Questions in a pregnancy health history

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HealthWiki > A Book for Midwives > Chapter 7: Learning a pregnant woman's health history > Questions in a pregnancy health history

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In this chapter:

 

In this chapter:

Does she have signs of pregnancy?

Some signs of pregnancy are sure signs — they mean the woman is definitely pregnant. Some signs are probable signs, meaning the woman is probably pregnant, but the sign could be caused by something else.

Probable signs of pregnancy

The woman’s monthly bleeding stops. This is often the first sign of pregnancy. Other possible causes of this sign are poor nutrition, emotional troubles, or menopause (change of life).

The woman has nausea or wants to vomit. Many pregnant women have nausea in the morning (which is why this feeling is often called “morning sickness”), but some women may feel this way all day. Nausea is common during the first 3 months of pregnancy. Other possible causes of this sign are illness or parasites.

The woman feels tired and sleepy during the day. This is common in the first 3 or 4 months of pregnancy. Other possible causes of this sign are anemia, poor nutrition, emotional troubles, or too much work.

The woman needs to urinate often. This is most common during the first 3 months and the last 1 or 2 months of pregnancy. Other possible causes of this sign are stress, bladder infection, or diabetes (blood sugar disease).

The woman’s belly grows. After 3 or 4 months, the pregnancy is usually big enough to be seen from the outside. Other possible causes of this sign are that the woman has a cancer or another growth in her belly or that she is just getting fatter.

The woman’s breasts get bigger. A pregnant woman’s breasts get bigger to prepare to make milk for the baby. Another possible cause of this sign is that breasts often get bigger just before monthly bleeding.

The woman feels light baby movements inside. Most women start to feel their babies move between about 16 weeks and 20 weeks of pregnancy (at about 4 or 5 months). Another possible cause of this sign is gas in the belly.

Sure signs of pregnancy

The woman feels strong baby movements inside. Most women begin to feel the baby kicking by the time they are 5 months pregnant.

The baby can be felt inside the womb. By the 6th or 7th month, a skilled midwife can usually find the baby’s head, neck, back, arms, bottom, and legs by feeling the mother’s belly.

The baby’s heartbeat can be heard. By the 5th or 6th month, the heartbeat can sometimes be heard with tools made for listening, like a stethoscope or fetoscope. By the 7th or 8th month, a skilled midwife can usually hear the baby’s heartbeat when she puts her ear on the woman’s belly.

A medical pregnancy test says the woman is pregnant. This test can be done with a kit at home or in a laboratory with a little of the woman’s urine or blood. This test can be expensive and is usually not necessary. But it can be useful, for example, if a woman needs to know if she is pregnant before taking a medicine that might harm a baby inside her.

Now I can be sure I am pregnant.

How pregnant is she now? When is the baby due?

Find out how many months pregnant the woman is at the time of her first checkup. This will also tell you the date that she will probably give birth (the due date).

There are 3 ways to figure out how pregnant the woman is now and her due date:

• Use the date of her last monthly bleeding.
• Measure the size of her womb.
• Have the woman get an ultrasound at a medical center.

Note: It is normal and safe for the baby to be born as much as 3 weeks earlier or 2 weeks later than the due date.

Using the last monthly bleeding to predict the due date

If a woman bleeds regularly every 4 weeks, her pregnancy will start about 2 weeks after the first day of her last monthly bleeding. To find out if you can use this method to estimate her due date, you must first ask the mother 3 questions:

1. Has your monthly bleeding been mostly regular, once every 4 weeks (once every month)?
2. Was your last monthly bleeding normal for you (not unusually light or heavy)?
3. Do you remember the date of the first day of your last monthly bleeding?

If the woman answers “no” to any of these 3 questions, you cannot be certain this method will give you a correct due date.

If she answers “yes” to all 3 questions, you can figure out the due date and how pregnant the woman is at this visit.

Remember that a pregnancy lasts about 40 weeks or 280 days. This is about 9 calendar months or 10 lunar months from the last monthly bleeding.

Using a calendar

Her last monthly bleeding started May 6th.

If I add 9 months, that comes to February 10th. Then I add 7 days, which tells me her baby should be born around February 17th.

To figure out the due date, add 9 months and 7 days to the day that her last monthly bleeding began.

(You could also subtract 3 months and then add 7 days to get the same date.)

See a helpful tool to estimate the due date using the last monthly bleeding.

To figure out how pregnant the woman is now, take the first day of the last monthly bleeding and count the number of weeks that have passed between that day and this visit.

By the end of May she had been pregnant for 4 weeks, and...

...by the end of June, 8 weeks.

Today is July 12th, so she is 9 weeks and 4 days pregnant, or a little more than 2 months.

Using the moon

If you do not use calendars, you can find the due date using the moon. If a woman’s monthly bleeding is usually about one moon (4 weeks) apart, the baby is due 10 moons after the first day of her last monthly bleeding. If a woman’s monthly bleeding started on a quarter moon, the baby is due 10 quarter moons later. If her bleeding started on a new moon, the baby is due 10 new moons later, and so on.

For example:

If her bleeding started on the full moon,	she probably got pregnant on the new moon.	The baby is due 10 lunar months after the first day of her last monthly bleeding —	in this case, 10 full moons after the first day of her last monthly bleeding.

Measuring the womb

With practice, a midwife can feel the size of the woman’s womb to know how long a woman has been pregnant. Use this method when:

• the woman does not remember when her last monthly
  bleeding started.
• the last monthly bleeding was unusually light or heavy.
• her monthly bleeding is not regular.
• the woman was breastfeeding and not bleeding regularly
  when she got pregnant.

There are two ways to measure the womb. During the first 12 weeks (3 months) of pregnancy you can do a bimanual exam to feel the womb from inside the vagina. After 3 months you can measure the womb from the outside.

Using a sonogram

A sonogram (or ultrasound) machine takes a picture of the baby inside the womb by using sound waves. A sonogram done in the first 6 months of pregnancy is an accurate tool for showing how far along the pregnancy is and if there are any problems. Sonograms are not dangerous for the baby

How old is she?

Pregnancy can cause problems for women of any age. But very young women and much older women tend to have more problems.

Girls who become pregnant before they are 17 years old may not have finished growing themselves. A girl’s pelvis might not be grown enough to give birth normally. Girls are more likely to have other problems too — like pre-eclampsia, long labors, and babies born too early. Girls who get pregnant when they are very young can be wonderful and caring mothers, but many of them will need extra advice and support.

Older mothers also may have more problems in pregnancy and birth.

It may be safer for older women and very young women to give birth in a well-equipped medical center rather than at home.

How many children has she had?

Women who have had 1 or 2 babies and whose children were born alive and healthy usually have the fewest problems giving birth.

I have already had one normal birth. My birth will probably be safe.

Other women may have more problems. First births are often more difficult than later births. It may be safer for a woman giving birth for the first time to give birth near a medical center. Watch carefully for risk signs and have transportation available for emergencies.

A woman who has given birth to 5 or more babies is more likely to have some of the following problems:

• a long labor
• a torn womb (after a long, hard labor)
• a fallen womb (prolapsed uterus)
• a baby in a difficult position for birth
• heavy bleeding after birth

For these reasons, it may be safer for a woman who has had 5 or more births to give birth in or near a medical center.

Has she had any miscarriages or abortions?

Miscarriage

A miscarriage (spontaneous abortion) is when a pregnancy ends before the woman is 6 months pregnant, while the baby is still too small to live outside the mother. This is common and often happens before the woman even knows she is pregnant.

It is usually difficult to know why a miscarriage happens, but some causes of miscarriage are preventable. Malaria, sexually transmitted infections, injury, violence, and stress can all cause a pregnancy to end.

Women who work with pesticides or other chemicals are more likely to have miscarriages.

Sometimes miscarriages happen because a woman has been near poisons or toxic chemicals. For example, women who work on farms often breathe or handle pesticides which can cause miscarriage. These women have more miscarriages than other women.

Some miscarriages can be prevented by treating women for illness and infection and by helping them avoid chemical poisons and violence. But some women have one miscarriage after another, and you may not know why. Get medical advice to find the cause and to help her carry this pregnancy all the way through.

Abortion

Many women use plant medicines and other remedies to regulate or bring on their monthly bleeding, or prevent or end a pregnancy. These remedies may be safe, but ask the woman if she has ever had a problem — such as pain, heavy bleeding, or infection — after using any plant or any kind of medicine.

If some person, or the woman herself, does something to her body to end a pregnancy, we call this an abortion. Where abortion is legal and available, a woman can have a safe abortion that will not usually endanger her future pregnancies. There are 3 kinds of abortion that can be safe:

• Medication Abortion. The woman takes medicines that end the pregnancy and empty the womb. The safest and most effective medicines are misoprostol, used either by itself or with mifepristone. used.Learn how these drugs can be used safely.
• Vacuum aspiration. A health worker uses a machine or manual vacuum aspiration (MVA) syringe to create suction that empties the womb (see Chapter 23). When vacuum aspiration is done correctly, it is very safe.
• D&E (dilation and evacuation). A health worker uses a combination of suction and sterile medical instruments to empty the womb. This should only be done by a trained medical worker.

In places where abortion is illegal, a woman trying to end a pregnancy may harm herself or turn to someone who does not give abortions safely. Unsafe abortions can cause heavy bleeding, serious infection, infertility, or even death. See Chapter 22 to learn how to help a woman after an unsafe abortion.

A woman who was sick, injured, or bled heavily after any kind of abortion may have scars in her womb that could cause problems in this pregnancy or birth. It is probably safest for her to give birth in or near a hospital or medical center.

Has she had any problems with past pregnancies or births?

If a woman has had problems with past pregnancies or births, she may have problems with this birth too.

I bled a lot with both children. I was very weak for many days after the births.

Since you bled at past births, we should be ready in case you bleed at this one.

Ask the mother to tell you the story of each of her past pregnancies and births. Let her tell you everything: the good and the bad. Then ask the following questions to learn more about problems in past pregnancies and what to be prepared for during this one. If you can, write down what you learn. (Many of these problems are explained more fully in other parts of this book. Click on the link to learn more about the problem.)

Was she tired or weak (anemic)?

Extreme tiredness or weakness in pregnancy is usually caused by anemia (lack of iron in the blood). If she had anemia in another pregnancy, she is likely to have it again in this pregnancy. Anemia causes problems in pregnancy and birth, but it can be prevented by eating lots of foods with protein and iron in them and by taking iron pills. Women with anemia are often also at risk for pre-eclampsia.

Did she have high blood pressure?

If she had high blood pressure in a past pregnancy, she is likely to get it again. High blood pressure can be a sign of pre-eclampsia.

Did she have pre-eclampsia?

If a woman had pre-eclampsia in a past pregnancy, she is in danger of getting pre-eclampsia again. Check her blood pressure and other signs of pre-eclampsia regularly in this pregnancy. Be prepared to get medical help if pre-eclampsia develops.

Did she have fits (convulsions)?

If she had convulsions in a past pregnancy or birth, get medical advice. She probably had eclampsia. She is likely to get it again, and she should give birth in a medical center or hospital.

Did she have diabetes (blood sugar disease)?

If she had diabetes in a past pregnancy, she is more likely to get it again. If possible, she should be tested by a doctor or health worker. Diabetes in the mother can lead to miscarriage or other problems with the mother or baby after birth.

Did she have a very long labor or a long pushing stage?

Was her labor longer than 24 hours for a first baby, or longer than 12 hours other babies? Did she push for more than 2 hours? Ask if her long labor caused problems for her or her baby. If that birth was healthy and the baby was OK, then she will probably not have a problem with this birth. If that birth was not normal, ask her if she knows why the labor was long. Did she have anemia? Was the baby in a difficult position or very big? Was she very afraid? You may need to get medical advice.

Did she have a fistula?

If she had a long labor leading to a fistula (an opening in the tissue of the vagina) she should have this birth in a hospital.

Did she have a very short labor (less than 3 hours)?

If the mother had a very short labor in the past, make sure she and her family know what to do if you do not get there in time. You can teach the family how to deliver a baby in an emergency.

Did she have an early birth?

If she had a baby born more than a month early, ask her if she has signs of bacterial vaginosis (BV). Bacterial vaginosis can lead to early births. Be ready in case this baby is early too, and watch for signs of labor.

Did she have a small baby (less than 2.5 kilograms or 5 pounds)?

Find out if the baby was born early (it is normal for early babies to be small). If the baby came on time, ask the mother if she had anemia, high blood pressure, or pre-eclampsia. Also ask if she had enough to eat, or if she smoked cigarettes or used drugs. Any of these things could have made the baby small.

Check to see if this baby is growing normally. If you think this baby may be very small for her age, the mother should probably give birth in or near a medical center, because small babies can have more health problems.

Did she have a big baby (over 4 kilograms or 9 pounds)?

Ask if the birth was difficult. If it was not, this birth will probably be OK too. Look for signs of diabetes. Check carefully to see if this baby seems big too. If possible, have the mother tested for diabetes.

Did she have heavy bleeding before or after the birth?

If she bled a lot in a past pregnancy or birth, it is likely to happen again. Ask her to tell you as much as she can remember about her bleeding. Did she need medical help? Was she anemic? Was she too weak to stand? The answers to these questions will help you prepare for what may happen at this birth. If possible, a woman who bled heavily before should have her babies in a medical center. Be ready to treat her for heavy bleeding after the birth.

Did she have any problems with the placenta?

If the woman’s placenta did not come out easily in a past birth, she may have the same problem again. Be ready to treat her for bleeding. It is better if she gives birth in or near a medical center.

Did she have a fever or infection of the womb during or
after the birth?

This birth may be fine, but she has more risk of infection than other women. Be sure to check her for signs of vaginal infection (see Chapter 18).

Was she very sad (depressed) after the birth?

If a woman became depressed after a past birth, it may happen again. Be prepared to help if this happens.

Did the baby get sick or die before, during, or after the birth?

Find out if the baby was sick or died. If some of her babies died, she may have a problem in her blood called Rh incompatibility. Or the deaths could have had other causes. Check the mother for high blood pressure, diabetes, anemia, malnutrition, and illness. These can all cause death in babies. Get medical advice.

Did her baby have birth defects?

• Some birth defects run in the family. Ask about the type of birth defect and if anyone else in her or the baby’s father’s family has that birth defect. The next baby may have the same problems.
• Some defects are caused by illnesses like herpes or rubella. If the woman had herpes or rubella in a past pregnancy, it probably will not cause birth defects in this pregnancy. Pregnant women should avoid people who are sick.
• Some birth defects are caused by exposure to toxic chemicals, drugs, or medicines.
• Some birth defects are caused by poor nutrition.
• Some birth defects just happen — no one knows why.

Learn more about birth defects.

Did she have a cesarean surgery (birth by operation)?

In a cesarean surgery, a doctor cuts open the woman’s belly and womb to get the baby out. After the baby is out, the doctor sews the womb and belly closed. This leaves one scar on the womb and a second scar on the belly. Sometimes a cesarean surgery is done because the baby does not fit through the mother’s pelvis. Sometimes it is done because the baby is in danger and must be born very quickly.

Note: Cesarean surgeries save lives, but in many places they are used too much — usually for the convenience of the doctor or because women falsely believe that a cesarean will be easier. Cesareans should only be used in emergencies.

Most women can have a safe vaginal birth even if they had a cesarean with a previous baby. But there is a very small chance that the scar on the womb may tear open during labor. If this happens, the woman could bleed inside and she or the baby could die. For this reason, it is safest for a woman who has had a cesarean to give birth in or near a medical center or hospital. If she is planning to give birth at home, arrange for her to have medical care in case there are any problems during the labor.

If any of the following are true, this woman should definitely go to a medical center for the birth:

	A scar on the womb that goes this way is more likely to open up in labor.
A scar that goes one way on the outside...	...may be hiding a scar on the womb that goes another way.

• The cesarean was less than 2 years ago.
• This baby is big or in a difficult birth position.
• The woman had a cesarean
  because her pelvis was not formed well as a child. This is usually caused by poor nutrition.
• The scar on the womb is up-and-down.

Unfortunately, you cannot tell anything about the scar on the womb by looking at the belly. The scar on the belly can be one way, and the scar on the womb inside can be another. You can only find out by checking the medical records at the hospital or by asking the doctor who did the surgery.

Is she healthy?

A pregnancy is more likely to go well for a woman who is in good health. See Chapter 4 for general ideas for staying healthy. Also see Chapter 18 to learn about avoiding vaginal infections. Some general health problems can cause serious problems in pregnancy.

Ask if she uses tobacco, alcohol, or other substances or works with chemicals.

If a pregnant woman has, or might have, any of the following problems, she should be tested, get medical help to plan for her needs during pregnancy, and decide if it would be safer for her to give birth in a medical center:

• diabetes
• HIV
• bladder or kidney infection
• malaria
• fever over 38°C (100.4°F) for more than 2 days
• any sexually transmitted infections (STIs), especially syphillis or gonorrhea
• high blood pressure
• liver disease (hepatitis, especially hepatitis B
• heart problems
• tuberculosis
• deformity of the hips or lower back

Malaria

Malaria is an infection of the blood spread by mosquitos that causes chills and fever. It is very common in young girls, first-time mothers, and women who are sick with other illnesses. Malaria is especially dangerous for pregnant women and their babies. A pregnant woman with malaria is more likely to have anemia, miscarriage, early birth, small baby, stillbirth (baby born dead), or to die from problems like eclampsia or bleeding.

It is important for pregnant women to avoid malaria — and to be treated quickly if they get sick. Malaria medicines may be costly and can have side effects, but these medicines are much safer than becoming sick with malaria. There is a rapid test for malaria. Midwives can learn to use it to know quickly who should be receiving treatment. There is a rapid test for malaria. Midwives can learn to use it to know quickly who should be receiving treatment.

For severe malaria, anyone who is pregnant will need emergency treatment in a hospital or clinic with the same medicines used for any other adult. Signs of severe malaria include: mental confusion or convulsions, difficulty staying awake, repeated vomiting, difficulty or rapid breathing, and being too weak to sit or stand.

With regular malaria, treating right away is important so that it does not get worse. During the first 3 months of pregnancy, usually malaria is treated with quinine and clindamycin, or quinine only. After 3 months, the treatment for malaria is the same as for any other adult in your region. In most countries, an artemisinin-based combination therapy, or ACT, will be used. There are many types of ACT and malaria treatment is not the same everywhere, so find out which medicines are used where you live. Common ACT combinations are listed below.

If a woman is already sick with malaria, she should be treated right away. The safest treatment in the first 3 months of pregnancy is: give 600 mg of quinine by mouth, 3 times a day for 7 days AND give 300 mg of clindamycin by mouth, 4 times a day for 7 days. If you cannot get those medicines, any time during pregnancy you can give artemisinin-based combination therapy, or ACT. There are many types of ACT, so find out what the local health authority recommends.

Common combinations of ACT include:

• Artemether + lumefantrine
• Artesunate + amodiaquine
• Artesunate + mefloquine
• Artesunate with sulfadoxine + pyrimethamine
• Dihydroartemisinin + piperaquine

Where chloroquine still works against malaria, it is safe to give in pregnancy, but do not give primaquine to a pregnant person, as it could harm the developing baby.

To prevent malaria, avoid mosquito bites and control mosquitoes

• Get rid of standing water and stay away from wet places where mosquitoes breed.
• Use local remedies to get rid of mosquitoes. Some people use citronella oil on their skin.
• Use mosquito repellent when mosquitoes are biting.
• Sleep under treated bed nets or hang treated curtains in doors and windows.

Treated bed nets are safe, but do not spray pesticides on bedding.

HIV

HIV is a virus that weakens a person’s immune system so he or she cannot fight illness. Ongoing, regular treatment with medicines (called ART) can control it so a person with HIV can live a healthy life. Without treatment, a person with HIV may seem healthy for years, but will become ill more often and more seriously, and eventually will develop AIDS and die. Medicines and good nutrition are both important to stay healthy with HIV. Treatment also helps prevent HIV from spreading.

How HIV/AIDS spreads

HIV lives in the body fluids of people who are infected with HIV: blood, semen, wetness from the vagina, and breast milk. The virus spreads when those fluids get into the body of another person. This means that HIV can be spread by:

sex with someone who has HIV, if the person does not use condoms.	unsterile needles or tools that pierce or cut the skin.	infected blood that gets into cuts or an open wound of another person.	infected blood that gets into a baby during pregnancy, birth, or breastfeeding, if the person has HIV.

In places where blood has not been tested for HIV, people have also been infected with HIV from blood transfusions.

It is impossible to know by looking at someone whether he or she has HIV. Without an HIV test, most people do not know they have HIV until they are very sick. Their HIV can spread at any time though. For this reason, it is important for everyone to protect themselves and others from HIV by practicing safer sex, by getting tested and starting ART if they are HIV positive, by using condoms or HIV prevention medicines, and by sterilizing tools and equipment.

Midwives can help stop HIV/AIDS

With treatment, HIV is a manageable illness, but preventing it is still important. As a midwife, you can work to stop the spread of HIV. Encourage all pregnant women and their partners to be tested for HIV. Help women who have HIV plan carefully for pregnancy, and prevent pregnancies they do not want (see Chapter 17). Help women who are pregnant or breastfeeding avoid becoming infected with HIV. New HIV infections during pregnancy are very likely to spread HIV to the baby too.

HIV medicines can protect women from HIV. In some places, a woman at risk of HIV because her partner is infected (or might be) may be able to take a medicine combination regularly that will prevent her becoming infected. This is called Pre-Exposure Prophylaxis, or PrEP.

An important way to help prevent HIV is to teach people about using condoms. Remember though, even when people know how condoms protect them from HIV, they may need support to use this knowledge. For example:

• Some people, especially young people and women, cannot choose how they have sex. If they do not want sex, or they want to use condoms, their partners may not agree.
• Some people do not want to use condoms. Other people cannot afford to buy condoms, or cannot find them easily.
• Some people just feel hopeless, especially if life in general is very hard and many people around them are dying.

These challenges are not easily solved. Find ways to talk to people and to encourage them to talk to each other about HIV, about why people have difficulty protecting themselves from HIV, and how to change this.

How can I ask my husband to use a condom?

My husband would use them but we cannot afford them.

Care for pregnant women with HIV

Give a pregnant woman with HIV the same respect and care you would give any woman. If they are using ART, the medicines that fight HIV, women with HIV can safely be pregnant and have healthy babies.

Note: Some women first find out they have HIV when they are tested during pregnancy. These women need support to cope with this news and what it may mean for their families. Health workers and midwives should take care not to discuss a woman’s HIV status with anyone (including each other) without her knowledge and consent.

Pregnant women with HIV need to take even more care with their health than others. Eating well, avoiding infections, and treating illness quickly are most important. Encourage a pregnant woman with HIV to start ART treatment right away, and if possible, join an HIV treatment program or a support group. Explain why she should see you or another health worker regularly, and help her identify where to get good medical care nearby in case she needs it. If there is a well-equipped medical center in your area, it might be better for her to give birth there.

Watch women with HIV for signs of other sexually transmitted infections, especially syphilis (see Chapter 18). Help them prevent malaria and get tested for TB (tuberculosis) and hepatitis. Help women (and their partners) get treatment for these or other infections.

A woman with HIV can prevent many infections (pneumonia, diarrhea, malaria, and others) by taking a low-cost antibiotic called cotrimoxazole every day.

ART medicines also protect developing babies
Without treatment, about 1 out of 4 babies born to women with HIV is infected with HIV at birth. But pregnant women on ART lower the risk their baby will have HIV to 1 out of 50. The baby also needs to take ART medicines after birth. See more about these uses of ART. (Learn about preventing the spread of HIV while breastfeeding.)

Other problems to watch for

Along with causing infections, HIV can also cause:

• miscarriage, especially late in pregnancy (loss of pregnancy and stillbirth).
• early birth.
• bleeding and infection after birth.

Try to be prepared for any of these if caring for a pregnant woman with HIV.

Has she been vaccinated against tetanus? If yes, when?

Tetanus (lockjaw) is caused when a germ that usually lives in dirt or stool enters the body through a wound. A woman can get tetanus if something that is not sterile is put into her womb or vagina during or after childbirth or from an unsafe abortion. A baby can get tetanus if the cord is cut with something that is not sterilized, or when anything (like dirt or dung) is put on the cord stump.

Tetanus vaccinations

Everyone should get a series of vaccinations to prevent tetanus (lockjaw). Every country has its own schedule of when to give them and which vaccines are given together. In general, a child gets 3 injections during the first year of life, and three more (called “boosters”) afterwards. The combination vaccines have names including DPT, Tdap, Dt, DTaP, and others. It is best if these vaccinations happen early in life to prevent ever getting sick with tetanus. If someone did not get all 6 injections, and has not had an anti-tetanus vaccination in the past 10 years, they need a “booster” now to be protected.
People who have received all the 6 vaccinations will not get sick if they are exposed to tetanus.

These shots will protect you and the baby against tetanus—for a while.

Good!

If a pregnant woman has not received all of the vaccination doses, give her the first dose of anti-tetanus vaccine as soon as possible when you begin seeing her. Give her another dose at least 4 weeks later, and at least 2 weeks before she gives birth. If she gets only 1 dose of the vaccine, it will not protect the baby from tetanus.

If the woman cannot remember if she has had the vaccination or not, assume that she has not and give her the vaccinations. Extra doses will not harm her.

Vaccinations during pregnancy will also protect the baby from tetanus during the first few weeks after birth. But the baby must be vaccinated after birth so that the protection will continue.

Is she taking any medicines now?

It is best for a woman to avoid most modern medicines and plant medicines during pregnancy. Many medicines can harm the baby inside the womb.

If a woman needs to take a medicine, see the Medicines Pages of this book to find out whether that medicine is listed as safe in pregnancy. If the medicine is not listed, get medical advice.

Supplements and tonics

Some modern and plant medicines that are not dangerous are called supplements or tonics. Prenatal vitamins and iron pills are healthy and safe supplements. They help the body get the vitamins and minerals it needs.

Stinging nettles (Urtica dioica) contain calcium, vitamin K, folic acid, and other important nutrients.

But cover your hands when you pick them or you will be stung!

Some plants are not used to heal sickness, but to make the body stronger. These herbs have vitamins and minerals that help the baby grow. They are safe and helpful in pregnancy. Some of these tonic plants are nettles, alfalfa, and red raspberry leaf. These plants have different names around the world, so ask someone experienced with plant medicines before giving any tonic herbs to pregnant women.

Has any medicine ever given her problems?

If the woman has ever had a health problem after taking a medicine, like a rash, swelling, or difficulty breathing, do not give her that medicine. Those problems are signs of allergy. If a woman takes a medicine that she is allergic to, she might become very sick or even die. An allergic reaction can happen at any time during the rest of her life.

Write down the name of the medicine so you can both remember it. Explain to the woman that she must never use the medicine again, and that she should always tell her doctors or health workers what happened when she used the medicine.

Note: Some kinds of medicines come in “families.” They are very similar to each other. For example, penicillin and ampicillin are in the same family. This is why their names are similar. If a woman is allergic to one member of a family of medicines, she is probably allergic to the other members of that family.

Medicines that are not in the same family as the one she is allergic to are as safe for her as for
anyone else.

What else in her life might affect her pregnancy and birth?

Money

Not having enough money causes many problems for women and their families. It causes physical problems, like not having enough food. And it also causes emotional problems, like feeling stress, fear, and sadness. All of these problems can make pregnancy, birth, and raising children much harder.

The very least that a woman needs during pregnancy is healthy food and a way to get medical help in an emergency.

If the woman you are helping cannot afford these things, help her find them or borrow them.

Living conditions

• Is there a clean and private place she can give birth?
• Is clean water available?
• Does anyone in her house have a serious disease that she might catch (contagious disease)?
• Does anyone smoke cigarettes in the house? Is there a smoky cooking stove inside the house? This smoke is very harmful.

Help her find a clean, safe place to give birth.

Distance from care

• Will she be able to come to her pregnancy checkups? Can you go to her?
• If she lives far away, can you teach her to do some of the pregnancy checkup herself?
• How far is the maternity center, clinic, or hospital? Does she need to stay somewhere else near the end of her pregnancy to be closer to medical help?
• How can she get there quickly if she needs help?
• Is there a telephone or radio she can use in an emergency?

Work

• How much does she work at home and outside her home?

• Does she have time to rest?
• Does her work expose her to dangers — like chemicals? Can she be protected from work dangers?

It is important for the woman to get regular breaks from her work. She should be able to eat, drink, and urinate often. Her work should not put too much strain on her body.

Family

Partners and other family members can be supportive and can share in the responsibility of the pregnancy. They can help with housework, care for other children, help the woman get enough good food and rest, and can enjoy the growing pregnancy with the woman.

Would you like some stew?

Thank you.

Some women need extra support

Women who do not have much family support, have no partner, or who have a partner who is not supportive may need extra care.

Single mothers are often wonderful and caring parents, but their lives may be harder than those of married women. People may treat single mothers badly, making assumptions about their morals and ignoring their needs. Give single mothers the kindness they deserve, and offer extra care if they do not have family or friends to help.

Very young mothers may have been forced into marriage as young girls, often to much older partners. These girls need particular support.

Women with abusive partners who get drunk or abuse drugs, are often away from home, have sex with other people, or abuse the woman will need support from family, friends, and you. A woman may need to leave her partner, or may choose to stay until she has a safe place to go. See the book Where Women Have No Doctor for more information on abusive partners.

Families save lives
Partners and family are usually the key to a good emergency plan. Find out if the woman needs permission to get medical help in an emergency. For example, if the community expects the husband to give the woman permission to go to a medical center or hospital, he should do so during the pregnancy, so that if he is away during the birth there will be no delay in getting life-saving care.

Teach the husband, mother-in-law, or other close family members the warning signs that mean a woman must be taken to get medical help.

Making a transport plan

Any woman can have serious problems that require medical help. If a woman has heavy bleeding, an infection, pre-eclampsia, or some other serious problem during labor or birth, she may need emergency care. A family with no car who lives far from medical help may have no way to get there. A family with little money may be unable to pay what the local hospital demands.

We must make sure there is a way for Devi to get to the hospital if necessary.

If everyone waits until a problem arises to think about how to solve it, the help may come too late. But with planning before the birth — while the woman is still pregnant — the woman, her family, her midwife, and her community can make a plan that can save the life of the woman or her baby. Make a transport plan before the birth with each woman. Involve her family and community in making the plan.

Mariama, you lost
3 women last year. Do you know why?

More women die in storm season, when the road is flooded.

A community transport plan should address all the reasons for delays in getting medical help. To understand these reasons, talk to other midwives who have lost mothers or babies during labor or birth. Talk to families who lost a baby or a mother too. Ask about when the midwife or family first knew there was a problem, and how long it took them to get help. Find out why the midwife and family did not go for help sooner. If possible, these families could meet and all talk to each other. Invite community leaders to listen to what these families and midwives have to say.

A midwife or a family might delay getting emergency care for many reasons:

• The person who must give permission for the woman to get care is not available.
• The midwife may feel afraid that people at the medical center will blame her for causing the problem.
• The family or the midwife may feel there is no hope — that going to a medical center will not help. Or the family may not trust the hospital.
• The family may not have money.
• There may be no car, truck, or other transportation.

After naming the reasons why families in the community do not get help, find solutions. You may be able to find a solution within the family. If the husband must give permission for the woman to go to the hospital, he can give permission in advance of the birth in case he is not home. Some problems are best solved by the whole community. In some villages, every family contributes a small amount of money every year. Anyone in the community who needs medical help can use the pool of money to pay for transportation to a medical center in an emergency.

Teach family members the warning signs. If everyone understands the problems that women in labor face, they can work together to help women get medical care. By talking to families and communities about the need for emergency medical care, you can help them make a plan that works. See Hesperian's Health Actions for Women for ways to begin these conversations.

This page was updated:24 May 2023