Prepared By : Group-A

 Safoora Syed
 Qurat-ul-Ann
 Razia Mushtaq
 Usama Mushtaq
 Asmat Jan
 Nuzhat Nazir
 Hedu Jan
UNDER GUIDANCE OF
Miss Salma Amin
Lecturer, FPNC
OBG
INTRODUCTION
 A Skilled Birth Attendant (SBA) is a healthcare professional who is trained and
certified to manage normal pregnancies, childbirth, and the immediate postnatal
period. They are also capable of identifying, managing, and referring complications
that may arise during pregnancy and delivery.
 The Skilled Birth Attendant (SBA) Module is a structured training program
designed to equip healthcare providers, such as midwives, nurses, and other health
professionals, with the necessary knowledge and skills to manage normal and
complicated deliveries. It aims to reduce maternal and neonatal mortality by ensuring
safe and effective childbirth practices.

Objectives of SBA Module

 Enhance Knowledge and Skills:
 Train healthcare providers in evidence-based practices for safe delivery and newborn
care.
 Improve Maternal and Neonatal Outcomes:
  Reduce maternal and infant mortality and morbidity through timely interventions and
proper management of complications.
 Promote Safe and Hygienic Practices:
 Emphasize infection prevention, proper handling of medical instruments, and
maintaining a clean birthing environment.
 Early Detection and Management of Complications:
 Identify high-risk pregnancies and manage complications such as hemorrhage,
eclampsia, and obstructed labour.
 Strengthen Communication and Counselling Skills:
 Support and educate pregnant women and families on prenatal care, birth
preparedness, and postnatal care.
 Encourage Teamwork and Referral Systems:
 Collaborate with higher-level healthcare facilities for timely referrals in case of
emergencies.
 Promote Respectful Maternity Care:
 Ensure the dignity and rights of mothers are respected during labor and delivery.
 Data Collection and Reporting:
 Maintain accurate records of births, complications, and maternal and neonatal
outcomes for monitoring and evaluation.

Pregnancy:

Pregnancy is the biological process in which a fertilized egg develops into a baby inside a
woman’s womb. It typically lasts about 40 weeks (9 months), starting from the first day of
the woman’s last menstrual period (LMP) to childbirth.

The Three Trimesters of Pregnancy:

1. First Trimester (Weeks 1-12):
o Key Developments:
 Formation of major organs and body systems.
 The heart begins to beat by the 6th week.
 Arms, legs, fingers, and facial features start to develop.
 o Symptoms:
 Nausea (morning sickness), fatigue, breast tenderness, and mood
swings.
o Risks:
 Higher risk of miscarriage during this period.
2. Second Trimester (Weeks 13-26):
o Key Developments:
 The baby’s movements (known as quickening) can be felt.
 Development of facial features and the ability to hear sounds.
 Growth of hair and nails.
o Symptoms:
 Decreased nausea, increased energy, and a growing belly.
 Back pain and leg cramps may start.
o Medical Tests:
 Ultrasound to check the baby’s anatomy and gender.
3. Third Trimester (Weeks 27-40):
o Key Developments:
 Rapid weight gain and development of the brain and lungs.
 The baby moves into the head-down position in preparation for birth.
 The baby’s bones harden.
o Symptoms:
 Frequent urination, swelling of feet, and shortness of breath.
 Braxton Hicks contractions (false labour pains).
o Preparation for Birth:
 The cervix begins to dilate, and labour contractions begin.
SIGNS OF PREGNANCY
1. Presumptive Signs of Pregnancy (Subjective Signs)
These are experienced by the woman but are not conclusive since they can also occur due
to other conditions.
 Amenorrhea: Absence of menstruation (one of the earliest signs).
 Nausea and Vomiting (Morning Sickness): Common in the first trimester due to
increased hCG levels.
 Breast Tenderness and Enlargement: Due to hormonal changes (estrogen &
progesterone).
 Fatigue: Increased progesterone levels cause tiredness.
 Frequent Urination: Due to increased blood flow to the kidneys and uterine pressure
on the bladder.
 Quickening: First fetal movements felt around 16-20 weeks (experienced only by the
mother).
 Changes in Skin Pigmentation:
o Chloasma ("Mask of Pregnancy") – Dark patches on the face.
o Linea Nigra – A dark line from the pubic area to the navel.
o Striae Gravidarum (Stretch Marks) – Appears on the abdomen, breasts, and
thighs.
2. Probable Signs of Pregnancy (Objective Signs)
These are observed by healthcare providers and indicate pregnancy but are not 100%
conclusive as they may be caused by other conditions.
Cervical and Uterine Signs:
 Goodell’s Sign: Softening of the cervix.
 Chadwick’s Sign: Bluish discoloration of the cervix, vagina, and vulva due to
increased vascularity.
 Hegar’s Sign: Softening of the lower uterine segment.
 Braxton Hicks Contractions: Irregular, painless uterine contractions starting in the
second trimester.
 Ballottement: When the fetus rebounds after gentle pressure is applied to the cervix.
 Enlargement of the Abdomen: Due to the growing uterus.
 Positive Pregnancy Test: Detection of hCG (Human Chorionic Gonadotropin) in
urine or blood.
(Note: Pregnancy tests can sometimes give false positives or negatives.)
3. Positive Signs of Pregnancy (Definitive Signs)
These are 100% confirmatory and indicate the presence of a fetus.
 Fetal Heartbeat Detection:
o By Doppler ultrasound (as early as 10-12 weeks).
o By a fetoscope (after 18-20 weeks).
 Fetal Movements Felt by Examiner: Around 20 weeks of pregnancy.
 Ultrasound Confirmation of Fetus:
o Visible fetal structures and heartbeat on ultrasound as early as 5-6 weeks.

Physiological Changes During Pregnancy

During pregnancy, a woman's body undergoes various physiological changes to support the
growing fetus. These changes affect multiple organ systems. Below is an overview of these
changes along with some important clinical signs observed during pregnancy.

1. Reproductive System
 Uterus: Increases in size from about 50g to 1000g by term.
 Cervix: Becomes soft and vascularized, leading to clinical signs such as:
o Goodell’s Sign: Softening of the cervix.
o Chadwick’s Sign: Bluish discoloration of the cervix and vagina due to
increased vascularity.
o Hegar’s Sign: Softening of the lower uterine segment.
 Vagina: Increased vascularization and secretions (leukorrhea).
 Ovaries: Ovulation ceases due to high progesterone levels.

2. Cardiovascular System
 Blood Volume: Increases by 40-50% to meet fetal and maternal needs.
 Cardiac Output: Increases by 30-50% due to increased stroke volume and heart rate.
  Blood Pressure: Slight decrease in the second trimester, then returns to normal.
 Physiological Anemia: Due to hemodilution (plasma increases more than red blood
cells).
 Venous Pressure: Increases, leading to edema and varicose veins.

3. Respiratory System
 Tidal Volume: Increases by 30-40%, improving oxygen supply.
 Diaphragm Elevation: Due to enlarged uterus, leading to shortness of breath.
 Respiratory Rate: Remains unchanged, but oxygen demand increases.

4. Gastrointestinal System
 Progesterone Effects: Causes relaxation of smooth muscles, leading to:
o Constipation due to reduced peristalsis.
o Gastroesophageal reflux (heartburn) due to relaxation of the esophageal
sphincter.
o Nausea and vomiting (common in the first trimester).

5. Urinary System
 Kidney Filtration (GFR): Increases by 40-50%, leading to increased urination.
 Bladder Compression: Due to uterine enlargement, causing frequent urination.

6. Endocrine System
 hCG (Human Chorionic Gonadotropin): Maintains corpus luteum for progesterone
production.
 Progesterone: Relaxes smooth muscles, prevents uterine contractions.
 Estrogen: Promotes uterine and breast growth.
 Relaxin: Softens ligaments and cervix for childbirth.

7. Musculoskeletal System
 Lordosis: Increased lumbar curve due to the growing abdomen.
 Pelvic Ligament Softening: Due to relaxin, causing waddling gait.

8. Skin & Breast Changes

 Breasts: Increase in size, with Montgomery’s tubercles (small bumps on areola).
 Linea Nigra: Dark line running from the pubis to the navel.
 Striae Gravidarum: Stretch marks due to skin stretching.
 Chloasma ("Mask of Pregnancy"): Darkened skin on the face due to hormonal
changes.
Antenatal Care (ANC) or Care During Pregnancy
Antenatal care (ANC) refers to the comprehensive healthcare provided to pregnant women to
ensure the well-being of both the mother and the fetus throughout pregnancy. It involves
regular check-ups, screenings, health education, and interventions aimed at detecting and
preventing complications.
Objectives of Antenatal Care
1. Ensure Maternal and Fetal Health: Monitor the health and development of the fetus.
Maintain the mother's physical and mental well-being.
2. Early Detection and Management of Complications: Identify high-risk pregnancies and
obstetric complications early. Manage common conditions like anemia, hypertension, and
diabetes.
3. Health Education and Counselling: Educate mothers about nutrition, personal hygiene,
and healthy lifestyle choices. Prepare families for childbirth and postpartum care.
4. Immunization and Prophylaxis: Administer necessary vaccines (e.g., tetanus toxoid).
Provide supplements like iron and folic acid.
5. Birth Preparedness and Complication Readiness: Develop a birth plan and educate on
recognizing danger signs. Inform about available healthcare facilities and transportation
options.
6. Promotion of Safe Delivery: Guide mothers on choosing skilled birth attendants and
health facilities.
7. Reducing Maternal and Neonatal Mortality: Timely intervention and care help reduce
mortality and morbidity rates.
COMPONENTS OF ANC
1. Registration and History Taking:
Early Registration: Preferably within the first trimester (up to 12 weeks). We also confirm
the pregnancy by retesting.
Detailed History: Including personal, obstetric, medical, surgical, family, and social history.
1. Personal History:
 Name, Age, and Address
 Marital Status
 Occupation
 Lifestyle Habits
2. Menstrual History:
 Age at menarche and menstrual cycle regularity.
 Last Menstrual Period (LMP) to calculate the Estimated Date of Delivery (EDD).
 Duration and flow of menstruation.
 History of dysmenorrhea or menstrual irregularities.
3. Obstetric History:
 Gravida and Parity: Number of pregnancies (Gravida) and number of deliveries
(Parity).
 Previous Pregnancies:
 Number of live births, stillbirths, and abortions.
 Complications: Eclampsia, preeclampsia, postpartum hemorrhage (PPH), or cesarean
section.
 Birth Outcomes: Preterm, full-term, or post-term deliveries.
 Neonatal Outcomes: Birth weight, congenital anomalies, neonatal deaths.
 Mode of Previous Deliveries.
 Inter-pregnancy Interval.
 Antenatal and Postnatal Complications.

4. Medical History:
Chronic Illnesses
Infectious Diseases
Allergies.
Medications
Past Illnesses
5. Surgical History:
 Past Surgeries.
 Gynecological Surgeries.
 Blood Transfusions.
 Anesthesia Reactions.
6. Family History:
 Genetic or Hereditary Disorders.
 Maternal and Paternal Health.
 Congenital Anomalies.
 Twin or Multiple Births.
7. Social history:
  Socioeconomic status.
 Support System.
 Nutrition and dietary habits.
 Environmental hazards.
 Domestic violence or abuse.

2. Routine Physical Examination:

General Examination:
 Height, weight, and BMI calculation.
 Vital signs: Blood pressure, pulse, and temperature.
 Edema assessment (for signs of preeclampsia).
Systemic Examination:
 Cardiovascular, respiratory, and abdominal examination.
Obstetric Examination:
 Leopold’s Maneuvers :- Leopold's maneuvers are a systematic series of four palpation
techniques performed on a pregnant woman's abdomen to determine the position,
presentation, lie, attitude, and engagement of the fetus. They are usually performed
after 28 weeks of gestation when the uterus is sufficiently enlarged.
STEPS
First Maneuver (Fundal Grip):
 Purpose: Determine the fetal part in the uterine fundus to assess presentation.
Procedure:
 Stand facing the mother's head.
 Use both hands to palpate the upper abdomen.
 Identify whether the fetal part is soft and irregular (buttocks) or firm and round
(head).
Findings:
 Buttocks: Indicates cephalic presentation.
 Head: Indicates breech presentation.

Second Maneuver (Umbilical Grip):

 Purpose: Determine the location of the fetal back and extremities to assess lie and
position.
Procedure:
 Stand to the side of the abdomen.
 Place both hands on the sides of the abdomen.
 Apply gentle pressure with one hand while feeling on the opposite side.
Findings:
 Smooth, firm surface: Fetal back.
 Irregular, knobby parts: Fetal limbs.
Third Maneuver (Pawlik's Grip or Pelvic Grip):
 Purpose: Determine the presenting part and its descent/engagement.
Procedure:
 Gently grasp the lower abdomen just above the symphysis pubis with the thumb and
fingers.
 Assess whether the presenting part is mobile or engaged.
Findings:
 Firm, rounded head: Indicates cephalic presentation.
 Soft, irregular breech: Indicates breech presentation.
 Ballotable (floating) head: Indicates not engaged.
Fourth Maneuver (Pelvic Grip):
  Purpose: Confirm the fetal attitude and degree of engagement.
Procedure:
 Face the mother's feet.
 Place both hands on either side of the lower abdomen.
 Move fingers inward to assess engagement and attitude.
Findings:
 Flexed head: Palpate the occiput on the same side as the back.
 Extended head: Palpate the sinciput on the opposite side of the back.

3. Laboratory Investigations:
Basic Tests:
 Hemoglobin estimation (to detect anemia).
 Blood grouping and Rh typing.
 Urine analysis for protein, sugar, and infection.
 Blood sugar testing for gestational diabetes.
 HIV, Hepatitis B, and syphilis screening.
 VRDL ( Venereal Disease Research Laboratory) test to rule out syphilis.
 Special Tests:
o Ultrasound scan for fetal growth and anomaly detection.
o Triple/quadruple marker tests for chromosomal abnormalities.

4. Nutritional and Supplementary Care:

 Iron and Folic Acid Supplements: To prevent anemia and neural tube defects.
 Calcium and Vitamin D Supplements: To support fetal bone development.
  Dietary Counseling: Balanced diet rich in proteins, vitamins, and minerals.
5. Immunization: Tetanus Toxoid (TT) Vaccine:
 Two doses given at least four weeks apart.
 Booster dose if previously immunized.
6. Health Education and Counselling:
Nutrition and Diet Advice: Emphasis on iron, protein, and folic acid intake.
 Personal Hygiene: Maintaining cleanliness to prevent infections.
 Physical Activity: Safe exercises and avoiding strenuous activities.
 Birth Preparedness: Planning for skilled attendance at delivery.
 Complication Readiness: Identifying danger signs such as bleeding, severe headache,
and reduced fetal movements.
7. Psycho-Social Support and Mental Health Care:
 Emotional Support: Addressing anxiety and stress related to pregnancy.
 Mental Health Screening: Identifying depression or other psychological issues.
8. Follow-Up Visits and Monitoring:
Frequency of Visits:

 According to GOI guidelines : Minimum of 4 visits are

recommended
 First visit: Within the first trimester (up to 12 weeks).
 Second visit: Around 20-24 weeks.
 Third visit: Around 28-32 weeks.
 Fourth visit: Around 36-40 weeks.
 Additional visits if any complications arise.
B. According to WHO guidelines : Minimum of 8 visits are
recommended
 1st Contact: Up to 12 weeks (preferably as early as possible)
 2nd Contact: At 20 weeks
 3rd Contact: At 26 weeks
 4th Contact: At 30 weeks
 5th Contact: At 34 weeks
 6th Contact: At 36 weeks
 7th Contact: At 38 weeks
 8th Contact: At 40 weeks
Purpose of Follow-Up:
 Monitor fetal growth and maternal health.
 Update the birth plan as needed.
 Ensure continued counseling and education.
IMPORTANCE OF ANC CARE
 Early and regular ANC visits are crucial for the early detection and management of
complications.
 Effective ANC contributes to safer deliveries and improved neonatal outcomes.
 Educates mothers about safe motherhood and newborn care, thus reducing maternal
and neonatal mortality rates.