.

If you suspect that a pregnant woman’s health is poor due to inadequate nutrition, or lack of iodine in her diet, advise her about good nutrition and iodine supplementation. You will learn how to do this in Study Session 14 of this Module.

9.2  Checking her weight

Healthy weight gain

A woman in good health steadily gains between 9 to 12 kilograms during pregnancy. This is the same as 1 to 2 kilograms each month. However, routine weight measurement is not necessary for antenatal care because it is not a reliable indicator of pregnancy outcome. A woman with only a little weight gain can have a normal pregnancy outcome, though this is unusual.

Important!Warning sign A pregnant woman who gains weight suddenly near the end of her pregnancy should be referred to the nearest health centre.

If a woman gains weight suddenly near the end of her pregnancy, it may be a sign of twins, or pre-eclampsia (high blood pressure and protein in the urine appearing for the first time during pregnancy).

9.3  Checking her temperature

Body temperature is a measurement of how hot or cold the internal tissues of the body are. Although it varies a little bit in hot or cold weather, or if the person is wearing too many or too few clothes, or doing heavy physical work, it generally stays close to a value known as ‘normal’ temperature, unless the person is ill. Body temperature is measured using an instrument called a thermometer (Figure 9.2a), which has a ‘bulb’ at one end, usually filled with a silver liquid metal called mercury. (Some glass thermometers contain a red dye instead, and some use digital technology — see Figure 9.2b.) In a glass thermometer, when the bulb of mercury is warmed by a person’s body, the mercury expands and rises up the thin glass tube, which is marked with numbers showing the person’s body temperature.

A glass thermometer and a digital thermometer
Figure 9.2  (a) Glass thermometers may measure temperature in degrees Celsius (top) or Fahrenheit (below). (b) A digital thermometer shows the temperature as a number in a window.

Healthy temperature

Normal temperature is close to 37°C, or just under 98°F. The woman does not feel hot to touch.

Warning sign

The woman has a fever — a temperature of above 37.5°C (or 100°F) or above. She feels hot to touch.

A HEP feeling the forehead of a client to see if she has a high temperature
Figure 9.3  You can easily feel if she is hotter than you.

9.3.1  How to check her temperature

If you don’t have a thermometer, put the back of one hand on the woman’s forehead, and the other on your own, or that of another healthy person (Figure 9.3). If the woman has a fever, you should be able to feel that her skin is hotter than that of a healthy person.

Shaking a thermometer
Figure 9.4  Shake the mercury to below 36°C.

If you have a glass thermometer, clean it well with soap and clean water, or alcohol. Hold the thermometer with the ‘bulb’ containing the silver mercury pointing away from your hand. Shake it with a snap of the wrist (Figure 9.4), until the top of the thin column of silver mercury falls well below ‘normal’ body temperature, i.e. less than 36°C (or 96°F).

Put the bulb end of the thermometer under the woman’s tongue or in her armpit, and leave it there for three minutes. The woman should keep her mouth closed, or her arm close to her body.

Take the thermometer out and turn it until you see the silver line. The point where the silver stops marks the temperature. There is usually a little arrow at the ‘normal’ point.

  • What temperature is showing in Figure 9.2a?

  • The mercury has risen to about 39.6°C – a high fever.

Always clean the thermometer with soap and cool water, or with alcohol, after you use it. Do not use hot water — it can break the thermometer! Mercury is a very poisonous metal. Be careful with glass thermometers, and if they break, do not pick up the mercury with your bare hands. Sweep the mercury into a jar and bury it. Do not let children play with thermometers or mercury. Get a digital thermometer if you can (Figure 9.2b).

9.3.2  What to do if the woman has a fever

A fever can be caused by:

  • Sickness — for example, flu or malaria
  • An infection of part of the body — like a bladder infection, or an infection of the uterus
  • A mild fever can also be caused by dehydration (loss of body fluids due to not drinking enough water).

Important!If the fever does not come down in 8 hours, refer her to a health centre.

A high fever needs to be lowered right away. To lower a fever:

  • Give 500 to 1,000 mg (milligrams) paracetamol by mouth every four to six hours
  • Have her drink one cup of fluid every hour
  • Wash her body with a cloth dipped in cool water.

9.4  Checking her pulse

Feeling for the pulse on the side of the throat and the wrist
Figure 9.5  Use two or three fingers (never your thumb) to feel the pulse in the neck or inside of the wrist.

The pulse tells you how fast the heart is beating. Every time the heart beats (contracts) it pushes blood out into the arteries. You can feel each ‘pulse’ by pressing gently on an artery with your fingers. Everyone’s pulse is different. That is normal. You can find the pulse in the throat or wrist, as shown in Figure 9.5.

Healthy pulse

The normal pulse rate is about 60 to 80 beats a minute when the woman is resting.

Warning sign

The pulse rate is 100 or more beats a minute when the woman is resting.

9.4.1  How to measure her pulse rate

Wait until the woman is resting and relaxed. Put the pads of two fingers on the pulse (Figure 9.6). Do not use your thumbs, because there is a little pulse in your own thumbs which could confuse you.

A woman sitting in a relaxed position while a HEP measures her pulse rate
Figure 9.6  Make sure the woman is sitting in a relaxed position when you measure her pulse rate.

If you have a watch with a second hand, or there is a clock with a second hand, count the number of beats in the mother’s pulse for one minute. Write the number down.

At first, have someone look at the watch or clock for you, and tell you when one minute has passed. Many people find it hard to count accurately while looking at a watch. They tend to count one pulse beat every second, no matter how fast the pulse is really beating.

If you do not have a watch with a second hand, check the pulse anyway. You can learn to tell if it is slow, normal, or fast compared to your own pulse, and to other women’s.

9.4.2  What to do if the woman has a fast pulse

Important!If you do not know what is causing the fast pulse rate (above 100 beats per minute), refer the woman to the nearest health centre.

If her pulse rate is 100 beats or more a minute, she may have one or more of the following problems:

  • Stress, fear, worry, or depression
  • Anaemia
  • An infection like malaria
  • Bladder infection, or infection in her uterus
  • Heavy bleeding
  • Thyroid trouble
  • Heart trouble.

9.5  Checking for signs of anaemia

When someone has anaemia, it usually means the person has not been able to eat enough foods with iron. Iron helps the red blood cells carry oxygen from the air we breathe to all parts of the body. Some kinds of anaemia are caused by illness, not lack of iron. And some kinds of anaemia are inherited (genetic) and cannot be cured by eating iron-rich foods or taking iron pills. You will learn about a blood test for anaemia, and the treatment of anaemia during pregnancy, in Study Session 18, later in this Module.

A woman with pallor
Figure 9.7 Pallor may be a sign of anaemia.

Healthy signs and symptoms

General good health and plenty of energy. The woman does not have pallor (see below).

Warning signs and symptoms

  • Pallor — paleness inside the eyelids, pale fingernails and gums (Figure 9.7)
  • Dizziness or fainting
  • Weakness or tiredness
  • Fast pulse (over 100 beats a minute)
  • Difficulty breathing (shortness of breath).

9.6  Checking for shortness of breath

Healthy respiration

Some shortness of breath, especially late in pregnancy, is normal. Many women get a little short of breath when they are 8 or 9 months pregnant.

  • What do you think causes this?

  • As the baby gets bigger, it squeezes the lungs so there is less room to breathe. Breathing may get easier when the baby drops lower in the belly shortly before labour begins.

A woman finding it hard to breathe
Figure 9.8  Shortness of breath can be a warning symptom.

Warning symptom

If shortness of breath is making a pregnant woman uncomfortable, this is a warning symptom, especially if she has other signs of illness (Figure 9.8).

Shortness of breath can also be caused by:

  • Anaemia
  • Heart problems
  • Tuberculosis
  • Asthma
  • Lung infection
  • A blood clot in the lung
  • Allergies.

Important!If a pregnant woman has trouble breathing all of the time, or severe trouble even once, or if you think she may have any of the illnesses listed, refer her to a health centre.

9.7  Checking her blood pressure

Blood pressure (BP) refers to how hard the blood is ‘pushing’ on the walls of the major blood vessels as it is pumped around the body by the heart. The pressure is measured in millimetres (mm) of mercury (a liquid silver metal, which has the chemical symbol Hg), so blood pressure measurements are expressed as a number followed by mmHg. We will show you how to measure blood pressure in Section 9.7.1.

Doctors and nurses call the top number the systolic pressure (pronounced ‘siss toll ick’). They call the bottom number the diastolic pressure (pronounced ‘dye ass toll ick’).

A blood pressure measurement is two numbers written one above the other. The top number tells you the woman’s blood pressure at the moment when her heart ‘beats’ and pushes blood out into her body. The bottom number tells you her blood pressure when her heart relaxes between each beat, so it can refill with blood.

Healthy blood pressure

Normal blood pressure stays between 90/60 mmHg (you say this aloud as ‘ninety over sixty millimetres of mercury’,) and below 140/90 mmHg (‘one hundred and forty over ninety millimetres of mercury’). It does not go up much during pregnancy.

Warning signs

High blood pressure is known medically as hypertension and is a warning sign. The woman has high blood pressure if either of these is true:

  • The top number is 140 or above.
  • The bottom number is 90 or above.

Very low blood pressure (less than 90/50 mmHg) is also a warning sign, which is usually caused only by heavy bleeding or shock (a dangerous reduction in blood flow throughout the body). This is a very dangerous situation.

A woman with very low blood pressure should be referred to the nearest health centre immediately.

The heart is like a pump, pumping blood through the body. High blood pressure means that the heart must work harder to press the blood through tight or shrunken blood vessels (veins and arteries). Blood pressure numbers show how hard the blood has to press. Note that blood pressure is not the same as pulse. You can have a slow pulse with a high blood pressure.

It is very important to check the mother’s blood pressure at every antenatal visit and refer her to a health centre if it is too high.

When a woman has high blood pressure during pregnancy, it is harder for her blood to bring food and oxygen to the baby via the placenta. (You learned about this in Study Session 5.) The baby then grows too slowly. Very high blood pressure can also cause the woman to have kidney problems, bleeding in the uterus before birth, or bleeding in the brain (stroke). It can also be a sign of pre-eclampsia, which can cause premature birth, bleeding, convulsions, or even death for the mother.

9.7.1  How to check blood pressure

There are several types of blood pressure equipment (Figure 9.9).

Blood pressure equipment with a tall gauge and a round and a stethoscope.
Figure 9.9  Blood pressure equipment may have a tall gauge (left) or a round one (middle). You will also need a stethoscope (right).

When you take the woman’s blood pressure, first tell her what you are going to do, and why. Make sure she is sitting or lying comfortably and feels relaxed. Figure 9.10 shows the process step by step.

Diagram showing how to measure blood pressure
Figure 9.10  Diagrams 1 to 7 show you how to measure blood pressure.

As the air leaks out, you will start to hear the woman’s pulse through your stethoscope. Notice where the needle is (see Figure 9.11), or where the column of mercury stops if you have a tall gauge (as on the left of Figure 9.9).

A round blood pressure gauge, pressure is indicated by a needle
Figure 9.11  This gauge is round, and the pressure is indicated by a needle. The other type of blood pressure equipment has a tall gauge with a vertical column of silver mercury and numbers at the side (left image of Figure 9.9); the top of the silver column indicates the blood pressure.

Important!If a woman’s blood pressure is ever higher than 140/90, then it is too high and can be a warning sign. She needs to be referred to a health centre.

You can record the woman’s blood pressure:

  • when you start to hear the pulse (this will be the top number), and
  • when the pulse disappears or gets very soft (this will be the bottom number). Check the woman’s blood pressure at each visit.
    Diagram showing that it is normal for a woman’s blood pressure to go up and down a little from month to month
    Figure 9.12  Record the woman’s blood pressure as shown in this example.
  • Write the blood pressure down on her antenatal record card so you can check for changes over time (see the example in Figure 9.12). If her blood pressure is going up, ask her to come back every week until you are sure that it is not still rising.
  • Look carefully at Figure 9.12. Is there a month in which this woman’s blood pressure is high enough to be a warning sign?

  • No. The top number never goes above 110, and the bottom number never goes above 72. It is normal for each number to vary a little bit from month to month.

9.8  Checking for diabetes

When a woman has diabetes, her body cannot use all the sugar in her blood, so it stays too high and some of it may appear in her urine.

Warning signs and symptoms

If a woman has some of the following warning signs, she may have diabetes. Women with diabetes do not always have all of these signs. But the more signs a woman has, the more likely it is that she has diabetes.

A woman urinating
Figure 9.13  Frequent urination may be a warning symptom of diabetes.
  • She had diabetes in a past pregnancy.
  • One of her past babies was born very big (more than 4 kilograms); this is because the excess sugar in the mother’s blood makes the baby put on excess weight.
  • One of her past babies was very ill or died at birth and no one knows why.
  • She is fat.
  • She is thirsty all the time.
  • She has frequent itching and a bad smell coming from her vagina.
  • Her wounds heal slowly.
  • She has to urinate more often than other pregnant women (Figure 9.13).
  • Her uterus is bigger than normal for how many months she has been pregnant.

9.8.1  Urine tests for diabetes

There is a urine test for diabetes that you can do at the Health Post and a more reliable blood test that can only be done at a health centre.

The dipstick test

If a woman has the warning signs or symptoms listed above, and you suspect she may have diabetes, test her urine in the following way. You will need the urine testing ‘dipsticks’ supplied for your Health Post. The dipsticks have strips of a chemical at one end that changes colour when it reacts with sugar.

  • Ask the woman to urinate in a clean container. If possible, collect a sample of ‘mid-stream’ urine (i.e. the urine she produces after the first trickle; stop collecting before she completely empties her bladder).
  • Hold the dipstick by the end opposite the chemical strips, and dip the end with the chemical strips into the fresh urine. Take it out immediately.
  • Remove excess urine from the dipstick by drawing it along the rim of the container.
  • Hold the dipstick horizontally before reading the result.
  • If there is excess sugar in the urine, it will react with the chemical on the dipstick. The colour will change from light green to brown, depending on the amount of sugar in the urine.
A simple urine test she can do at home
Ants attracted to sugar in the urine of someone with diabetes
Figure 9.14  Ants are attracted to sugar in the urine of someone with diabetes.

If a woman has the warning signs and symptoms listed on the previous page, but she seems reluctant to visit a health centre for the blood test, or you don’t have dipsticks to test her urine, you can advise her on a simple test she can do at home. Ask her to urinate into a clean container like a pot or a cup, and leave the container outside. If ants climb into the container (Figure 9.14), there is probably sugar in the woman’s urine — a sign of diabetes. Tell the woman to make sure she tells you if the sign is there! Seeing the evidence herself may be enough to convince her to go to the health centre for confirmation of the diagnosis and to get treatment.

9.8.2  How to help a woman with diabetes

If you think that a woman has diabetes, she should get medical help. She should plan to have her baby in a hospital.

Sometimes diabetes in pregnancy will improve if the woman eats a good diet and exercises. She must eat a variety of healthy foods, avoid candy and sugar, and eat frequent, small meals. But diabetes can make a woman very sick and can make childbirth more dangerous. Her baby may be very big, have birth defects, or it may become very ill and die after the birth. Sometimes medicine is needed to prevent serious problems.

9.9  Checking for a vaginal infection

The normal vaginal discharge is not smelly, it is small in amount, and it does not stain or wet the underwear.

Warning symptoms

If a pregnant woman has an infection in her vagina, the signs are:

  • Whitish or curd-like discharge
  • Bad-smelling discharge
  • Itching of the external genitalia (look back at Figure 3.2 in Study Session 3 to remind yourself of the anatomy of the female genital area)
  • The vulva could be swollen
  • There may be burning during urination
  • The woman may report she has pain during sex.

If a pregnant woman has an abnormal discharge, or reports any of the other symptoms listed above, refer her to the nearest health centre as soon as possible.

9.10  Conclusion

In this study session, you have learned how to make a routine assessment of a pregnant woman at an antenatal visit, and identify healthy or warning signs and symptoms and the possible actions you should undertake. You have learned how to assess women for poor nutrition, pallor, shortness of breath, hypertension, fever, diabetes and vaginal infection. You have learned how to measure temperature, pulse and blood pressure, and test for sugar in the urine. In the next study session, you will learn how to conduct an examination of the pregnant woman’s abdomen to measure the height of her uterus. This helps you to know whether the fetus is growing normally during the pregnancy.

Summary of Study Session 9

In Study Session 9, you have learned that:

  1. At every antenatal visit you should assess all pregnant women for signs and symptoms of poor nutrition or iodine deficiency, including pallor, lack of energy and goitre.
  2. Most women gain 9-12 kg during a normal pregnancy, but weight gain is not a reliable indicator of pregnancy outcome. Sudden weight gain near the end of pregnancy is a warning of possible pre-eclampsia and the woman should be referred to a health centre.
  3. Fever (a temperature of above 37.5°C) should be treated initially with fluids, paracetamol and cold sponging. Refer a pregnant woman to a health centre if her temperature stays high. She needs to be screened for infections such as malaria.
  4. If the pulse rate rises above 100 beats per minute, it is a sign of ill health and the woman needs referral to a health centre.
  5. Signs and symptoms of anaemia include pallor, tiredness, fast pulse and shortness of breath. Refer pregnant women with these characteristics.
  6. Shortness of breath is usual near the end of pregnancy as the growing baby crowds the mother’s lungs. Refer her if it causes major discomfort.
  7. If the blood pressure of a pregnant woman reaches 140/90 mmHg or higher, she has hypertension. All hypertension in pregnancy is a serious illness, which requires immediate referral to a health centre.
  8. Abnormal vaginal discharge, itching or swelling of the external genitalia, and burning or pain when urinating or during sex, are symptoms of vaginal infection, and the woman should be referred.

Self-Assessment Questions (SAQs) for Study Session 9

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 9.1 (tests Learning Outcome 9.1)

Match each of the diagnoses with its associated warning sign or symptom.

Using the following two lists, match each numbered item with the correct letter.

  1. pallor

  2. neck swelling

  3. fever

  4. larger uterus than expected for this stage of pregnancy

  5. high blood pressure

  • a.Diabetes

  • b.Pre-eclampsia

  • c.Malaria

  • d.Anaemia

  • e.Goitre

The correct answers are:
  • 1 = d
  • 2 = e
  • 3 = c
  • 4 = a
  • 5 = b

SAQ 9.2 (tests Learning Outcomes 9.2 and 9.3)

Which of the following statements is false? In each case, say why it is incorrect.

A  Maternal goitre is caused by iron deficiency.

B  Maternal diabetes often results in a big baby.

C  Shortness of breath may be caused by anaemia, a heart problem, lung infection or a blood clot.

D  A blood pressure of 90/50 mmHg is a sign of good health.

E  A pulse rate of 80 beats per minute or less is a possible warning sign of anaemia.

F  Blood pressure and pulse rate should be measured when the woman is sitting comfortably.

Answer

A is false. Goitre is caused by iodine deficiency, and not by iron deficiency.

B is true. Maternal diabetes often results in a big baby because the mother has too much sugar in her blood, which makes the baby fat.

C is true. Shortness of breath may be caused by anaemia, a heart problem, lung infection or a blood clot.

D is false. A blood pressure of 90/50 mmHg is very low, and is a characteristic sign of heavy bleeding or shock. In such a case the woman has to be referred to a health centre right away.

E is false. Normal resting pulse rate is 60-80 beats a minute. A fast pulse (100 beats a minute or above) may be a sign of anaemia.

F is true. Blood pressure and pulse rate should be measured when the woman is sitting comfortably.

SAQ 9.3 (tests Learning Outcomes 9.2 and 9.3)

At an antenatal visit to see Zufan, you record the following measurements:

  • Temperature: 37.2°C
  • Pulse rate: 96 beats a minute
  • Blood pressure: 142/100 mmHg

Should you refer Zufan to a health centre? Explain why or why not.

Answer

You should refer Zufan immediately. Although her temperature is close to normal and gives no cause for concern, her pulse rate is faster than normal, and her blood pressure is very high — the top and the bottom numbers are both above the warning level of 140/90 mmHg.