International Journal of Advancements in Research & Technology, Volume 4, Issue 2, February -2015
ISSN 2278-7763
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ANALYSIS OF ROLES & RESPONSIBILITIES OF 2ND ANMs
Lead & corresponding author
Kalapatapu Ravikiran Sharma, Assistant Professor- health
communication, Indian Institute of Health & Family Welfare (IIHFW),
Government of Telangana, Hyderabad
Co-author
Prof. Shankar Das, Professor- health system studies & ChairpersonCentre for Health Policy, Planning & Management, Tata Institute of
Social Sciences, (TISS), Mumbai
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ANALYSIS OF ROLES & RESPONSIBILITIES OF 2ND ANMS
5.1 Introduction
In the healthcare system, sub-centre is the most peripheral level of contact with the
community covering an average of 3000 population in rural areas, but in Andhra Pradesh it
is effectively serving 4424 population on an average. In order to do justice to the larger
population, the state government has divided the geographical area of each sub-centre into
two parts and has allocated one part to 1st Auxiliary Nurse and Midwife (ANM) and the other
part to the 2nd ANM. The sub-centre is a focal public health institution in the National Rural
Health Mission (NRHM) which was launched in April 2005. The NRHM aims at strengthening
state health systems with a special focus on reproductive and child health (RCH) services
and disease control programmes.
Since most 2nd ANMs are not familiar with their detailed job profile, this article seeks to
delineate the roles, duties and responsibilities of the 2nd ANM in public health to enable her
to discharge her functions with better results. This article shall serve as a ready reckoner for
every 2nd ANM as it contains an essence of her daily engagements and dwells crisply on the
expected work of a 2nd ANM. Such a manual shall itself serve as a strategy to improve the
2nd ANMs performance.
Goals of NRHM in 12th five year plan
In the 12th five year plan period, efforts will be made to consolidate the gains and
build on the successes of the Mission to provide accessible, affordable and quality universal
healthcare, both preventive and curative, which would include all aspects of a clearly defined
set of healthcare entitlements including preventive, primary and secondary health services.
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At the national level, the targets are as under:

Reduction of MMR to < 100 per 1,00,000 live births

Reducing IMR to < 27 per 1,000 live births

Reduction in NMR to < 18 per 1,000 live births

Reducing TFR to 2.1

Elimination of filaria– in all 250 districts; Kala-azar in all 514 blocks and leprosy
in all districts

Reduction in TB prevalence and mortality by 50%

Reduction in annual malaria incidence to <1/1000 population

Reduction in JE mortality by 50%

Sustaining case fatality rate of less than 1% for dengue
5.2 Current status
Comparative picture of major demographic, socio-economic and health indicators in
Andhra Pradesh, rest of South India & India
Indicators
Andhra Pradesh
Kerala
Tamil
Nadu
Karnataka
Total population
(in
crore)
(Census 2011)
8.4
3.33
7.21
6.11
Decadal growth
(%)
(Census
11.11
4.86
15.60
15.67
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Puducherry
India
0.12 121.0
1
27.72
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International Journal of Advancements in Research & Technology, Volume 4, Issue 2, February -2015
ISSN 2278-7763
Indicators
Andhra Pradesh
Kerala
Tamil
Nadu
Karnataka
3
Puducherry
India
2011)
Infant mortality
rate (SRS 2011)
43
12
22
35
22
44
Maternal
mortality
rate
(SRS 2007-09)
134
81
97
178
Not available
(NA)
212
Total
fertility
rate (SRS 2011)
1.8
1.8
1.7
1.9
NA
2.40
Crude birth rate
(SRS 2011)
17.50
15.20
15.90
18.80
16.70
21.80
Crude
death
rate (SRS 2011)
7.50
7.0
7.40
7.10
7.40
7.10
Natural growth
rate (SRS 2011)
10.0
8.20
8.50
11.70
9.30
14.70
Sex
ratio
(Census 2011)
992
1084
995
968
1038
940
Child sex ratio
(Census 2011)
943
959
946
943
965
914
Total
literacy
rate
(%)
(Census 2011)
67.60
93.91
80.33
75.60
86.55
74.04
Male
literacy
rate
(%)
(Census 2011)
75.56
96.02
86.81
82.85
92.12
82.14
Female literacy
rate
(%)
(Census 2011)
59.74
91.98
73.86
68.13
81.22
65.46
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Millennium Development Goals (MDGs)
Alongside the NRHM goals, there are MDGs which can be attained only with the
crucial support of the 2nd ANM. MDGs are eight international development goals that were
officially established following the Millennium Summit of the United Nations in 2000,
following the adoption of the United Nations Millennium Declaration. All 189 United
Nations member states and at least 23 international organisations have agreed to achieve
these goals by the year 2015. The goals are:
1.
Eradicating extreme poverty and hunger,
2.
Achieving universal primary education,
3.
Promoting gender equality and empowering women,
4.
Reducing child mortality rates,
5.
Improving maternal health,
6.
Combating HIV/AIDS, malaria, and other diseases,
7.
Ensuring environmental sustainability, and
8.
Developing a global partnership for development.
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5.3 The 2nd ANMs role in VHSNC & VHND
The village health sanitation & nutrition committee (VHSNC) is jointly run by the Gram
sarpanch and herrself. The mandate of VHSNC is to focus on nutrition and sanitation apart
from community health at the village. Her basic service activities are awareness generation,
conduct of village survey on nutritional status, nutrition needs assessment, monitoring and
supervision of both VHNDs every month, referral of severely malnourished children to
nearest Nutritional Rehabilitation Centre (NRC) and grievance redressal.
The village health & nutrition day (VHND) is organised twice every month at the
anganwadi centre (AWC) in the village. Her VHND activities comprise the following:
 She will focus on ANC services, immunisation and counselling with support of
ASHAs, members of VHSNC, AWWs, etc. during VNHD-1.
 She will focus on growth monitoring and counselling with the support of ASHAs and
AWWs during VHND-2.
5.4 Antenatal care (ANC)- care during pregnancy
Antenatal care is the systematic supervision of women during pregnancy to monitor
the progress of foetal growth and to ascertain the well-being of the mother and the foetus. It
helps to identify any complications of pregnancy such as anaemia, pre-eclampsia,
hypertension, etc. in the mother and slow/inadequate growth of the foetus and allows for the
timely management of complications through referral and a prepare a birth plan and identify
the facility for delivery and referral in case of complications.
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The 2nd ANM must therefore:
•
Register every pregnancy within 12 weeks. Confirm pregnancy in the 1st
trimester by conducting a urine examination using a Nischay kit.
•
Estimate the number of pregnancies in her area and track every pregnancy
by name for provision of quality ANC, skilled birth attendance and postnatal
services.
•
Ensure four antenatal visits to monitor the progress of pregnancy. This
includes the registration and 1st ANC in the first trimester.
o
o
o
o
1st visit : Within 12 weeks—preferably as soon as pregnancy is suspected
— for registration of pregnancy and first antenatal check-up
2nd visit : Between 14 and 26 weeks
3rd visit : Between 28 and 34 weeks
4th visit : Between 36 weeks and term
•
Give every pregnant woman Tetanus Toxoid (TT) injections and Iron Folic
Acid (IFA) supplementation (ensure consumption of 100 IFA for all pregnant
women and 200 for anaemic women).
•
Test the blood for haemoglobin, urine for sugar and protein at every visit.
Haemoglobin level
> 11 g/dl
7–11 g/dl
Less than 7 g/dl
Degree of anaemia
Absence of anaemia
Moderate anaemia
Severe anaemia
•
Record blood pressure and weight at every visit.
•
Advise and encourage the woman to opt for institutional delivery.
•
Maintain proper records (MCP card and antenatal register) for better case
management and follow-up.
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Do not give a pregnant woman any medication during the first trimester
unless advised by a doctor.
Preparation and conduct of an ANC
•
Before beginning each antenatal check-up at your SC or during the VHND, ensure
that all the required instruments and equipment are available and are in working
condition. These include a stethoscope, blood pressure apparatus, weighing scale,
inch tape, foetoscope, thermometer, mother and child protection card and register,
watch, gloves, 0.5% chlorine solution, syringes and needles, hub cutter, spirit swabs,
IFA tablets, TT injections, and equipment for testing hemoglobin and urine.
•
During each antenatal check-up she must greet every pregnant woman in a
friendly manner at each visit; listen to the woman's problems and concerns, and
counsel her and her relatives; remember, all women need social/psychological
support during pregnancy; she should ensure that the antenatal examination should
be carried out at an appropriate place where there is enough privacy for conducting
abdominal palpation.
•
After each antenatal check-up she must accurately record all findings.
Important aspects of antenatal check-up
History taking
Menstrual
history
calculate the EDD
Symptoms
Type
to Record the date of the LMP during the first visit as this helps
to calculate the EDD (Date of LMP+ 9 months + 7 days) and
prepare a birth plan.
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Look and ask for the following symptoms and take action
accordingly.
Action to be taken
Heartburn and nausea
•
•
•
Advise the woman to avoid spicy and oily foods.
Ask her to take cold milk during attacks.
If severe, antacids may be prescribed.
Vomiting during the first
trimester
•
Advise the woman to eat small frequent meals; avoid
greasy food; eat lots of green vegetables; and drink plenty
of fluids.
If vomiting is excessive in the morning, ask her to eat dry
foods, such as biscuits or toast, after waking up in the
morning.
•
Excessive vomiting,
especially after the
first trimester
•
Start IV Ringer lactate, 500 ml, and refer the woman to the
MO.
Palpitations, easy
fatiguability,
breathlessness at rest
•
Refer her to the MO for further management and advise her
to undergo a hospital delivery.
Puffiness of the face,
generalised body
oedema
•
Advise on danger signs and re-assess at the next antenatal
visit or in one week if more than eight months pregnant.
If hypertension persists after one week or at next visit, refer
to hospital or MO.
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Action to be taken
•
Revise birth plan.
Puffiness of the face,
generalised body
oedema, severe
headache, blurred
vision, epigastric pain,
reduced urine output
•
•
Give Inj Magsulf 5 g (10 ml), deep IM, in each buttock.
Increased frequency
of urination up to 10–12
weeks of pregnancy
Re-assure her that it will be relieved on its own.
Persistent increased
frequency of urination
after 12 weeks, or
burning sensation
Refer the woman to the MO at the PHC.
Constipation
•
•
Refer urgently to hospital.
Advise the woman to take more fluids, leafy vegetables and
a fibre rich diet. If not relieved, give her Isabgol (2
tablespoons to be taken at bedtime, with water or milk).
Do NOT prescribe strong laxatives as they may start
uterine contractions.
Pain in the abdomen
Refer the woman to the MO at the FRU.
Bleeding P/V, before 20
weeks of gestation
•
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•
•
•
•
If the woman is bleeding and the retained products of
conception can be seen coming out from the vagina,
remove them with your finger.
Start IV fluids.
Refer her to the MO of a 24-hour PHC/FRU.
Put her in touch with local support groups.
Do NOT carry out a vaginal examination under any
circumstances.
Bleeding P/V, after 20
weeks of gestation
As it is ante partum hemorrhage, refer to MO
Fever
•
•
Refer her to the MO.
If malaria is diagnosed, refer her to the PHC for
management of malaria according to the NVBDCP
guidelines.
Decreased or absent
foetal movements
•
•
Re-assure the woman. Repeat FHS after 15 minutes.
If the FHS is still out of the normal range, refer her to the
MO.
Inform the woman and her family that the baby might not be
well.
•
Abnormal vaginal
discharge, with or
without abdominal pain
•
•
Leaking of watery fluids
P/V
Refer the woman to the MO.
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Refer the woman to the MO.
Advise her on vaginal hygiene, i.e. cleaning the external
genitalia with soap and water.
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Obstetric history
The 2nd ANM must obtain the following information while taking the obstetric history:
•
Number of previous pregnancies. Confirm whether they were all live births, any
stillbirth or neonatal loss.
•
Three or more spontaneous consecutive abortions
•
Obstructed labour, premature births, twins or multiple pregnancies
•
Weight of the previous baby <2500 g or >4500 g
•
Admission for hypertension or pre-eclampsia/eclampsia
•
Surgery on the reproductive tract
•
Congenital anomaly
•
Treatment for infertility
•
Any spinal deformities
•
Rh negative in the previous pregnancy
Physical examination
This activity will be nearly the same during all the visits. The initial readings may be
taken as a baseline with which the later readings are to be compared.
•
Pallor: The presence of pallor indicates anaemia. The woman should be
examined for pallor at each visit. Estimate the woman’s haemoglobin.
•
Jaundice: Look for yellowish discolouration of the skin and sclera (the whites of
the eyes).
•
Pulse: The normal pulse rate is 60–90 beats per minute. If the pulse rate is
persistently high or low, refer to PHC/FRU.
•
Respiratory rate: Normal respiratory rate is 18-20 breathes per minute. If the RR
is above 30 breaths per minute and pallor is present, refer.
•
Oedema: Any oedema of the face, hands, abdominal wall and vulva is abnormal.
If there is oedema in association with high blood pressure, heart disease,
anaemia or proteinuria, the woman should be referred to the MO. Non-pitting
oedema indicates hypothyroidism or filariasis and requires immediate referral for
investigations.
•
Blood pressure: Measure the woman’s blood pressure at every visit.
Hypertension is diagnosed when two consecutive readings taken four hours or
more apart show the systolic blood pressure to be 140 mmHg or more and/or the
diastolic blood pressure to be 90 mmHg or more. If the woman has high blood
pressure but no urine albumin, she should be referred to the MO at 24x7PHC.
•
Weight
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 A pregnant woman's weight should be taken at each visit. A pregnant woman
gains around 2 kg every month after the 1st trimester. Normally, a woman
should gain 9-11 kg during her pregnancy. Low weight gain usually leads to
intrauterine growth retardation (IUGR) and results in the birth of a baby with a
low birth weight. Advise adequate dietary intake.
 Excessive weight gain (more than 3 kg in a month) should raise suspicion of
preeclampsia, twins (multiple pregnancy) or diabetes.
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•
Breast examination: Observe the size and shape of the nipples for the presence
of inverted or flat nipples. If the nipples are inverted, the woman must be advised
to pull on them and roll them between the thumb and index finger. A 10 cc or 20
cc disposable plastic syringe can also be used for correcting inverted nipples.
•
Abdominal examination: Examine the abdomen to monitor the progress of the
pregnancy and foetal well-being and growth. Maintain privacy throughout the
examination. The abdominal examination includes the following:
1. Measurement of fundal height
2. Determination of foetal lie and presentation by fundal palpation, lateral
palpation and pelvic grips
3. Auscultation of the FHS
4. Inspection of scars/any other relevant abdominal findings
•
Fundal height: This indicates the progress of the pregnancy and foetal growth.
The uterus becomes an abdominal organ after 12 weeks of gestation. The
gestational age (in weeks) corresponds to the fundal height (in cm) after 24
weeks of gestation. Remember that while measuring the fundal height, the
woman’s legs should be kept straight and not flexed.
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•
Palpation to determine foetal lie and presentation: Is relevant only in late
pregnancy 32 weeks onwards). The normal lie at term in the majority of
pregnancies is longitudinal, with a cephalic presentation. Any other lie is
abnormal and the woman must be referred to an FRU for the delivery. The
following four pelvic grips are to be performed.
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The 2nd ANM should be able to recognise a transverse lie. Missing it can be
disastrous because there is no mechanism by which a woman with a transverse lie
can deliver normally, i.e. vaginally. The woman needs an elective caesarean section,
i.e. she must not go into labour, hence refer to a FRU.
•
Foetal heart sound (FHS) and foetal heart rate (FHR): FHS should start only
when the gestational age is more than 24 weeks. The normal FHR is between
120 and 160 beats per minute, if < 120 or > 160 beats per minute, refer to the
MO.
•
Foetal movement: If fetal movement is at around 18-22 weeks of pregnancy and
is less than 10 in the entire day, refer to FRU.
•
Multiple pregnancies:
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 An unexpectedly large uterus for the estimated gestational age
 Multiple foetal parts discernable on abdominal palpation.
If a multiple pregnancy is suspected, refer the woman to the MO in the PHC for
confirmation of the diagnosis and counsel her to have her delivery in an
institution.
•
Laboratory investigations: The following laboratory investigations have to be
done
At the SC
 Pregnancy detection test
 Haemoglobin estimation
 Urine test to assess the
presence of sugar and
proteins (every ANC)
 Rapid malaria test
At the PHC/CHC/FRU






Blood group, including Rh factor (3rd ANC)
RPR
HIV testing
Rapid malaria test (if unavailable at SC)
Blood sugar testing
HBsAg
The 2nd ANM must counsel the women on IFA supplementation & Diet:
Explain the woman the necessity of taking IFA tablets and the dangers associated
with anaemia. And side-effects such as nausea, constipation, and black stool are common
and not serious. Emphasise the importance of a high protein diet, including items such as
black gram, groundnuts, ragi, whole grains, milk, eggs, meat and nuts, and encourage her to
take plenty of fruits like mango, guava, orange and sweet lime, green-leafy vegetables and
other vegetables, as these enhance the absorption of iron.
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5.5 Micro-birth planning
Micro-birth planning is an integral part of the JSY. The 2nd ANM has to draw up a
micro-birth plan or birth preparedness plan for each pregnant woman in her area. It is
necessary to draw up the micro-birth plan in advance to prepare the pregnant woman and
her family for any unforeseen complications and to prevent maternal morbidity and mortality
due to delays.
a. Micro-birth planning has the following components:
1. Registration of pregnant woman and filling up of the maternal and child protection
(MCP) card, antenatal register and JSY card/below poverty line (BPL)
certificates/necessary proofs or certificates for the purpose of keeping a record.
2. Informing the woman about the subsequent dates of antenatal visits, schedule for
TT injections and the EDD.
3. Identifying the place of delivery and the person who would conduct the delivery.
4. Identifying a referral facility and the mode of referral.
5. Taking the necessary steps to arrange for transport for the beneficiary.
6. Making sure that funds are available to the ANM/ASHA.
As part of her preparation of micro birth plan, she must encourage the pregnant
woman to opt for an institutional delivery. She needs to explain the women that a delivery at
a health facility would protect her from any complication that may arise during pregnancy,
delivery or in post natal period. In case, the woman/ family insists only on home delivery, the
2nd ANM must make sure she uses DDK to conduct the delivery and also explain the “six
cleans” to such women.
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She should keep a record of such women and continue counselling them to opt for
an institutional delivery. She should prepare herself to attend to such women at their home
during delivery & keep herself abreast of schemes like JSY and JSSK implemented in the
state.
b. Complication readiness- recognising danger signs during pregnancy, labour and
after delivery/abortion
The pregnant woman and her family/caretakers should be informed about the
potential danger signs during pregnancy, delivery and in the post-partum period. She must
be told by the 2nd ANM that if she has any of the following signs during pregnancy or delivery
or in the post-partum/ post-abortion period, she should immediately visit a PHC/FRU without
waiting, be it day or night. The 2nd ANM must also counsel her to inform herself and the
ASHA.
Danger signs during pregnancy and labour and after delivery/abortion- visit PHC/ visit
FRU
Visit PHC
•
•
•
•
Weight <38 kgs. at first
trimester
Short stature <145 cms or 4
feet-10 inches
High fever with or without
abdominal pain, too weak to get
out of bed
Fast or difficult breathing
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Visit FRU
•
Age less than 18 years or more than 35 years
•
•
•
Malpresentation
Multiple pregnancy
Any bleeding P/V during pregnancy and after
delivery (a pad is soaked in less than 5 minutes)
Severe headache with blurred vision
Haemoglobin <7 g%
•
•
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Haemoglobin 7–11 g% even
after consuming IFA tablets for
30 days
•
Excessive vomiting, unable to
take anything orally
•
•
Breathlessness at rest
Reduced urinary output with
high BP
High BP (>140/90 mmHg) with
or without proteins in the urine
•
•
•
•
•
•
•
•
•
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Convulsions or loss of consciousness
Decreased or absent foetal movements
Active labour lasting longer than 12 hours in a
primi-para and more than 8 hours in a multi-para
Continuous severe abdominal pain
Premature rupture of membranes (PROM)
before 37 weeks
High BP (>140/90 mmHg) with proteins in the
urine, and severe headache with blurred vision
or epigastric pain
Temperature more than 38°c
Foul smelling discharge before or after
delivery/abortion
•
•
Ruptured membranes for more than 18 hours
FHR >160/minute or <120/minute
•
Perineal tear ( 2nd , 3rd and 4th degree)
Note: If the 2nd ANM is not able to decide on whether to send a case to the FRU or
PHC, she should refer her to the FRU
5.6 Breastfeeding
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Pregnancy is the ideal time for the 2nd ANM to counsel the mother on the benefits of
breastfeeding her baby. She must impart the following messages on breastfeeding:
•
Initiate breastfeeding, especially colostrum (rich in vitamin A and protective
antibodies) feeding within an hour of birth.
•
Do not give any pre-lacteal feeds, not even water.
•
Ensure good attachment of the baby to the breast.
•
Exclusively breastfeed the baby for six months.
•
Breastfeed the baby whenever he/she demands.
•
Follow the practice of rooming in.
5.7 Family planning
Pregnancy is the best period for family planning counselling as it gives the couple
time to think about and choose the method they would want to use after the birth of their
baby. The 2nd ANM should advise the woman on birth spacing or limiting, as necessary.
Impart advice to the couple on the range of contraceptive methods (temporary and
permanent) available and help them choose the method best suited to them.
•
Temporary methods: Lactational amenorrhoea method; intrauterine
contraceptive device (IUCD); condoms; injectables (DPMA); natural methods;
oral contraceptive pills; emergency contraception pills;
She must explain the benefits and risk associated with each of the above
mentioned contraceptive methods for spacing.
•
Permanent methods: Female sterilization (tubectomy); and Male sterilization
(non scalpel vasectomy).
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5.8 Intra-partum care - care during labour and delivery
Points to remember
Mother
Newborn
•
Let the woman choose the position
she desires and feels comfortable in
during labour.
•
•
Maintain airway and breathing.
Maintain a partograph which will help
the 2nd ANM to recognise the need for
action at the appropriate time and
thus ensure timely referral.
•
Initiate breastfeeding within the first
hour of birth.
•
Recognise danger signs and make
timely and appropriate referrals.
•
•
Ensure active management of the
third stage of labour, thereby
preventing postpartum hemorrhage
(PPH).
Maintain body temperature and prevent
hypothermia.
The 2nd ANM has the responsibility of providing the necessary care for the
management of labour as well as emotional support, and must ensure a successful outcome
for the mother and the baby.
Supportive care during labour
•
Encourage and re-assure the woman that things are going well.
•
Maintain and respect the privacy of the woman during examination and
discussion.
•
Explain all examinations and procedures to be carried out on the woman, seek
her permission before conducting them and discuss the findings with her.
•
Make sure that the birthing area is clean, so as to prevent infection.
•
Encourage the birth companion to help relieve the woman’s pain by massaging
her back, holding her hand, sponging her face between contractions.
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Stages of labour & monitoring and managing the stages of labour
First stage
This is the period from the onset of labour pain to the full dilatation of the
cervix, i.e. to 10 cm. This stage takes about 12 hours in primi-gravidas and
6-8 hours for multi-gravidas. It is divided into the latent and active stages.
• Latent stage (not in active labour)
o Cervix is dilated <4 cm
o Contractions weak (less than 2 contractions in 10 minutes)
• Active stage
• Cervix is dilated >4 cm
Second stage
This is the period from full dilatation of the cervix to the delivery of the
baby. This stage takes about two hours for primigravidas and about half an
hour for multigravidas.
Third stage
This is the period from after delivery of the baby to delivery of the placenta.
This stage takes about 15 minutes to half an hour, irrespective of whether
the woman is a primagravida or multigravida.
Fourth stage
This is the first two hours after the delivery of the placenta. This is a critical
period as PPH, a potentially fatal complication, is likely to occur during this
stage.
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Oxytocic drugs for inducing/ accelerating labour should not be administered before
delivery as their use is associated with a high incidence of rupture of the uterus.
Monitoring
Action / Management
Latent stage (not in active labour)- monitor
the following every one hour:
•
•
Contractions:
o Frequency – how many
contractions in 10 minutes
o Duration – for how many seconds
each contraction lasts
• FHR: Normal FHR is between 120 and
160 beats / minute
• Presence of any sign of an emergency
(difficulty in breathing, shock, vaginal
bleeding, convulsions or
unconsciousness)
Latent stage (not in active labour)- monitor
the following every four hours:
•
•
•
•
Cervical dilatation (in cm)
Temperature
Pulse
Blood pressure
Record time of rupture of membranes and
colour of amniotic fluid.
• Never leave the woman alone
• Allow her to remain mobile
• Let her choose the position in which she is
comfortable.
If after eight hours, the contractions are
stronger and more frequent but there is not
progress in cervical dilatation, with or without
rupture of the membranes, it indicates non
progress of labour. Refer the woman urgently
to an FRU.
If after eight hours, there is no increase in
intensity/ frequency/ duration of contractions,
the membranes are not ruptured and there is
no progress in cervical dilatation, ask the
woman to relax. Advise her to come/send for
you again when the pain/discomfort increases,
and/or there is vaginal bleeding, and/ or the
membranes rupture.
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Active stage - monitor the following every
30 minutes:
• Maternal pulse
• Contractions – frequency and duration
• FHR
• Presence of signs such as meconium
blood-stained amniotic fluid, prolapsed
cord.
•
•
Active stage - monitor the following every
four hours:
• Cervical dilatation (in cm) by P/V
• Temperature
• Blood pressure
•
•
•
•
•
•
Never leave the woman along
Start maintaining a partograph when the
woman reaches active labour
Re-assess the woman and consider criteria
for referral
Call a senior person, if available. Alert
emergency transport services.
Encourage the woman to empty her
bladder
Ensure adequate hydration but omit solid
foods
Encourage her to maintain an upright
position and walk, if she wishes
Monitor intensively, using the partograph.
Refer immediately if there is no progress.
Partograph
The partograph is a graphic recording of the progress of labour and the condition of the
mother and foetus. It is a tool which helps assess the need for action at the appropriate time.
Follow the instructions below carefully while filling the partograph:
•
Identification data–Note down the woman’s name and age, parity, date and time of
admission, registration number and time of rupture of the membranes.
•
Foetal condition

Count the FHR every half an hour.
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•
14

Count the FHR for one full minute.


The rate should be preferably counted immediately after a uterine contraction.
If the FHR is below 120 beats per minute or above 160 beats per minute, it
indicates foetal distress.

Remember that each of the small boxes in the vertical column of the partograph
represents a half-hour interval.


Note the condition of the membranes and observe the colour of the amniotic
fluid as visible at the vulva every half an hour.
Record in the partograph as follows:


Membranes intact (mark ‘I’)
Membranes ruptured:

Clear liquor (mark ‘C’)

Meconium-stained liquor (mark ‘M’)
Labour

Begin plotting on the partograph only when active labour starts. Active labour
starts when the cervical dilatation is 4 cm or more and the woman is having at
least two good contractions every 10 minutes.


Record the cervical dilatation in centimeters every four hours.

Plot the first recording of cervical dilatation on the alert line. Write the time
accordingly in the corresponding row for time. After four hours, conduct a vaginal
examination and plot the cervical dilatation in centimeters on the graph.

If the alert line is crossed (the plotting moves to the right of the alert line), it
indicates prolonged/obstructed labour and the 2nd ANM should be alert that
something is abnormal with the labour.

Note the time when the alert line is crossed. The woman needs to be referred
urgently to the FRU. Please remember to send the partograph along.

Crossing of the action line (the plotting moves to the right of the action line)
indicates the need for intervention. There is a difference of four hours between
the alert line and the action line. By the time the action line is crossed, the
woman should ideally have reached the FRU for the appropriate intervention.
Refer as soon as alert line is crossed and do not wait for referral till the
action line is crossed.

Chart the contractions every half an hour; count the number of contractions over
10 minutes and note their duration in seconds.
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In this phase, cervical dilatation progresses by approximately 1 cm per hour and
is often quicker in multi-gravida.
Maternal condition

Record the maternal pulse on the graph every half an hour and mark with a dot
(.).

Record the woman’s blood pressure on the graph every four hours, using a
vertical arrow ( )with the upper end of the arrow signifying the systolic blood
pressure and the lower end indicating the diastolic blood pressure.

Record the temperature every four hours and note it on the temperature graph.
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5.9 Care of the newborn
•
Place an identity label on the baby’s wrist or ankle and weigh the baby.
•
Ensure that the baby is given vitamin K injection 1.0 mg, intra muscular to all
newborns weighing 1500 gms. and above and in a dose of 0.5 mg to newborns
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weighing less than 1500 gms. The site for the injection is the quadriceps muscle
group of the upper, outer thigh by sterile 1-inch needle of the smallest size available.
•
Examine the baby quickly for malformations or any birth injury. If there is major
malformation or severe birth injury, refer the baby to the newborn unit in the FRU.
•
Check the baby’s colour and breathing every five minutes.
•
If the baby becomes cyanotic (bluish) or is having difficulty breathing (less than 30 or
more than 60 breaths per minute), make initial attempts at resuscitation. If this does
not help, a referral to the MO at the FRU is necessary.
•
Check if the baby is warm, by feeling his/her feet every 15 minutes and if the baby’s
feet feel cold, check the auxiliary temperature.
•
If the baby’s temperature is below 36.5°c, provide warmth to the baby by placing
him/her under a radiant warmer.
•
Teach the mother to provide skin-to-skin contact, a component of Kangaroo Mother
Care (KMC).
•
Check the cord for bleeding and if cord is bleeding, re-tie it more tightly.
•
Do not apply any substance to the stump. Leave the stump uncovered and dry.
•
Wipe the baby’s skin. Delay the baby’s first bath to beyond 24 hours of birth.
•
Encourage breastfeeding within an hour of birth and emphasise the importance of
colostrum. Check if the baby’s position and his/her attachment to the breast are
correct at the first feed.
•
Watch for complications such as convulsions, coma and feeding problems. Refer the
baby if these are present.
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Newborn resuscitation
•
Approximately 10% of newborns require some assistance to begin breathing at birth;
about 1% needs extensive resuscitative measures to survive.
•
Resuscitation must be anticipated at each birth. Up to half of newborns who require
resuscitation have no identifiable risk factors before birth. An increased risk of
breathing problems may occur in babies who are:
•
Pre-term, born after a long traumatic labour, born to mothers who received sedation
during the late stages of labour, babies who are not breathing or are gasping need
resuscitation.
•
If the baby needs resuscitation, initiate all the initial steps in the flowchart below
within a few seconds.
Preparing for discharge
The 2nd ANM has to perform following activities to be performed before the discharge
and also explain the mother about the danger signs which require her or the baby to return
for care immediately.
Mother
Baby
Ensure that the uterus is hard and is not
bleeding
Ensure that the baby is warm, breathing
normally, and accepting and retaining
breast milk, and that the cord is clean.
Ensure that the baby receives
• BCG
Counsel the mother about:
•
Diet and rest
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•
•
•
•
•
•
•
Exclusive breastfeeding
Need to take iron tablets
Family planning
Hygiene to prevent infection of mother
and her baby
Avoiding sexual intercourse till perineal
wound heals
When to return for follow-up
Complete immunisation of baby
17
• OPV – 0
• Hepatitis B – 0
Vaccinations preferably before discharge
from the health facility. A record of these
vaccinations should be entered in the MCP
card.
Danger signs – return immediately
•
•
•
•
•
•
•
•
•
Increase in vaginal bleeding
Convulsions
Fast or difficult breathing
If mother has fever and is too weak to
get out of bed
Severe abdominal pain
Swollen, red or tender breasts
Pain / burning sensation while passing
urine
Pain in the perineum or pus
Foul smelling discharge
•
•
If baby is breastfeeding poorly
If baby develops fever or feels cold to
the touch
Breathes fast
Has difficulty in breathing
Has blood in the stool
If the palms and soles are yellow
Has convulsions
•
•
•
•
•
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In case of home delivery, if the 2nd ANM identifies the above mentioned danger signs
both for mother and the baby-she should refer them to MO/FRU.
5.10 Post-partum care - care after delivery
Points to remember
Mother
•
•
•
•
•
Make at least four post-partum visits
to ensure that complications during
the post-partum period are recognised
in time.
Look out for symptoms and signs of
PPH and puerperal sepsis during
post-partum visits as they are the
major causes of maternal mortality.
Advise the mother on colostrum
feeding and exclusive breastfeeding.
Advise the mother for nutritious food.
Advise the couple on family planning.
Newborn
•
•
•
•
•
Keep the baby warm.
Ensure care of the umbilicus, skin and
eyes.
Ensure good suckling while
breastfeeding.
Screen the newborn for danger signs.
Advise the mother and family members
on immunisation
Conventionally, the first 42 days (six weeks) after delivery are considered the postpartum period. The first 48 hours of the post-partum period, followed by the first one week,
are the most crucial period for the health and survival both of the mother and her newborn.
Most of the fatal and near-fatal maternal and neonatal complications occur during this
period. Evidence has shown that more than 60% of maternal deaths take place during the
post-partum period.
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Post-partum visits by the 2nd ANM
After delivery at PHC/FRU (48
hours)
st
First visit
1 day (within 24 hours)
Not applicable
rd
Second visit
3 day after delivery
3rd day after delivery
th
Third visit
7 day after delivery
7th day after delivery
Fourth visit
6 weeks after delivery
6 weeks after delivery
nd
The 2 ANM should make three additional visits in case of babies with low birth
weight, on days 14, 21 & 28.
Visits
After delivery at home/SC
Post partum care
Activity
History
Taking
Examination
Mother
1st visit
Look for the following signs of complications
/ danger signs
• Excessive bleeding (use of >5 pads a
day)
• Abdominal pain
• Puerperal sepsis (infection)
• Anaemia
• Breast engorgement
• Convulsions
• Fever, etc.
• Pulse
• Blood pressure
• Respiratory rate
• Pallor (Hb estimation for anaemia)
• Abdomen
• Pads for excess bleeding
• Discharge of puss or foul smell
• Breasts
Baby
•
•
•
•
•
•
Any difficulties in breast-feeding
Fever
Difficulty in breathing
Umbilical cord is red or swollen, or is
discharging pus
Pustules (skin infection)
Convulsions
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•
•
•
•
•
•
Management •
•
/
Counselling
•
•
•
•
•
•
Advise for personal hygiene
Hand washing before feeding and after
cleaning the baby
Intake of nutritious food and plenty of
fluids
IFA supplementation for three months
Exclusive breast-feeding for six months
Help the mother in case of any problems
during breast-feeding (attachment, sore
nipples, engorged breast)
Explain importance of registration of
birth/birth certificate
Counsel the mother to visit FRU for the
following danger signs :
Copyright © 2015 SciResPub.
•
•
•
•
•
Count the respiratory rate. If <30 or >60
breaths per minute-refer
Chest indrawing – Mild- normal, severe
chest indrawing needs referral
Check body temperature, if it is <36.50C
& > 37.40C – refer
Treat for umbilical cord problem, if no
improvement after two days – refer
Check for pallor, jaundice, pustules, eye
discharge, congenital malformation,
injury, if found – refer
Check for normal cry and activity, if the
baby is lethargic or unconscious – refer
Advise the mother to maintain hygiene
while handling the baby.
Keep the baby covered and warm.
Not to apply anything on the umbilicus.
Ensure good attachment while
breastfeeding.
Ensure immunisation.
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Excessive bleeding (> 2 to 3 pads in
20-30 min. after delivery)
o Convulsion
o Puerperal sepsis(infection)
o Fever
o Severe abdominal pain
o Difficulty in breathing
o Foul smelling discharge
Advise the couple on contraceptive
methods for spacing or limiting the size
of the family
o
•
History
taking
Examination
•
•
•
•
•
•
Management •
/
Counselling
•
2nd & 3rd visits
• Same as in 1st visit, if any problem
Same as in 1st visit + ask the mother for
persists refer the baby to FRU
continued bleeding P/V
Foul smelling vaginal discharge
Engorgement / tenderness of the breast
Fatigue / depression
Any other complaint
Same as in 1st visit and
Same as in 1st visit
• Observe for good suckling
• Diarrhea with blood in the stool
• Convulsions
• Counsel the mother for exclusive
Inform the mother to enhance intake of
breastfeeding for six months
food, and also food rich in calories,
• Feed the baby on demand
proteins, iron, vitamins and micro
• Maintain hygiene
nutrients (milk, milk products, cereals,
green leafy vegetables, ground nuts,
• Inform the 2nd ANM in case of signs of
jaggerry, egg, meat and fruits.
illness
Inform the couple about various choices • Immunisation as per UIP
of contraceptive methods and help them
to choose the method best suitable to
them.
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4th visit
History
taking
•
•
•
Examination
•
•
•
Management •
/
Counselling •
(Tell)
Ask if vaginal bleeding stopped,
menstrual cycle resumed, any foul
smelling discharge
Any problem while passing urine
Any problems with breastfeeding
Check BP and Pallor
Vagina for any swelling or puss
Breast for presence of lumps or
tenderness
As in 2nd & 3rd visits, emphasise the
importance of nutrition
Emphasise the importance of using
contraceptive methods for spacing or
limiting the size of the family
•
•
•
•
•
•
•
•
Ask the mother if the baby has received
all the vaccines recommended so far
Is the baby taking breastfeeds well?
If the baby has gained weight?
Any other problem
Check the weight of the baby
Check if the baby is active / lethargic
Emphasise the importance of exclusive
breastfeeding
In case of any problem, the child should
be immediately taken to MO.
Complications during pregnancy, delivery and in the post-partum period
Complications can arise at any time during pregnancy or delivery and may also develop
in the woman after child birth. The 2nd ANM must be alert to these danger signs and she
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should also educate the woman and her family members on how to recognise these
complications and be prepared for immediate referral.
During pregnancy
Danger signs / complications
How to recognise
Emergency referral
Bleeding from vagina
Any amount of blood (bright red bleeding or clots or
tissue)
Loss of foetal movement
Absence of foetal movements/ kicking, severe
abdominal pain
Headache/ giddiness/ blurred vision
Severe headache + blurred vision or severe headache
+ spots before the eyes
Swellon face/ hands
Pitting oedema on back of the palm
Convulsions/ fits
Eyes roll, face and limbs twitch, body gets stiff and
shakes, fists clinched.
Non-emergency referral
Problem
How to recognise
Action to be taken
Severe anaemia
Tongue very pale, weakness, general
swelling in body
Refer to PHC / DH
Night blindness
Pregnant women find it difficult to see
at dusk
Give vitamin D & E for 30
days,
No improvement- refer to PHC
Skin warm to touch, temperature
>1000F (37.80C)
Give tab. Paracetamol, if no
relief after 48 hours, refer to
PHC
Pain / burning when
urinating
Frequent urination and urgency. Pain/
burning when passing urination
Let mother drink plenty of
water. If no relief after 24
hours, refer to PHC.
Itching/Scabies/boil
on skin with pus
Skin rashes with itching could be
present in other family members as
well, scabies, presence of pus- filled
boils
For boils, advise hot
fomentations in affected area
thrice daily, if no improvement
after two days, refer to PHC
for scabies-refer to ANM/PHC
Bad obstetric history
Ask the pregnant woman about past
history of abortion, still birth or
neonatal death, or whether she
developed complications in last
pregnancy, especially one which
required surgery(CS).
Refer to CHC/DH
Multiple pregnancies
Suspicion/knowledge: usually
suspected by the 2nd ANM during
ANC or by doctor after abdomen
examination
Refer to CHC/DH-ultrasound
examination would confirm
this.
Malpresentation
Suspicion/knowledge: usually
suspected by the 2nd ANM during
ANC or by doctor after abdomen
examination
Refer to CHC/DH-ultrasound
examination would confirm this
Fever
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During delivery
nd
The 2 ANM should be aware of the following danger signs that can occur at any time
during labour and delivery.
•
•
Bleeding (fresh blood)
Swollen face and hands
•
•
•
•
Baby lying sideways
Water breaks but labour does not start within 24 hours or less
Colour of water – green or brown
Prolonged labour – woman pushing for more than 12 hours (eight hours in the case
of women who have already had children) with the baby not coming out
Fever
Fits
Retained placenta – If it does not come out within 30 minutes of the delivery. If the
placenta doesn’t come out even after 10 minutes of breast feeding, the woman needs
medical attention.
•
•
•
During post partum period
nd
The danger signs that the 2 ANM must be alert of during the post partum period:
Danger signs /
complications
Action to be taken
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Excessive bleeding
Ask the mother if the bleeding is heavy (use of >5 pads per day)
Puerperal Sepsis
(Infection)
Ask if the discharge is foul smelling. If it is so, suspect infection.
Fever, chills and pain in abdomen along with the foul smell confirms
infection. Treat her with antibiotics and refer her to a PHC.
Convulsions with or
without swelling of face
and hands, severe
headache, and blurred
vision
Eyes roll, face and limbs twitch, body gets stiff and shakes, fists
clinched. The 2nd ANM needs to stabilise the patient before referral.
Anaemia
Check for pallor and estimate Hb status, if moderately anaemic give
her at least 2 IFA tablets per day for 3 months. If severely anaemic,
refer to PHC.
Breast engorgement and
infection
Help the woman to prevent engorgement and infection by starting
breastfeeding soon after delivery and feeding often, ensure correct
attachment, encourage on demand feeding. Ask her to continue to
breastfeed even if she is taking antibiotics.
Perineal swelling and
infection
Emphasise on personal hygiene, advice to apply cloth dipped in hot
water twice a day. If there is fever, refer to PHC/CHC. A tablet of
Paracetomol would help both in pain and fever.
Post-partum mood
changes
Counsel and support the woman as these changes usually
disappear after a week. If the changes become severe then refer.
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5.11 Newborn health
Points to remember- Identification of high risk baby
•
Birth weight less than 2000 gm.
•
Pre-term (delivery which happens when mother is 8 months and 14 days
pregnant or less).
•
Baby not taking feeds on day one.
Using the following table, determine whether the baby is high risk or not:
Day on which the baby is weighed for
the first time
Weight of baby
Diagnosis
1 to 14 days
Less than 2 kg
High risk baby
15 to 21 days
Less than 2 kg- 100 gm
High risk baby
22 to 27 days
Less than 2 kg- 200 gm
High risk baby
28th day
Less than 2 kg- 300 gm
High risk baby
Guidance that the 2nd ANM should impart to the family
•
Keep the baby clothed from the very first day. In winter, cover the baby with a
blanket.
•
Do not bathe a baby until its weight is 2000 gm.
•
Ensure that mother’s nails are cut and that her hands are washed every time the
baby is breastfed and all family members must wash their hands with soap before
touching the baby.
•
High risk babies should be breastfed after every two hours.
•
If baby is not suckling milk, squeeze the breast milk in a small bowl and then feed the
baby with a spoon.
•
The weight of high risk babies should improve every week from second week. If this
does not happen, the 2nd ANM must counsel them to consult her.
•
The 2nd ANM must ask them to call her immediately if the baby develops any of the
following: All limbs become limp, stops feeding, has chest indrawing, has fever, and
is cold to touch.
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If the baby is at high risk, then the 2nd ANM must
•
Increase the number of home visits after delivery. A daily visit, if possible, for the first
week.
•
Once every three days until the baby is 28 days old, and if the baby is improving
once on the 42nd day.
•
Monitor the weight of babies on day 7, 15, 21, 28, 42. Babies who weigh less than
2300 gm on the 28th day have a higher risk of dying. If the baby is not gaining
weight, refer the baby to the hospital.
•
Explain the high risk issues to the parents and family.
•
Provide specific care as per the problem but in general, keep the baby warm and
breastfeed more often every two hours.
•
For poor breastfeeding, observe the mother breastfeeding. Ensure proper latch-on
and positioning. Encourage the mother so that she is motivated to feed the baby well.
Counsel the mother that she should not give other liquids or feeds.
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23
If on day 28 the weight is less than 2300 gm or weight gain in 28 days is less than
300 gm, then the 2nd ANM should continue to visit once a week in the 2nd month and
take the weight every day.
Two common emergencies among newborns, the 2nd ANM must know about:
1. Asphyxia
2. Neonatal Sepsis
Asphyxia – diagnosis and management
Symptoms
Consequences
Management
At the time of birth:
Immediate:
•
•
•
No cry/weak cry
No breathing / weak
breathing
During labour:
•
•
•
•
•
•
•
•
Still birth / dies at once
or within a few days
• Unable to suckle
Long term
Pre-term labour
Prolonged or difficult
labour
Ruptured membrane
with little fluid
Green or yellow colour
thick amniotic fluid
Cord comes out first or
cord is wound tightly
around the neck
•
Mental retardation
Epilepsy (seizures and
fits)
Spasticity (difficulty
walking or moving arms
and hands)
•
Immediately clean the
mouth with mucus
extractor. If the baby does
not breathe, suction the
throat. If baby still doesn’t
breathe, suction the nose
with mucus extractor.
Baby does not cry, start
immediately to ventilate (in
less than one minute from
birth), use bag & mask (40
times per minute). If the
baby starts to cry or
breathe, stop.
If no cry or breathe
continue ventilation, call for
help.
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•
Neonatal Sepsis – diagnosis & management
nd
The 2 ANM must know to diagnose and manage neonatal sepsis as it is the most
common killer of newborn in the first month of life.
Causes
•
•
•
•
•
Prevention
•
Mother has infection during pregnancy or delivery
Unclean techniques/ conditions during delivery (Poor hand
washing, unclean blade and cord ties)
Baby is weak
Born pre-term or with LBW (<2000 gms)
Baby becomes weak from poor feeding practices (absence of
early and exclusive breast feeding)
•
•
•
Good hygiene (frequent hand washing; clean instruments during
delivery; clean cloths)
Keeping the baby warm (especially during the cold season)
Breast feeding (early initiation, on demand and exclusive)
Keeping the umbilical cord clean and dry
Signs/Symptoms
•
•
•
•
•
Limbs become limp
Stops feeding
Has chest indrawing
Has fever
Is cold to touch
Treatment
•
The 2nd ANM can start the treatment of sepsis by
o Cotrimaxozole syrup – ¼ teaspoon twice a day for 7 days if
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baby is full term.
Cotrimaxozole syrup – ¼ teaspoon twice a day for 10 days, if
baby is pre term.
Gentamicin injection once a day and help the parent to visit the
PHC.
o
•
When to refer
•
•
•
•
•
•
•
•
If there are breastfeeding problems and these are not solved by
the 2nd ANMs counselling and home management after 24 hours.
Baby has the following danger signs
Not responding – after antibiotic treatment for 24 hours
Becomes yellow (jaundice) on first day or jaundice persists after
14 days
Bleeding from nose, mouth or anus
Convulsions
Body temperature of baby continues to remain less than 950F
even after re-warming the baby for 24 hours.
Tetanus (stiffness after the fourth day), unable to suckle or open
mouth.
5.12 Child health & nutrition
Facts that the 2nd ANM should know about malnutrition in young children
•
Malnutrition increases susceptibility to disease. Malnutrition is one of the
contributory factors to over half of all child deaths.
•
Malnutrition is highly related to poverty. Poor families have less money to spend
to get the quantity and variety of food, they find it more difficult to get healthcare
and also there is less time for childcare.
•
Counselling can help the family in making the right choices on using their scarce
resources to feed their children and protect them from malnutrition.
•
Prevention is easier to manage the problem of malnutrition among children.
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Six important messages for preventing child malnutrition
The 2nd ANM should know the following messages for preventing child malnutrition and
educate the mother and family members accordingly
1. Exclusive breastfeeding: Till the age of six months, give only breast milk; not even
water should be added.
2. Complementary feeding: At the age of six months, add other foods. There are five
things to remember here, namely consistency, quantity, frequency, density and
variety.
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3. Feeding during the illness: Give as much as the child will take; after the illness, to
catch up with growth, add an extra-feed.
4. Prevent illness: Recurrent illness is a major cause of malnutrition. Counsel the
mother / family on prevention of illness.
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•
Hand washing: before feeding the child, before preparing the child’s food, and
after cleaning up the child. This is the single most useful measure to prevent
recurrent diarrhoea.
•
•
•
Drinking water to be boiled: particularly for the malnourished child with diarrhoea.
•
Full immunisation of the child: Ensure full immunisation as per the UIP schedule.
Vitamin A: This reduces infections and night blindness, all of which is more
common in malnourished children.
Avoid persons with infections: avoid contact of the child with infected persons.
Though this does not apply to mother, she should practice hand washing.
•
Preventing malaria: Ensure use of insecticide treated bednet as malaria too is a
major cause of malnutrition.
5. Access to health services
•
Access to health services enables prompt treatment of illness and malnutrition.
On the very first day of the illness, the 2nd ANM should help the mother decide on
whether it is a minor illness for which home remedy would be adequate, or to be
referred to a doctor.
•
Access to contraceptive services is important. If the age of mother is less than 19,
or the gap between two children is less than three years, there is a much higher
chance of the children being malnourished.
6. Access to anganwadi services
•
Ensure food supplements for the pregnant women and lactating mothers up to six
months and children up to the age of five. Monitor the weight of the baby and
inform the family of the level of malnutrition.
Few parameters to assess malnutrition
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•
Anaemia: Look for pallor of the skin of the soles or palms as a sign of anaemia in
children as it commonly comes along with malnutrition. Treat the anaemic child by
giving one tablet of pediatric IFA daily for three months and also one tablet of
Albendazole for de-worming once in six months (for a child <2 years give half a tablet
of Albendazole). If anaemia does not improve, the child must be referred to PHC for
more complete blood tests and treatment. Counsel the mother and family members
regarding complementary feeding.
•
Identifying visible severe wasting: A child with visible severe wasting is very thin,
has no fat, and looks like skin and bones, and there are many folds of skin on the
buttocks and thigh. Face may appear normal but the abdomen is large and
distended. In order to identify such child, the 2nd ANM has to determine grade of
malnutrition i.e. plotting weight for age along with AWW. There is a separate chart for
boys and for girls under the age of five years.
Plotting weight for age and identifying malnutrition:
•
•
•
The left hand vertical line is the measure of the child’s weight.
The bottom line of the chart shows the child’s age in months.
Find the point on the chart where the line for the child’s weight meets the line for the
child’s age.
After plotting, see
•
•
If the point is below the bottom most (-3SD) curve, the child is severely underweight.
•
If the point is on or above the curve marked zero or between the curve zero and 2SD (second curve) or exactly on the 2nd curve, then the child is normal.
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If the point is between 2nd and 3rd curve or exactly on the 3rd curve, the child is
moderately underweight.
Refer the children who are moderately underweight to 24 x 7 PHC or higher facility.
Children who are severely malnourished need prompt hospitalisation, often at District
Hospital.
Assessing the sick child
Common illnesses in the young child could include: diarrhea, cough and cold, fever,
pneumonia, meningitis or malaria which make the child so sick that the child is not able to
drink or take feeds. Assess every sick child for the presence of danger signs like: not able to
drink or breastfeed; vomits everything; has convulsions; is lethargic or unconscious. A child
who has even one general danger sign should be urgently referred to hospital.
Fever: Assessment, classification and management
Fever is a common problem among young children. A child with fever may have malaria
or cough and cold or other viral infection. The 2nd ANM has to check for fever and if the child
has fever for more than seven days refer the child.
Any general danger
sign or stiff neck
Danger signs:
• Not able to drink
Very
severe
febrile
disease
or breastfeed
• Vomits
everything
• Has convulsions
• Is lethargic or
unconscious
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Give first dose of Cotrimoxazole
Give first dose of antimalarial, after making a smear.
Give one dose of paracetamol to bring the high fever
down.
Refer urgently to hospital
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Give first dose of anti-malarial, after making a smear.
Give one dose of paracetamol to bring the high fever
down.
Advise extra fluids, continue feeding and advise about
danger signs.
Follow up in two days if fever persists.
If fever is present every day for more than seven days,
refer the child.
nd
Note: If fever is high, the 2 ANM can do ‘tepid water sponging’ to lower the fever. If
fever is high, and child is above two months of age, the 2nd ANM can give
paracetamol.
Fever (by history or
feels hot) in a
malarial area
Malaria
Diarrhoea: Assessment ,classification and management
Signs/symptoms
Two of the following signs:
• Lethargic or unconscious
• Sunken eyes
• Not able to drink or drinking
poorly
• Skin pinch goes back very
slowly.
Two of the following signs:
• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly.
Status
Not enough signs to classify as
some or severe dehydration.
Passing urine normally.
No
dehydration
Diarrhoea for 14 days or more.
Severe
persistent
diarrhoea
Dysentery,
no
dehydration
Action to be taken
•
Severe
dehydration
Refer urgently to hospital with mother
giving frequent sips of ORS/ fluids on
the way.
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Blood in the stool. Some or
severe dehydration.
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•
Some
dehydration
•
Give extra fluids/ORS frequently and
food.
Give only ORS along with
breastfeeding for children aged <6
months.
Follow-up in two days.
Give extra fluids/ORS frequently and
food to treat diarrhoea at home.
Follow-up in two days if not improving.
•
Refer to hospital.
•
•
•
Referral if possible.
or give Cotrimoxazole for five days.
Follow-up in two days.
•
•
•
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•
Remember to counsel the mother regarding good hygiene practices including
washing hands with soap after cleaning the child and before feeding the child and
use of safe drinking water.
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Step 2
Step 1
Management of acute respiratory infection (ARI)
Identifying
the signs of
ARI
Ask the mother if the child has cough or difficult breathing. If the
mother says that the child has cough or difficult breathing, ask for the
duration. A child who has had cough, even if mild, for more than 30
days, needs to be referred to hospital for further assessment. Any
cough with fever for more than three days should also be referred.
Look for
chest
indrawing
Chest indrawing in a child with cough or difficult breathing indicates
that the child has pneumonia. In a child less than one year, in normal
breathing, the whole chest wall (upper and lower) and the abdomen
move out when the young infant breathes in. When chest indrawing is
present, the lower chest wall goes in when the young infant breathes
in. In children less than one year of age, mild chest indrawing can
occur. But in children more than one year of age, mild chest indrawing
is not normal. A child with any chest indrawing should be referred to
the hospital.
Count the breaths in one minute
Count the breaths the child takes in one minute. Decide whether the child has normal
breathing or fast breathing.
If the child’s age is
The child has fast breathing if you count
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2 months up to 12 months:
50 breaths per minute or more
12 months up to 5 years:
40 breaths per minute or more
Note : The child who is exactly 12 months old has fast breathing if you count 40
breaths per minute or more.
Classify cough or difficult breathing
Here is the classification table for cough or difficult breathing.
Signs/Symptoms
Any general danger
sign or chest
indrawing
Fast breathing
Status
Action to be taken
Severe Pneumonia or •
very severe disease
•
Pneumonia
•
•
No signs of
pneumonia or very
severe diseases
Cough or cold
•
•
Give first dose of Cotrimoxazole
Refer urgently to hospital
Give Cotrimoxazole for five days. (2
paediatric tablets twice daily for a child
from 2 up to 12 months and 3 tablets
twice daily for a child from 12 months up
to 5 years.
Follow-up in two days
o If improving, advise for home care
and tablets to continue.
o If no improvement, insist on referral.
Advise home care for cough or cold
If coughing for more than 30 days, refer
for assessment.
Counselling the mothers on home management of common cold or cough
•
Keep the young child warm and away from the draught.
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•
If the child’s nose is blocked and this is interfering with feeding, clean the nose by
putting in nose drops (boiled and cooled glass of water mixed with pinch of salt) and
by cleaning the nose with a soft cotton wick.
•
Breastfeed frequently and for longer period at each feed. Exclusively breastfeed for
six months.
•
Child should continue to be given normal diet during cough and cold as this will
prevent malnutrition and also help the child to recover from illness.
•
After the illness, at least one extra meal should be given to the child for at least a
week to help the child in speedy recovery.
•
Give increased amounts of fluids (as much as the child will take), such as dal soup,
vegetable soup, plain clean water or other locally available fluids.
•
Always feed from a cup or spoon. Never use a bottle.
•
For babies over six months of age, soothe the throat and relieve the cough with a
safe home-made cough remedy (decoction of sugar, ginger, lemon, elaichi, tulsi
leaves or mint).
5.13 Reproductive health needs of women
Safe abortion- Medical Termination of Pregnancy (MTP)
The 2nd ANM must identify the women in need of MTP services and information to take a
decision; assist them to go to the nearest legal and safe public and private providers of such
care; and must also keep the information confidential.
Legality
Safety
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Points to remember
In India, abortions are legal up to 20 weeks. They are legal only if done by a
qualified practitioner. Up to 12 weeks, one doctor can do it. After 12 weeks,
two doctors need to sign the consent form. Abortion services are free in all
government hospitals. Women over 18 do not need anyone else to sign a
consent form.
Only a doctor can perform an abortion, and this should be done under clean
conditions, and with proper instruments.
Abortion is unsafe, if it is done
•
By someone who has not been trained to do it.
•
With the wrong instruments or medicines.
•
Under unclean conditions.
MTP can be done by a trained, legal provider by following methods:
•
Medical abortion: Tablets are prescribed & can be done in only very early
pregnancies (less than seven weeks or 49 days after last missed period).
•
Manual Vacuum Aspiration (MVA): It can be done up to eight weeks of pregnancy.
The woman has to stay in the health facility for a few hours.
•
Dilatation and curettage (D & C): This method can be done up to 12 weeks of
pregnancy. It is associated with a higher risk of complications.
Post-abortion care: The 2nd ANM should visit the women at home after abortion and
advise:
•
To avoid sex for at least five days after the abortion.
•
Drink plenty of fluids for faster recovery.
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•
Some bleeding from vagina for up to two weeks is normal, but it should be light. Next
monthly period will be after 4-6 weeks.
•
Motivate the woman for use of contraception as the risk of pregnancy exists as soon
as intercourse is resumed,
•
Immediate referral in case of post-abortion complications like heavy bleeding, high
fever, severe pain in the abdomen, fainting and confusion, foul smelling discharge
from the vagina .
Family planning
Points to remember
(Different people have different needs for contraception)
Category
Method of contraception
Unmarried
Condoms or pills or emergency pills
Newly married and wanting to delay
the first child
Condoms or pills
Just delivered (postpartum) or just had
an abortion (post-abortal)
Condoms, pills, IUCD (after six weeks), injectables
(currently not available in the public sector, but
being used in the private sector)
Wanting to space children (spacing)
Condoms, pills, IUCD, injectables
Not wanting more children (Limiting the
family size):
Long acting (10) IUCD and sterilisation for the man
or the woman
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Types of family planning methods and information on side-effects
Inform the women/family members about the various contraceptive methods, help them
to choose the best suited to them and explain the benefits and side-effects of each
contraceptive method/device.
The pill (oral contraceptive pills)
If a woman takes birth control pills every day, pills will protect her from pregnancy for the
entire monthly cycle. As the 2nd ANM is required to dispense these, it is important for her to
know a few important facts.
Taking pills may be dangerous for women with the following signs:
•
Woman has jaundice, recognised by yellow skin and eyes.
•
Woman has ever had signs of a stroke, paralysis or heart disease.
•
Woman has ever had a blood clot in the veins of her legs.
•
If the woman smokes and is over 35 years old.
•
Has high blood pressure (more than 140/90).
If the woman has any of the problems listed above, the doctor would then counsel her to
use a method other than the pills.
Side-effects of pills
•
The pills may cause side-effects like nausea, headaches, swelling of legs, changes in
monthly period. These often get better after the first two or three months. If they do
not, and they are annoying or worrying her, the 2nd ANM should advise the woman to
see a doctor.
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Do not advise pills for women who are breastfeeding.
Emergency contraceptive pills
These are for emergency use, when the couple has not used a contraceptive and have
had unprotected sex. It can also be used in instances of rape, or accidental breaking of the
condom. The pills are effective within 12- 24 hours of intercourse. These pills are to be used
only as an emergency method, so the 2nd ANM should advise users to shift to regular
methods of family planning.
Condoms
The condom is a useful device to be used as a contraceptive and to protect against
Sexually Transmitted Infections (STIs) and HIV. It is also useful for couples where the male
is a migrant and returns home for short durations. A condom is to be used only once.
The Intrauterine Contraceptive Device (IUCD, Copper-T, the Loop)
The IUCD is a small device that is inserted into the uterus and prevents the man’s sperm
from fertilizing the woman’s egg. The IUCD can stay in the uterus for up to 10 years.
The 2nd ANM should not counsel IUCD use if the woman:
•
Has never been pregnant.
•
Has anaemia (Low Hb).
•
Is in danger of contracting a sexually transmitted infection.
•
Has ever had an infection in her tubes or uterus, or an infection after giving birth or
having an abortion.
•
Has had a pregnancy in her tubes.
•
Has a lot of bleeding and pain during monthly bleeding.
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The best time to have the IUCD inserted is during the monthly bleeding/period. It can be
inserted during first 48 hours postpartum (PPIUCD). If not, then delay insertion until after six
weeks postpartum.
Common side-effects
The woman may have some light bleeding during the first week after getting an IUCD.
Some women also have longer, heavier and more painful monthly bleeding, but this usually
stops after the first three months.
Sterilisation (Permanent method of contraception)
•
The surgery is fast and safe, and does not cause side-effects.
•
The services for sterilisation are provided on certain days at a PHC or CHC.
The operation for the man (vasectomy)
A vasectomy is a simple operation, with only a small puncture to block the tubes that
carry the sperm. The operation does not change a man’s ability to have sex. The couple
must be advised to use condoms or other contraceptives for 90 days following vasectomy.
The operation for the woman (tubectomy)
This is a slightly more difficult operation than a vasectomy, but it is still very safe. It takes
about 30 minutes. A trained doctor makes a small cut in the woman’s abdomen, and then
cuts or ties the tubes that carry the egg to the womb. The woman can have the operation
within seven days of the start of the menstrual cycle, 24 hours after delivery, or six weeks
after the delivery.
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Important points to communicate:
Sterilisation, IUCDs,or pills do not protect against STIs and human immuno-deficiency
virus (HIV). So, for protection from STIs and HIV, a condom should be used during every
sexual intercourse, if the woman is at risk of contracting them.
Reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI)
Points to remember
•
The 2nd ANM should know that some amount of white discharge is normal. It is
the vagina’s way of cleansing itself.
•
Discharge that is bad smelling (smell of menstrual blood, fishy odour), white
lumpy discharge (curd, coloured greenish, yellowish, reddish, bloody),
accompanied by itching, a rash, sores, burning urination, and lower abdominal
pain, pain during intercourse is indicative of RTI or STI.
•
A change in colour and odour is an alert to the women of a possible infection. In
addition, if there is itching or burning, there is high possibility of an infection.
•
Discharge is also indicative of certain hormonal problems or even cancer.
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Sexually Transmitted Infections (STI)
STIs are infections that are passed from an infected person to another during sexual
intercourse. Mothers can pass on STIs to babies during the delivery process. Most STIs are
RTIs. However, a few like Hepatitis-B and HIV are STIs but not RTIs.
STIs are a serious problem for women
•
Because the infected semen stays longer inside a woman’s body.
•
The entire genital tract in women is hidden, therefore, the infection stays inside
silently for a longer time.
•
It is harder for a woman to protect herself from STIs, because she is often unable to
negotiate with the male partner to use a condom.
Consequences of STIs
Signs of RTIs
•
Infertility in men and women;
•
Abnormal discharge
•
•
•
Babies to be born too early, too small or blind; and
Long lasting pain in lower abdomen, or even cancer.
Death from severe infection or AIDS
•
•
Lower abdominal pain
Rash, swelling in the groin
or sore in genital area.
The 2nd ANM has to:
•
Counsel women at risk on preventive measures.
•
Counsel women with symptoms of RTI/STI to visit 24X7 PHCs or higher facilities as
they are equipped and skilled to provide necessary care.
•
Advise women to take course of medicine fully (all courses are for a week or ten
days). Not completing the course of medicines makes the bacteria resistant and can
cause a worse infection that does not respond to drugs the next time.
•
Ensure that the husband also gets treated.
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Counsel women to abstain from sexual activity during the period of treatment and to
maintain personal hygiene.
HIV and AIDS
The2nd ANM can increase awareness on HIV and AIDS with focus on its transmission, its
prevention and services available. The 2nd ANM can also help in reducing myths and
misconceptions as well as stigma and discrimination associated with it.
Communicate the following:
Mode of transmission
Prevention
•
Unprotected sex (sex without condom);
•
•
Receiving HIV infected blood or blood
products;
Protected sex (using condom during
sexual intercourse), avoid multiple sex
partners
•
Using/sharing unsterilised needles or
lancets; and
Transfusion of safe blood from blood
bank of government hospitals or
recognised hospitals only
•
Using sterilised needles/avoid sharing of
needles
•
Motivate high risk pregnant women to get
tested for timely treatment to prevent
transmission from mother to baby.
•
•
From HIV infected mother to her baby.
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•
It does not spread through any other mode such as kissing and touching, holding
hands, mosquito bites, sharing clothes or things, etc.
•
Persons with HIV are at greater risk of getting Tuberculosis. Every 1 in 20 persons
suffering from TB in India is also HIV infected.
•
The 2nd ANM should encourage persons at high risk i.e. commercial sex workers,
injecting drug users, migrant labourers, multiple partners, etc. to go for HIV test.
In addition to aforementioned roles, duties and responsibilities related to maternal and child
health, the 2nd ANM has to perform the following tasks:
5.14 Communicable diseases
1. Notify the MO, PHC immediately about any abnormal increase in cases of
diarrhea/dysentery, fever with rigours, fever with rash, flaccid paralysis of acute onset
in a child <15 years (AFP), Tetanus, fever with jaundice or fever with
unconsciousness, minor and serious AEFIs which the 2nd ANM comes across during
her home visits, take the necessary measures to prevent their spread, and inform the
health assistant (male)/LHV to enable him/her to take further action.
2. HIV/STI counselling, HIV/STI screening if trained.
3. Leprosy
♦ Impart health education on leprosy and its treatment to the community.
♦ Refer suspected new cases of leprosy and those with complications to PHC.
♦ Provide subsequent doses of MDT to patients. Ensure regularity and completion
of treatment and assist health supervisor in retrieval of absentee/defaulter.
♦ Update the case cards at subcentres & treatment register at sector PHC.
♦ Assist leprosy disabled people in self-care practices, monitor them and refer them
to PHC whenever required.
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4. Assist the health worker (male) in maintaining a record of cases in her area of those
who are under treatment for malaria, tuberculosis and leprosy, and check whether
they are taking regular treatment, motivate defaulters to take regular treatment and
bring these cases to the notice of the health worker (male) or health assistant (male).
5. Give oral rehydration solution to all cases of diarrhea/dysentery/vomiting. Identify and
refer all cases of blindness including suspected cases of cataract to MO, PHC.
6. Education, counselling, referral, follow-up of cases of STI/RTI, HIV/AIDS.
7. Malaria
♦ The 2nd ANM will identify suspected malaria fever cases during ANC or
immunisation clinic and home visits, and will make blood smears or use RDT for
diagnosis of Pf malaria.
♦ To advise seriously ill cases to visit PHC for immediate treatment. All the fever
cases with altered sensorium must be referred to PHC/District Hospital. The
cases will be referred after collection of blood smear and performing RDT. To
arrange transportation for such patients from home to the PHC/District Hospital.
♦ To contact all ASHAs of the area during visit to the village and collect blood
smears for transportation to laboratory. To cross-verify their records by visiting
patients diagnosed positive between the previous and current visit.
♦ To provide treatment to positive cases as per the drug policy.
♦ To replenish the stock of micro slides, RDKs and/or drugs to ASHAs wherever
necessary.
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♦ To keep the records of blood smears collected and patients given anti-malarial
treatment.
♦ To ensure early diagnosis & radical treatment of the diagnosed positive cases
(PV & Pf) compliance of radical treatment (Pf – 45 mg …. & Pv – 15 mg) for 15
days.
♦ To take all precautions to use properly sterilised needles and clean slides while
collecting blood smears.
♦ The 2nd ANM will ensure that all pregnant women are provided insecticidal treated
nets in high malaria endemic areas.
8. Where filaria is endemic:
♦ Identification of cases of lymphoedema/elephantiasis and hydrocele and their
referrals to PHC/CHC for appropriate management.
♦ Training of patients with lymphoedema/ elephantiasis about care of feet and
home based management remedies.
♦ Identification and training of drug distributors including ASHAs and Community
Health Guides for mass drug distribution of DEC + Albendazole on National
Filaria Day.
9. Where kala-azar is endemic:
♦ From each family
a) The 2nd ANM shall enquire about the presence of any fever cases having a
history of prolonged fever for more than 15 days duration in a village during
her visit.
b) The 2nd ANM will refer such cases to the nearest PHC for clinical examination
by the Medical Officer and confirmation by RDK.
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c) The 2nd ANM shall take the migratory status of the family/guest during last
three months.
♦ The 2nd ANM will also follow up and persuade the patients to ensure complete
treatment.
♦ The 2nd ANM will keep a record of all such cases and shall verify from PHC about
their diagnosis during the monthly meeting or through health supervisor during
her visit.
♦ The 2nd ANM will carry a list of all Kala-azar cases in her area for follow up and
will ensure administration of complete treatment at PHC.
♦
The 2nd ANM will assist the male health worker in supervision of the spray
activities.
♦ The 2nd ANM will conduct all health education activities particularly through interpersonal communication by carrying proper charts etc. for community awareness
and their involvement.
10. Where dengue/chikungunya is endemic
a) From each family
♦ The 2nd ANM shall enquire about the presence of any fever case having rash
and joint pain in a village during her visit.
♦ The 2nd ANM will refer such cases to the nearest PHC for clinical examination
by the medical officer and for laboratory confirmation by sending blood
sample to the nearest sentinel surveillance hospital.
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b) The 2nd ANM will supervise the source reduction activities in her area including at
the time of observance of anti-dengue month.
c) The 2nd ANM will coordinate the activities carried out by village health & sanitation
committee.
d) The 2nd ANM will conduct health education activities particularly through interpersonal communication by carrying proper charts, etc. for social mobilisation and
community awareness to eliminate source of Aedes breeding and also guide the
community on proper water storage practices.
11. Where JE is endemic:
a) From each family
♦
The 2nd ANM shall enquire about the presence of any fever case having
encephalitis presentation.
♦ The 2nd ANM will refer such cases to the nearest PHC for early diagnosis and
management of such cases.
b) The 2nd ANM will conduct health education activities particularly through interpersonal communication by carrying proper charts etc. for social mobilisation and
community awareness for early referral of cases.
5.15 Non-communicable diseases
1. IEC activities for prevention and early detection of hearing impairment/deafness in
health facility, community and schools, harmful effects of tobacco, mental illnesses,
Iodine Deficiency Disorders (IDD), diabetes, CVD and strokes.
2. House-to-house surveys to detect list & refer cases of hearing & visual impairment
and (along with annual survey register/enumeration survey. The minimum is an
annual survey, desirable to be done twice yearly subject to availability of second
ANM).
3. Sensitisation of ASHA/AWW/PRI about prevention and treatment of deafness.
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4. Mobilising community members for screening camps and assisting in conduct of
screening camps to identify hearing or visual impairment cases if needed.
5. Motivation for quitting and referrals to tobacco cessation centre at district hospital.
6. Sensitisation of ASHA/AWW/PRI about the non-communicable diseases.
7. Identification and referral of caregiver of common mental illnesses and epilepsy for
treatment and then follow up with them in community.
8. Greater participation/role of community for primary prevention of NCD and promotion
of healthy lifestyle.
9. Ensuring regular testing of salt at household level for presence of iodine through salt
testing kits by ASHAs.
10. In fluorosis affected districts
♦ IEC to prevent fluorosis.
♦ Identify the persons at risk of fluorosis, suffering from fluorosis and those having
deformities due to fluorosis.
♦ Line listing, source reduction activities, reconstructive surgery cases,
rehabilitative intervention activities, focused local action and referral of what is not
possible locally.
11. Promoting formation and registration of self healthcare group of elderly persons.
12. Oral health education especially to antenatal and lactating mothers, school and
adolescent children, first aid and referral for cases of oral problems.
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13. Health communication on disability, identification of disabled persons and their
appropriate referral.
•
Vital events: Record and report to the health authorities the vital events including
births and deaths, particularly of mothers and infants in her area.
5.16 Record keeping
1. Maintenance of all the relevant records concerning mothers, children and eligible
couples in her area.
2. Register (a) pregnant women at earliest contact (b) infants from zero to one year of
age (c) women aged 15-44 years (d) Under and above five children (e) adolescents.
3. Maintain the pre-natal and maternity records and child care records.
4. Prepare the eligible couple and child register and maintaining it up-to-date.
5. Maintain the records as regards contraceptive distribution, IUD insertion, couples
sterilised, clinics held at the sub-centre and supplies received and issued.
6. Prepare and submit the prescribed weekly/ monthly reports in time to the health
assistant (female).
7. While maintaining passive surveillance register for malaria cases, the 2nd ANM will
record:
♦ No. of fever cases
♦ No. of blood slides prepared
♦ No. of malaria positive cases reported
♦ No. of cases given radical treatment
5.17 Treatment of minor ailments
1. Provide treatment for minor ailments, first-aid for accidents and emergencies and
refer cases beyond her competence to the primary health centre/community health
centre or nearest hospital.
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2. Provide treatment as per AYUSH as needed at the local level. (The 2nd ANM should
be trained in AYUSH system for distribution of AYUSH medicines).
Team activities
1. Attend and participate in staff meetings at primary health centre/community
development block or both.
2. Coordinate her activities with the health worker (male) and other health workers
including the health volunteers/ASHAs and Dais.
3. Coordinate with PRI and village health and sanitation committee (VHSC)
4. Draft annual village health plan with the help of Health Worker (Male), PRI and VHSC
for submitting the same to block.
5. Meet the health assistant (female) each week and seek her advice and guidance
whenever necessary.
6. Maintain the cleanliness of the sub-centre.
7. Dispose medical waste as per the IMEP guidelines of GOI.
8. Organise, participate and guide in organising the VHN Days at anganwadi centers.
9. Participate as a member of the team in camps and campaigns.
House-to-house surveys:
These surveys would be done once in April annually. Some of the diseases would
require special surveys- but at all times not more than one survey per month would be
expected. Surveys should be done with support and participation of HW (male), ASHAs, and
anganwadi workers, community volunteers, panchayat members and village health and
sanitation committee members.
The 2nd ANMs role as a facilitator of ASHA: The 2nd ANM will guide ASHA in performing
the following activities:
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♦ She will hold weekly/fortnightly meeting with ASHA and discuss the activities
undertaken during the week/fortnight. She will guide her in case ASHA encounters
any problem during the performance of her activities.
♦ She will act as a resource person for the training of ASHA.
♦ She will inform ASHA regarding date and time of the outreach session and will also
guide her for bringing the beneficiary to the outreach session.
♦ She will participate and guide in organising the health days at anganwadi centres.
♦ She will take help of ASHA in updating eligible couple register of the village
concerned.
♦ She will utilise ASHA in motivating the pregnant women for coming to sub- centre for
initial checkups. ASHA will also help the 2nd ANM in bringing married couples to
subcentres for adopting family planning methods.
♦ She will guide ASHA in motivating pregnant women for taking full course of IFA
tablets and TT injections, etc.
♦ She will orient ASHA on the dose schedule and side effects of oral pills.
♦ She will educate ASHA on danger signs of pregnancy and labour so that she can
identify and help beneficiary in getting further treatment.
♦ She will inform ASHA on date, time and place for initial and periodic training
schedule. She will also ensure that during the training ASHA gets the compensation
for performance and also TA/DA for attending the training.
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ISSN 2278-7763
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♦ Train in salt testing using salt testing kits.
Mother and Child Protection Card
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5.18 The 2nd ANMs role in Janani Suraksha Yojana (JSY)
• She shall facilitate in obtaining necessary certificates well ahead of delivery time so
that non availability of white ration card / availability of BPL status certification by
Mandal Revenue Officer (MRO) does not become hindrance for non-payment of JSY.
• The 2nd ANM & MO of PHC should verify the applications i.e., JSY card, certification
of BPL status & number of children.
• The 2nd ANM (and MCH team) should sensitise every pregnant woman to submit
photocopy of white ration card at the time of registration, three times ANC checkup &
at the time of delivery.
• The 2nd ANM shall prepare a monthly work schedule of each village on:
 Number of pregnant women registered under JSY to be taken to Sub-centre,
PHC & Government health facilities for ANC checkup.
 Number of pregnant women registered under JSY to be taken to Government
health centres for deliveries with birth planning & referral services.
 Number of PNC visits to be made after deliveries.
 Number of pregnant women referred to higher health centres for assisted delivery
/ C.S/MTP.
 By 7th of each month, the 2nd ANM must submit accounts of the previous month in
a prescribed format to the M.O. of the PHC along with progress report.
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