1. 25-1
Pregnancy
Did you know this?
Boy or Girl? ....The man decides!
The woman’s egg only has X Chromosome. But the man’s sperms
can have either X or Y Chromosomes. If the man’s sperm is X
and it meets the woman’s egg which is always X, then a girl baby
(XX) will be born. But if a man’s Y sperm meet a woman’s X
egg, a boy (XY) will be born. So, it is the father’s sperms which
makes girls or boys.

2. 25-2
Pregnancy
Normal pregnancy lasts for 280 days on an average
from the last menstrual period (LMP). Roughly, it
Baby in the Uterus
lasts for 40 weeks (or 40 weeks X 30 days + 7 days = 277
days) but the actual range may be very different.
umbilical
placenta
cord
amniotic
To Calculate the Expected Date of Delivery (EDD) : fluid
Last mentrual period (LMP) + 9 months +
Seven days foetus
For example : If a woman had
her last menstrual period on
the 7th December, the her ex-
pected Date of delivery can be
calculated as:
7th December (7 /12/2001) + 9
months + 7 days = 14th Sep-
tember 2002
Similarly, a woman with her
last menstrual period on the
25th July 2001 should expect
her delivery on the 2nd of May
2002.
How to know that a woman is pregnant
1. No “Periods”: It is an important sign in those women who were getting regular “periods”
earlier. But this is not a sure sign as pregnancy may happen even in a girl who has not yet
started her “periods” or in women who are yet to regain their “periods” after delivery.
Though rare, a woman may get periods (“spotting”) in the first one or two months. In those
who have had no “periods”, the appearance of “periods like bleeding” may tell that the baby
inside is dead or dying.
2. Vomiting: In the first three months of pregnancy, nausea (feeling of vomit-
ing) and actual vomiting are common.
3. Painful Breasts: Mild pain maybe felt in the breasts
along with a feeling of “fullness” in the first few weeks of
pregnancy.
4. Frequent Urine : In the first few months, the growing womb is still
in the pelvis (hip bone area) and presses on the bladder. This may lead to
the woman wanting to pass urine more often.

3. 25-3
5. Breast Changes : As the pregnancy 6. Weight increase: A woman may gain
progresses, the woman’s breasts become 8 to 10 kilos in nine months. She gains less
enlarged. A darker area appears around than a kilo per month the first few months
the nipple and even a small bit of milk but more and more as she goes later in preg-
may come out. nancy.
7. Baby’s Heart Sounds: The
heart sounds of the baby can be
heard with a stethoscope from
the 4th month onwards. The best
place to look for the heart sounds
is halfway between the naval and
the hip bone on either side. A ba-
by’s heart sound varies between
120 and 160 per minute (almost
twice as fast as that of the mother).
8. Big Abdomen: From the 4th month onwards, the uterus grows out of the pelvis and the
abdomen starts looking bigger. For women who had irregular “periods” earlier, this may be the
first sign as she is unable to make out whether she has missed her periods because of pregnancy.
Learn to check the abdomen Feeling the womb can warn us of problems
If the Health Worker checks the ab-
domen, she can feel the uterus
(womb) as a slightly hard organ in
9 months
the abdomen. With one hand, push 8 months
the womb to her left side. With the 7 months
other hand reach the upper level of 6 months
the womb. 5 months The womb is
Compare the level with the weeks 4 months normally two
of pregnancy. 3 months fingers higher
(first felt in each month
a. If the level is too low, then it could the abdomen)
4 1/2 months
mean that the child is not growing prop-
(at level of
erly.
naval)
b. If the level is too high, it may be twins After 9th month until delivery, the baby may slip down to the pelvis.
or some other disease. Level comes down to that of the 8th month. But we can make out it is
the 9th month as the sides of the mother’s abdomen look full.
9. Foetal Movements & Foetal Parts: By the end of the 4th month,
most women should be able to feel the baby move inside the womb.
From the end of the 6th month, the health worker may be able to feel the
parts of the baby. The parts appear smooth on one side – the back of the
baby – and “knobby” (like knobs) on the other side – the folded elbows
and knees of the baby. On the upper and lower ends, a round part can
be felt. The harder of these round ends is the head and is usually felt
lower in the abdomen.

4. 25-4
ANTENATAL CARE
Care by a health worker must start even before pregnancy:
Ensure every adolescent girl has taken two T.T injections at a month’s inter-
val.
A woman married into the village has had two T.T injections.
A newly married woman gets to know all the methods of avoiding a baby.
Advise her to delay the first baby. Correct her anaemia if she is found to be
anaemic.
Make sure that every woman who has had an unsuccessful pregnancy earlier – abortion,
stillbirth (baby born dead), premature child (baby born before 9 months) or had difficulty in
labour, must be checked by a doctor.
Every woman who has had a disease like Rheumatic Heart Disease (RHD), diabetes or is on
medicines for some illness, should see a doctor before deciding to get pregnant.
Advise a woman above 45 years that a child born to her may not be normal and she should
avoid getting pregnant.
“Book” a pregnant woman
When we come to know that a woman is pregnant, we must get some time to speak to her. We
should record her details in our register book. This is called “booking” her.
Things to take note of while “booking” a pregnant woman:
1. Illnesses: Ask if she has had any illness or is on any treatment. Refer such women to a
doctor if you cannot cure her.
2. Previous pregnancy experiences: Ask her about her previous pregnancies. Refer
her if she has had twins or severe bleeding during or after delivery or fits in her
previous pregnancy. Even if her delivery took a long time, send her to a doctor
to see if she needs an operation for delivery this time.
Record the number of pregnancies, abortions and deliveries she has had
and also the number of children alive. A first child or a child born after a
number of attempts is precious. Refer her to a doctor for advice.
Record her Last Menstrual Period (LMP) and calculate her Expected Date
of Delivery (EDD).
Advise her 2 TT injections against Tetanus; one in th 4th month and
one in the 8th month
Record her pulse and Blood Pressure (B.P).
Check for anaemia and for any swelling in the feet. Give her Iron pills and
advise her a nutritious food.
Record the height of the womb as learnt earlier and measure against the
height it should be at. If there is too much of difference, refer to a doctor.
Listen to the baby’s heart sounds if possible and record it.
If you can feel the parts of the baby, record the findings in your register. Was
the head below or above? Was the back to the left or the right? Such
an examination must take place AT LEAST ONCE in the first three months and second three
months. In the last three months, there must be at least two examinations.
3. Refer to a doctor if:
a. The B.P is high.
b. The anaemia is not improving but has got worse.
c. There is swelling of the feet.
d. The baby (womb) is not matching the height by LMP.
e. She complains of bleeding and squeezing backache in the pregnancy.

5. 25-5
Advice to a pregnant woman
• Reassure her that you will be able to help her with advice during pregnancy.
• If the woman has never given birth earlier, explain to her the stages of delivery so that she
knows what to expect.
• Towards the end of pregnancy, she and her family must be advised to make some
arrangements to rush her to a hospital in case there is an emergency.
Get ready for an emergency
The fastest form of transport to a “hospital” in case of an
emergency. A vehicle / bullock cart, or handcart or even enough
men to carry the woman should be kept ready.
Some money, in case of an emergency which may arise.
Get ready for a normal Delivery from the 7th month onwards
A clean bed or room that can be used for delivery. Keep ready plenty
Washed and properly “sunned” clothing to spread below the of washed & sun
woman and to clean her during delivery. dried clothes for
A new unused blade and some string. delivery
Things to explain to the pregnant woman
a. Food that she eats : Pregnant women must take about 1 ½ times (or
50% more) food than what she was normally having. Proteins (preferably
from animal sources like fish, prawn and snails, lean pork, beef, milk etc,
should be increased. Pregnant women need more Calcium and Iron. Daal
and green vegetables are rich sources of iron and calcium. Since many
women are anyway anaemic, it is suggested that they are given two tab-
lets of Iron a day from the fourth month onwards.
b. Rest and exercise: Advise the pregnant woman not to do heavy work
or heavy exercise. All other work may be carried on.
All women must be taught to strengthen the muscles of their genital
area. Tell her to tighten and loosen the muscles of her genital area as if
she is trying to hold back her urine. This exercise should be repeated 10
to 20 times every day. Doing this will keep the womb and vagina from
Ask pregnant women to slipping later on.
get help in heavy work.
Much before delivery it would help to teach women to relax between delivery pains. Ensure that
the woman gets enough sleep. If needed, CHLORPHENIRAMINE two tablets at night can also
help her sleep well.
c. Shitting:
Many women have constipation. Advise them to take enough fluid and take more foods
with fibre - like vegetables, onions and green leafy vegetables.

6. 25-6
d. Sex:
Reassure women that they can continue having sex during pregnancy without any prob-
lems. They should not have sex only if they have had abortion or bleeding in their earlier
pregnancies.
Squeeze out
e. Breasts:
the nipples
Pregnant women must give attention to the breasts. The everyday.
baby will not be able to use a poorly developed nipple.
Pinch at the base of the nipple to see whether it comes
out or not. If not, advise mothers to pull out the nipples
everyday in the last few months of pregnancy.
Mothers must keep their breasts clean. Washing with plain water is enough. If the skin of
the nipple is dry, ask the mother to put milk, or milk cream or oil (olive oil is best) on it.
It a brassiere (bra) is worn, it should be well fitting but must not press on the nipples.
f. Vomiting:
Vomiting especially in the morning is common in pregnancy in the second and third month.
Nausea and retching instead of actual vomiting is common.
Usually, only comforting the woman is enough. If she is not able to eat any-
thing, she may be asked to take PROMETHAZINE 25mg (commonly sold as
AVOMINE or PROMET) or MECLIZINE (commonly sold as PNV or
PREGNIDOXIN). These are considered safe for pregnant women.
DO NOT use METOCLOPRAMIDE in pregnant women.
If vomiting continues even after the 3rd month or it does not allow
refer to doctor if
the woman to eat anything, refer to a doctor. It may be serious.
severe vomiting
g. Itching in Vulva: j. Leg Swelling
Some women may get severe itch- Swelling of legs is common in the last two
ing in the vulva (birth opening). months of pregnancy. But two other diseases
The area becomes red and she could make legs swell in pregnant women:
could also get white cheesy dis- a. High B.P of pregnancy: Refer to doctor.
charge from the vagina. This is usu- b. Low protein in blood: Treat by giving foods
ally due to fungal infection for with protein like eggs, meat, soyabean, daal
which MICONAZOLE Cream may etc.
be given. The itching can also be
due to TRICHOMONAS infection Ask such women to raise their feet up (above
(Check page 15-14 in Phase II Manual). the head) while lying down or when sitting.
h. Night Cramps
Cramps in the leg at night are also
common. Calcium tablets might
help. Good sleep is important.

7. 25-7
ABNORMAL PREGNANCY
1. Bleeding before Delivery (called Ante-Partum Haemorrhage or APH)
Any bleeding from vagina after the 6th month is called APH.
Usually, the amount of blood that comes out is not much. There
may be mild pain in the abdomen or if we press the abdomen
it may pain. This is a serious emergency. RUSH to a hospital.
What causes bleeding before delivery?
Bleeding may be due to direct injury to the abdomen - like an accident or even a
Bleeding before
kick by a drunken husband. Bleeding could also happen if a half-trained birth
delivery can be
helper tries to change the position of the baby. It is also seen that a mother’s smok-
serious.
ing can also cause bleeding. Most women who bleed before delivery are seen to
Refer to a doctor
have high B.P or pass protein in their urine.
immeditely!
Bleeding could lead to shock DO NOT try (or let any-
The bleeding may be so serious that the one else try!) to examine
woman may go into shock. The wom- the bleeding woman’s
an’s B.P falls lower than 90/60 mm Hg, parts by putting in an in-
Pulse goes beyond 90 per minute, Lips &
strument or fingers. This
toes may turn blue. At times the bleeding cannot be seen
i.e. it is internal or hidden. But that can also cause shock.
may turn a trickle of
In other words, checking the amount of bleeding is not blood to a flow of blood
important. Checking the B.P and pulse of the patient is and can even kill!
more important. RUSH TO A HOSPITAL.
2. Tubal Pregnancy
Rarely the sperm and the egg after meeting do not go to the womb. The pregnancy
develops in the fallopian tube itself! As there is no space, the tube tends to burst.
Sharp pain in the lower abdomen on the left or right side with mild bleeding in a
pregnant woman are signs of tube pregnancy. RUSH TO A HOSPITAL.
3. Large Abdomen
There are two main reasons for this:
a. Twins : 1 in 80 pregnancies result in twins. We can know this if we can feel
two heads and also by hearing heart sounds of two different babies. The
abdomen looks very large.
b. Extra Fluid in sac : At other times the abdomen looks like that of a twin
pregnancy but the reason is different. There is a large amount of fluid around
the baby. Some women may be able to make out that the baby makes a lot
of movement. The large abdomen may make it difficult for the woman to
breathe or even to digest food. The health worker might find it difficult to
feel the parts of the baby or to hear its heart sounds.
What can happen in large abdomen? What to do in large abdomen?
Whether it is twins or extra fluid, chances of se-
rious haemorrhage or serious bleeding is possi-
Always advise such women to be near
ble after delivery. When the fluid is more, the a hospital for their delivery. Or, in-
baby can move around more easily in the womb. sist that relatives or friends be close
This increases the chances for some abnormal by and make arrangements for quickly
part of the baby (like the buttocks or arms or moving the woman to the hospital in
even the cord) to come out first. This can cause
complications in the delivery.
case of an emergency.

8. 25-8
4. High B.P of Pregnancy
High B.P of women is seen after the 5th month of pregnancy, usu-
ally during the last part. In High B.P of Pregnancy, at least 2-3 signs
are seen:
a. High B.P b. Swelling of feet c. Protein in urine
Some of these women may get fits (convulsions) that may kill the baby
or the mother. Because of this we should learn to detect high B.P in preg-
nancy and manage it.
a. High B.P
An increase of 30 mm Hg in sysytolic B.P (the upper part) and 15 mm Hg in diastolic B.P (lower part) over
the baseline, seen on two different occasions is considered High B.P of pregnancy.
NOTE: The limit of 140 / 90 mm Hg being the upper limit of
normal B.P does not hold good for pregnancy! Note the baseline B.P when the
woman is not pregnant or early in the pregnancy.
b. Swelling of feet c. Protein in Urine
Check by pressing on the ankles to see if a de- Take urine of a pregnant woman in a clean
pression is made. However this is very com- bottle. Heat the top layer of the urine with a
mon in the last part of pregnancy. Nowadays, candle. If a whitish ring is seen, we will know
unless swelling is seen in the face or fingers, it that there is protein the in the urine.
is not counted as High B.P of pregnancy.
Who gets High B.P of Pregnancy ?
High B.P of pregnancy is usually seen in women getting pregnant for the first time and
are above 35 years of age.
Such women complain of severe and persistent headache in the forehead and may vomit.
These are warning signs of possible fits or convulsions and should be taken seriously.
Treating High B.P of Pregnancy
Bed rest is the most important part of the treatment. The
aim should be to continue with the pregnancy till the 9th
month (36 weeks) to allow the baby to grow and mature.
After this, no risk should be taken and a hospital deliv-
ery (by operation if necessary) should be advised. Bed Rest is needed
If fits are seen, RUSH TO A HOSPITAL. The more the
fits the higher the risk to the mother and to the baby.
5. POST MATURITY
Some women do not get labour and give birth even days after the Expected Delivery
Date. It is unwise to allow a baby to grow beyond two weeks of the EDD (ascertain EDD
as certain as possible). If too long in the womb, the mother’s supply may not be enough
for the baby’s growth. Also, the big size would be a problem during delivery.
If 42 weeks have passed after the LMP (last menstrual period)
refer the mother to the doctor for starting delivery.

9. 25-9
Know the Answers
Pregnancy
Please fill in the blanks:
1. If a woman’s LMP is 26th January 2002, her child is expected for delivery
on _________ day of ____ month, 2002.
2. The womb is first felt in the abdomen after the _______ month of delivery.
It reaches the naval by the ___________ month and then reaches the top of the
abdomen by ____ month.
3. The breast in pregnancy becomes _________ and the area around the nipple
becomes ___________.
4. On feeling a pregnant woman’s abdomen, feeling a smooth part means
____________ of the baby and knobby parts means that the ________ of the baby
are being felt.
5. The normal heart of a baby in the womb should be between _____ and ____ per
minute.
6. Twins and Extra Fluid in Sac may lead to more _____________ after the second
stage of labour.
Please mark if “right” or “wrong”:
1. A pregnant woman must be referred for high B.P
of Pregnancy if her B.P is more than 140/90 mm Hg.
2. Pregnant woman must avoid sex at all cost.
3. Bleeding before delivery must always be referred to a doctor.
4. METOCLOPRAMIDE tablets may be given to pregnant
women to avoid vomiting.

10. 25-10
My Notes