ANM / Multi-Purpose Health Assistant (Female) · Chapter 7

Maternal Health and Midwifery

What to remember

Antenatal care (ANC) means regular check-ups from early pregnancy: early registration, at least four visits, Td injections, iron-folic acid tablets, and screening for danger signs.
Labour has four stages. The partograph records progress, and active management of the third stage (oxytocin, cord traction, uterine massage) prevents bleeding.
The biggest killers of mothers are bleeding (haemorrhage), high blood pressure (pre-eclampsia and eclampsia), infection and obstructed labour. Early detection and quick referral save lives.

Basic terms and definitions

Gravida is the number of times a woman has been pregnant. Para is the number of pregnancies that reached viability (28 weeks or more in older books, 20 weeks in many current definitions) and ended in birth.
Antenatal period is from conception to the start of labour. Intranatal period is labour and delivery. Postnatal period (puerperium) lasts 6 weeks after delivery.
Maternal mortality ratio (MMR) = maternal deaths per 100,000 live births. Maternal death is death of a woman during pregnancy or within 42 days after its end, from causes related to or made worse by pregnancy, but not from accident.
Expected date of delivery (EDD) by Naegele's rule: take the first day of the last menstrual period (LMP), add 7 days, subtract 3 months (or add 9 months). Example: LMP 10 March gives EDD 17 December.
Term pregnancy is 37 completed weeks to less than 42 weeks. A preterm birth is before 37 weeks. A post-term pregnancy is 42 weeks or more.

Signs of pregnancy and fundal height

Presumptive signs: missed period, nausea and vomiting (morning sickness), breast changes, frequent urination, tiredness.
Probable signs: enlarged abdomen, Hegar's sign (softening of the lower uterus), Chadwick's sign (bluish vagina), positive urine pregnancy test, ballottement.
Positive (sure) signs: foetal heart sounds, foetal movements felt by the examiner, and foetus seen on ultrasound.
Foetal heart rate is normally 120 to 160 beats per minute.
Fundal height (approximate): the uterus is just above the pubic bone at 12 weeks, near the umbilicus at about 24 weeks, and near the lower end of the breast bone (xiphisternum) at about 36 weeks. Between 20 and 34 weeks the height in cm is roughly equal to the weeks of pregnancy.

Antenatal care

Register every pregnancy early, ideally in the first three months. Open the Mother and Child Protection card.
Minimum four ANC visits: first in the first trimester, then one in the second trimester (14 to 26 weeks) and two in the third trimester (28 to 34 weeks and 36 weeks to term). Women with problems are seen more often.
At each visit: weight, blood pressure, haemoglobin, urine for albumin and sugar, abdominal examination for fundal height and foetal position, and foetal heart sounds.
Tests: blood group and Rh factor, haemoglobin, urine, blood sugar, HIV and syphilis screening, malaria where needed, and ultrasound when advised.
Td vaccine: two doses 4 weeks apart for a first pregnancy, or one booster if she had Td/TT in the last three years.
Iron and folic acid (IFA): one tablet daily (60 mg elemental iron + 500 mcg folic acid, Anemia Mukt Bharat) for 180 days starting from the fourth month, and continued for 180 days after delivery. Calcium supplements are also given.
Diet and rest: extra about 350 kcal daily in the second and third trimesters (ICMR-NIN), more protein, green leafy vegetables, plenty of fluids, and 8 hours of sleep plus daytime rest.
Danger signs in pregnancy: vaginal bleeding, severe headache with blurred vision, swelling of face and hands, convulsions, fever, reduced or absent foetal movements, leaking of water before labour, severe breathlessness, severe pallor.
Anaemia in pregnancy: haemoglobin below 11 g/dl is anaemia. Below 7 g/dl is severe anaemia, which needs referral.
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): free check-up by a doctor on the 9th of every month at government facilities.

Trimester	Weeks	Main care points
First	1 to 12	Registration, tests, folic acid, treat vomiting, avoid drugs and X-rays
Second	13 to 26	Td, IFA, calcium, quickening (first movements felt around 18 to 20 weeks)
Third	27 to term	Birth plan, check position, spot pre-eclampsia, plan place of delivery

Labour and delivery

First stage: from true labour pains to full dilatation of the cervix (10 cm). It has a latent phase (up to 4 cm) and an active phase (4 to 10 cm).
Second stage: from full dilatation to birth of the baby.
Third stage: from birth of the baby to expulsion of the placenta and membranes. Normally within 30 minutes.
Fourth stage: the first 1 to 2 hours after the placenta comes out. Watch for bleeding, uterine tone and blood pressure.
Partograph: a graph to record labour progress. Plot cervical dilatation, descent of the head, contractions, foetal heart rate, maternal pulse, blood pressure and temperature. The graph starts when dilatation is 4 cm. The alert line rises 1 cm per hour from 4 cm. The action line is 4 hours to the right of the alert line. If the plot crosses the action line, refer to a higher centre.
Normal presentation: vertex (head first), with the occiput anterior position.
Active management of the third stage (AMTSL): (1) oxytocin 10 IU intramuscular within one minute of birth, (2) controlled cord traction after signs of separation, (3) uterine massage after the placenta is out.
Check the placenta for completeness: missing parts cause bleeding and infection.
Episiotomy is a cut in the perineum to widen the outlet. It is repaired with sutures after the placenta is delivered.
Clean delivery: clean hands, clean surface, clean blade, clean cord tie and clean cloth for drying the baby. Use a new sterile blade to cut the cord.

Immediate newborn care

Dry the baby, keep warm, and place skin to skin on the mother's chest.
Clear the airway only when needed. If the baby does not cry or breathe, start bag-and-mask ventilation within the first minute, called the golden minute.
Apgar score at 1 and 5 minutes: heart rate, breathing, muscle tone, reflex response and colour. Each is scored 0 to 2, so the total is 0 to 10. A score of 7 to 10 is normal.
Delay cord clamping for about 1 to 3 minutes. Cut the cord with a sterile blade, leave it dry, and apply nothing.
Start breastfeeding within one hour. Give exclusive breastfeeding for the first six months.
Give BCG, oral polio zero dose and hepatitis B birth dose, and vitamin K as per protocol.
A baby weighing less than 2,500 g at birth has low birth weight. Kangaroo mother care (skin-to-skin contact and exclusive breastfeeding) helps these babies.

Postnatal care

The mother and baby stay at the facility for at least 48 hours after delivery.
Postnatal visits: within 48 hours, on day 3, day 7, and at 6 weeks (more visits for home deliveries by health workers).
Check pulse, temperature, blood pressure, bleeding, uterine firmness, breasts, perineum and bladder.
Lochia: the vaginal discharge after delivery. It is red for the first days (lochia rubra), pale (lochia serosa) up to about day 10, and white-yellow (lochia alba) for up to about 6 weeks.
Danger signs after delivery: heavy bleeding, foul-smelling discharge, fever, severe abdominal pain, breast pain with redness, convulsions, and low mood that does not go away.
Counsel on breastfeeding, nutrition, iron tablets, hygiene, family planning and the baby's immunisation.

Complications that every health worker must know

Complication	Key point	First action
Antepartum haemorrhage	Bleeding after 28 weeks (placenta praevia, abruption)	Do not do a vaginal examination, refer urgently
Postpartum haemorrhage (PPH)	Blood loss over 500 ml after vaginal birth	Massage uterus, oxytocin, empty bladder, refer
Pre-eclampsia	BP 140/90 or more after 20 weeks with protein in urine	Rest, refer to a doctor
Eclampsia	Convulsions with pre-eclampsia	Magnesium sulphate, protect airway, refer
Obstructed labour	Labour not progressing despite strong pains	Refer early, avoid delay
Puerperal sepsis	Infection after birth with fever and foul discharge	Antibiotics, refer

Magnesium sulphate (MgSO4) is the drug of choice to prevent and treat eclamptic convulsions. The loading dose is 4 g IV and 10 g IM (5 g in each buttock).
Ectopic pregnancy: pregnancy outside the uterus, most often in the fallopian tube. Signs are pain in the lower abdomen, a missed period and bleeding. It is an emergency.
Abortion: loss of pregnancy before 20 weeks (viability). Under the Medical Termination of Pregnancy Act, termination is legal for specified reasons by a registered medical practitioner. The law was amended in 2021 to allow longer limits for certain special categories.
Rh incompatibility: an Rh-negative mother with an Rh-positive baby is given anti-D immunoglobulin to protect later pregnancies.

Government programmes for safe motherhood

Janani Suraksha Yojana (JSY): cash support to encourage delivery in a health facility.
Janani Shishu Suraksha Karyakram (JSSK): free delivery, free caesarean, free drugs, tests, diet, blood and transport (home to facility, between facilities, and back home) for mothers and sick newborns up to one year.
LaQshya: improves quality of care in labour rooms and operation theatres.
Pradhan Mantri Matru Vandana Yojana (PMMVY): cash support for pregnant and lactating women for the first live birth, and for a second child if it is a girl (PMMVY 2.0, from 2022).
Surakshit Matritva Aashwasan (SUMAN): assured respectful, free care for every mother and newborn.
In Andhra Pradesh the ward health secretary and ANM, with the ASHA, track pregnant women, and 108 ambulance services help transport mothers.

Exam traps

Naegele's rule: add 9 months and 7 days (not subtract 7 days).
Para counts births, not babies. Twins are one para.
Haemoglobin below 11 g/dl is anaemia in pregnancy, but below 7 g/dl is severe.
The partograph starts at 4 cm dilatation, not at the beginning of labour pains.
The action line is 4 hours right of the alert line, not 2.
Oxytocin in AMTSL is 10 IU intramuscular, not intravenous bolus.
PPH is more than 500 ml after vaginal birth (1,000 ml is the common limit after caesarean).
Lochia alba is the last stage, and lochia rubra is the first.
Magnesium sulphate treats eclampsia, and it is not a blood-pressure drug of first choice.
JSY is a cash support scheme, but JSSK gives free services.

One-liners

1. EDD = LMP + 9 months + 7 days.
2. Minimum antenatal visits: four.
3. IFA for 180 days in pregnancy and 180 days after delivery.
4. Normal foetal heart rate: 120 to 160 beats per minute.
5. Normal term: 37 to under 42 weeks.
6. Apgar score ranges from 0 to 10.
7. Low birth weight: less than 2,500 g.
8. Puerperium lasts 6 weeks.
9. AMTSL oxytocin dose: 10 IU intramuscular.
10. Anaemia in pregnancy: haemoglobin below 11 g/dl.
11. Eclampsia drug: magnesium sulphate.
12. PMSMA check-up day: 9th of every month.

Practice questions

A woman's last menstrual period began on 10 March. Using Naegele's rule, her expected date of delivery is:
1. 24 December
2. 17 December
3. 10 December
4. 17 November
Answer
B. 17 December
LMP + 7 days = 17 March; minus 3 months = 17 December.
The term 'gravida' means:
1. the number of living children
2. the number of times a woman has been pregnant
3. the number of deliveries by caesarean
4. the number of abortions only
Answer
B. the number of times a woman has been pregnant
Gravida counts all pregnancies, whatever the outcome.
Maternal mortality ratio is expressed per:
1. 1,000 population
2. 1,000 live births
3. 10,000 live births
4. 100,000 live births
Answer
D. 100,000 live births
MMR = maternal deaths per 100,000 live births.
The minimum number of antenatal visits recommended for every pregnant woman in the national programme is:
1. six
2. four
3. two
4. three
Answer
B. four
At least four ANC visits are advised.
The daily iron-folic acid tablet for a pregnant woman contains:
1. 200 mg elemental iron and 1 mg folic acid
2. 60 mg elemental iron and 100 mcg folic acid
3. 30 mg elemental iron and 500 mcg folic acid
4. 100 mg elemental iron and 500 mcg folic acid
Answer
D. 100 mg elemental iron and 500 mcg folic acid
Standard IFA tablet: 100 mg iron + 500 mcg folic acid, for 180 days in pregnancy.
In pregnancy, severe anaemia is defined as haemoglobin below:
1. 5 g/dl
2. 11 g/dl
3. 9 g/dl
4. 7 g/dl
Answer
D. 7 g/dl
Below 11 is anaemia; below 7 is severe anaemia needing referral.
Which is a positive (sure) sign of pregnancy?
1. Morning sickness
2. Foetal heart sounds heard on examination
3. Missed period
4. Hegar's sign
Answer
B. Foetal heart sounds heard on examination
Foetal heart sounds are a sure sign; the others are presumptive or probable.
The normal foetal heart rate per minute is:
1. 80 to 110
2. 120 to 160
3. 180 to 220
4. 60 to 100
Answer
B. 120 to 160
Normal range is 120 to 160 beats per minute.
The fourth stage of labour is:
1. the first 1 to 2 hours after the placenta is expelled
2. from birth to expulsion of the placenta
3. from onset of pains to full dilatation
4. from full dilatation to birth of the baby
Answer
A. the first 1 to 2 hours after the placenta is expelled
Fourth stage is close observation after placenta delivery.
The partograph is started when cervical dilatation reaches:
1. 10 cm
2. 6 cm
3. 2 cm
4. 4 cm
Answer
D. 4 cm
Plotting begins in the active phase at 4 cm.
On a partograph, the action line is drawn:
1. 4 hours to the right of the alert line
2. at 10 cm dilatation
3. 2 hours to the left of the alert line
4. 1 hour to the right of the alert line
Answer
A. 4 hours to the right of the alert line
If the plot crosses the action line, refer.
Oxytocin used in active management of the third stage is given as:
1. 10 IU intravenous bolus after 30 minutes
2. 10 IU intramuscular within one minute of birth
3. 20 IU subcutaneous after the placenta
4. 5 IU oral
Answer
B. 10 IU intramuscular within one minute of birth
AMTSL begins with 10 IU IM oxytocin within a minute.
Postpartum haemorrhage after a vaginal birth is blood loss of more than:
1. 250 ml
2. 100 ml
3. 50 ml
4. 500 ml
Answer
D. 500 ml
Standard definition: over 500 ml after vaginal delivery.
The drug of choice to prevent and treat eclamptic convulsions is:
1. paracetamol
2. iron sucrose
3. magnesium sulphate
4. oxytocin
Answer
C. magnesium sulphate
MgSO4 is the anticonvulsant of choice in eclampsia.
A baby has heart rate above 100, good cry, active movement, pink body and bluish hands, and cries on stimulation. The Apgar score is closest to:
1. 4
2. 6
3. 9
4. 2
Answer
C. 9
Colour loses one mark (acrocyanosis); all other items score 2, so 2+2+2+2+1 = 9.
The total range of the Apgar score is:
1. 0 to 5
2. 1 to 20
3. 0 to 100
4. 0 to 10
Answer
D. 0 to 10
Five features each scored 0 to 2.
A baby with a birth weight less than 2,500 g is called:
1. low birth weight
2. very low birth weight only
3. macrosomic
4. post-term
Answer
A. low birth weight
Low birth weight is below 2,500 g.
The vaginal discharge in the first days after delivery is called:
1. leucorrhoea
2. lochia rubra
3. lochia serosa
4. lochia alba
Answer
B. lochia rubra
Rubra is red, serosa pale, alba white.
The puerperium lasts about:
1. 6 weeks
2. 2 weeks
3. 3 months
4. 6 months
Answer
A. 6 weeks
The postnatal period is 6 weeks.
A pregnant woman at 28 weeks has painless heavy bleeding. The health worker should:
1. give iron tablets and wait
2. advise rest at home
3. do a vaginal examination to find the cause
4. avoid vaginal examination and refer urgently
Answer
D. avoid vaginal examination and refer urgently
Painless bleeding suggests placenta praevia; a vaginal examination can worsen the bleeding.
A woman in labour reaches the action line on the partograph at a sub-centre. The best step is to:
1. give oral iron
2. refer her to a higher centre
3. continue to wait for 4 more hours
4. give a sedative and let her sleep
Answer
B. refer her to a higher centre
Crossing the action line means prolonged labour needing referral.
After delivery the uterus is soft and bleeding heavily. The first action is:
1. give a hot drink
2. massage the uterus and give oxytocin
3. apply a tight abdominal binder only
4. wait for the placenta to come out alone
Answer
B. massage the uterus and give oxytocin
Uterine atony is the main cause of PPH; massage and oxytocin come first.
A pregnant woman at 32 weeks has a blood pressure of 150/100 and protein in the urine, with headache. This is most likely:
1. placenta praevia
2. anaemia
3. pre-eclampsia
4. normal pregnancy
Answer
C. pre-eclampsia
BP 140/90 or more after 20 weeks with proteinuria is pre-eclampsia.
A woman's fundus is at the level of the xiphisternum. The period of gestation is about:
1. 20 weeks
2. 12 weeks
3. 36 weeks
4. 24 weeks
Answer
C. 36 weeks
Fundal height reaches the lower breast bone at about 36 weeks.
An unregistered pregnant woman comes for the first time. The first priority is:
1. register her, check BP, Hb and urine, and start IFA and Td
2. advise home delivery
3. wait until the third trimester to register
4. give only calcium
Answer
A. register her, check BP, Hb and urine, and start IFA and Td
Registration and basic check-up with preventive care should start at first contact.
A woman delivers at home. The mother and baby should first be visited by a health worker within:
1. 10 days
2. 3 months
3. 6 weeks
4. 24 hours
Answer
D. 24 hours
Early home visit helps detect problems quickly.
If the Hb of a pregnant woman is 9.5 g/dl, she is classified as having:
1. no anaemia
2. severe anaemia
3. polycythaemia
4. mild to moderate anaemia
Answer
D. mild to moderate anaemia
Below 11 g/dl is anaemia and 9.5 is above 7, so it is not severe.
A woman received 5 g of magnesium sulphate IM in each buttock after a 4 g IV dose. The total loading dose is:
1. 14 g
2. 20 g
3. 9 g
4. 10 g
Answer
A. 14 g
4 g IV + 5 g + 5 g IM = 14 g.
A pregnant woman has 12 weeks of amenorrhoea. Her uterus would be felt:
1. at the xiphisternum
2. just above the pubic bone
3. not felt at all in the abdomen or pelvis
4. at the umbilicus
Answer
B. just above the pubic bone
At 12 weeks the fundus is just above the symphysis pubis.
Match the scheme with its feature. Which is correctly paired?
1. JSY: free ultrasound only
2. JSSK: free delivery, drugs and transport for mothers and sick newborns
3. PMSMA: cash for family planning
4. LaQshya: iron tablets distribution
Answer
B. JSSK: free delivery, drugs and transport for mothers and sick newborns
JSSK gives free entitlements; LaQshya improves labour room quality; PMSMA is the 9th-of-month check-up.
Match: Which pairing of sign and category is correct?
1. Morning sickness: positive sign
2. Quickening: positive sign
3. Hegar's sign: probable sign
4. Foetal heart sound: presumptive sign
Answer
C. Hegar's sign: probable sign
Hegar's sign is a probable sign; morning sickness is presumptive; heart sounds are positive.
Match: Which pairing of complication and first measure is correct?
1. Eclampsia: magnesium sulphate
2. Antepartum haemorrhage: vaginal examination
3. Obstructed labour: wait and watch
4. Puerperal sepsis: oxytocin alone
Answer
A. Eclampsia: magnesium sulphate
MgSO4 is for eclampsia; others have wrong first measures.
Which of the following statements is/are correct? 1. Td vaccine is given to pregnant women. 2. The normal term pregnancy is 37 to under 42 weeks.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. The first stage of labour ends at full cervical dilatation of 10 cm. 2. The third stage of labour ends with expulsion of the baby.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Third stage ends with expulsion of the placenta, not the baby.
Which of the following statements is/are correct? 1. Delayed cord clamping is advised for about 1 to 3 minutes in a healthy newborn. 2. Oxytocin is given after the placenta is delivered in AMTSL.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Oxytocin is given within one minute of birth, before the placenta is out.
Which of the following statements is/are correct? 1. Lochia alba is a white-yellow discharge near the end of the puerperium. 2. Lochia rubra appears at 6 weeks after delivery.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Rubra is the early red discharge.
Which of the following statements is/are correct? 1. A woman with Rh-negative blood and an Rh-positive baby is given anti-D immunoglobulin. 2. Anti-D is given to protect the mother in later pregnancies.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Anti-D prevents sensitisation that could harm future babies.
Which of the following statements is/are correct? 1. Kangaroo mother care involves skin-to-skin contact and exclusive breastfeeding. 2. It is suitable for low birth weight babies.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are true.
Which of the following statements is/are correct? 1. The mother and baby should stay at the facility for at least 24 hours after delivery. 2. Postnatal visits are made within 48 hours, on day 3, day 7 and at 6 weeks.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
B. 2 only
The stay is at least 48 hours.
Which of the following statements is/are correct? 1. A positive urine pregnancy test is a probable sign of pregnancy. 2. Ballottement is a probable sign of pregnancy.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are probable signs.
Which of the following statements is/are correct? 1. Gravida means the number of babies a woman has delivered. 2. Para refers only to abortions.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
D. Neither 1 nor 2
Gravida counts pregnancies; para counts pregnancies that reached viability and ended in birth.
Which of the following statements is/are correct? 1. PMSMA provides a free check-up on the 9th of every month. 2. JSSK is a scheme that provides free referral transport.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both statements are correct.
Which of the following statements is/are correct? 1. Episiotomy is a cut in the perineum made to widen the birth outlet. 2. It is repaired only after the placenta is delivered.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Repair is done after the third stage.
A woman's LMP was 1 January. Her EDD is:
1. 15 October
2. 1 October
3. 8 September
4. 8 October
Answer
D. 8 October
1 Jan + 7 days = 8 Jan; plus 9 months = 8 October.
Which sign after delivery needs urgent referral?
1. Mild after-pains while breastfeeding
2. Foul-smelling discharge with fever
3. Slight tiredness
4. Red discharge on the first day
Answer
B. Foul-smelling discharge with fever
Foul discharge with fever suggests puerperal sepsis.

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