Monthly Counseling Guide for High-Risk Pregnant Women

A comprehensive guide for counseling high-risk pregnant women by trimester.

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Important Disclaimer: This guide is for informational and support purposes only. It is NOT a substitute for professional medical advice, diagnosis, or treatment. Always advise beneficiaries to follow their doctor's instructions and to consult them for any health concerns.
🚩 Anytime Red Flags (Go to hospital immediately):

Core Care for All High-Risk Patients

Supplements & Spacing
  • Folic acid: 400 mcg daily through 12 weeks (5 mg only if prescribed for special indications). If nausea is severe in early weeks, continue folic acid and start iron after 12 weeks.
  • Iron + Folic Acid (IFA): 100 mg elemental iron + 500 mcg folic acid daily from after 12–14 weeks for 180 days in pregnancy and 180 days postpartum.
  • Calcium: 500 mg twice daily from 14 weeks to 6 months postpartum; take iron and calcium 2 hours apart.
  • Vitamin D: Sunlight 20–30 min/day; supplement if doctor advised.
  • Deworming: Single dose albendazole 400 mg anytime after 14 weeks (per local program).
Vaccines
  • Td: first dose around 16 weeks (or as soon as possible), second dose 4 weeks later. If vaccinated in last pregnancy within a year, give booster.
  • Tdap: if available per local policy, one dose between 27–36 weeks.
  • Influenza & COVID‑19: recommend as per local guidance.
Visits & Tests
  • Contacts: Aim for 8 contacts (≈12, 20, 26, 30, 34, 36, 38, 40 weeks).
  • Baseline tests (early): CBC, blood group & Rh, HIV, HBsAg, VDRL, urine R/M, TSH. Repeat CBC/urine each trimester.
  • Ultrasound: Dating + NT at 11–13+6 weeks; anomaly at 18–22 weeks; growth/placenta at 28–32 weeks; extra growth/NST as needed for high risk.
  • GDM screening: 24–28 weeks (earlier if high risk); postpartum 6–12 weeks OGTT if GDM diagnosed.
  • Rh‑negative: Antibody screen; Anti‑D at 28 weeks and after any bleeding/trauma; postpartum dose if baby Rh‑positive.
Everyday Counseling
  • Balanced diet with protein each meal (dal, egg, milk); iodized salt; safe food handling; avoid raw/undercooked foods and unpasteurized milk.
  • 30 min walking most days; avoid heavy lifting; avoid lying flat on back after 20 weeks (prefer left side).
  • No tobacco, alcohol, or drugs; offer help to quit. Screen gently for low mood/anxiety or domestic violence and refer if needed.
  • Oral health: dental care is safe in pregnancy.
  • Sex is safe unless doctor advised pelvic rest (e.g., bleeding, low‑lying placenta, leaking).

Trimester & Month‑Wise Quick Checklist

  • Start folic acid; register ANC and get MCP card; first ANC visit.
  • Book NT scan (11–13+6 weeks); baseline labs (CBC, blood group/Rh, HIV, HBsAg, VDRL, urine, TSH).
  • If high risk for preeclampsia (chronic HTN, diabetes, kidney/autoimmune disease, previous preeclampsia, multiple pregnancy), ask doctor about low‑dose aspirin by 12–16 weeks.
  • Ask about severe one‑sided pain/fainting (ectopic), fever >101°F, persistent vomiting/dehydration.

  • Start calcium; deworming (albendazole 400 mg) after 14 weeks per program.
  • Td dose 1 around 16 weeks; discuss quickening (first movements).

  • Anomaly scan (TIFFA/Level 2); check placenta location. If low‑lying, pelvic rest and plan repeat scan.
  • Td dose 2 (≥4 weeks after dose 1); continue IFA and calcium.

  • GDM screening (24–28 weeks); repeat CBC/urine.
  • Plan Anti‑D at 28 weeks if Rh‑negative.

  • Anti‑D if Rh‑negative; start daily fetal kick counts.
  • Discuss preterm labor signs; consider Tdap (27–36 weeks) if available.

  • Growth scan/Doppler if high risk; finalize birth facility (C‑section & NICU capable), transport, blood donor contacts.
  • Choose postpartum contraception (PPIUCD option).

  • Weekly visits if possible; review induction indications; reinforce kick counts and labor signs.
  • Plan early initiation of breastfeeding; newborn birth‑dose vaccines (BCG, OPV, Hep B).

First Trimester (Months 1-3): Building a Strong Foundation

🚩 Red Flags for this Trimester: Advise immediate doctor/hospital visit for: any vaginal bleeding, severe abdominal pain or cramping, severe nausea/vomiting preventing any food/water intake.

Months 1-3

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
All High-Risk Patients
  • Folic Acid is Crucial: Explain that taking folic acid tablets every day is vital to prevent birth defects in the baby's brain and spine.
  • Iron start timing: If nausea is severe in early pregnancy, continue folic acid now and start iron after 12 weeks.
  • Nutrition: Advise eating small, frequent meals. Focus on green leafy vegetables, fruits, and dals. Avoid unpasteurized milk and raw meat.
  • Baseline Tests & First Scan: CBC, blood group & Rh, HIV, HBsAg, VDRL, urine R/M, TSH; book NT scan at 11–13+6 weeks.
  • Preeclampsia Prevention: If high risk (e.g., chronic HTN/diabetes, kidney/autoimmune disease, previous preeclampsia, twins), ask doctor about low‑dose aspirin by 12–16 weeks.
  • Lifestyle: Adequate rest, avoid heavy weights; no tobacco/alcohol; dental care is safe.
  • "Have we started taking our daily folic acid and iron tablets?"
  • "Are we able to eat and keep our food down? What does our daily diet look like?"
  • "Have we had our first check-up with the doctor or ANM Didi?"
  • "Are we feeling overly tired or stressed? Do we have support at home?"
  • "Have we done our baseline tests and scheduled the NT scan?"
  • "Did the doctor mention starting a small aspirin tablet at night (only if advised)?"
History of Abortion/Loss
  • Emotional Support: Acknowledge their past experience with empathy. Reassure them that this is a new pregnancy and that feeling anxious is normal.
  • Adherence to Plan: Gently remind them to strictly follow their doctor's specific advice (e.g., taking progesterone, getting extra rest).
  • "How are we feeling emotionally about this pregnancy? Is there anyone we can talk to about our feelings?"
  • "Has the doctor given we any special instructions or medicines for the first few months?"
Anemia (Low Hemoglobin)
  • Iron & Folic Acid (IFA): Stress the importance of starting their IFA tablets (after 12–14 weeks if early nausea is severe).
  • Iron-Rich Foods: Advise spinach (palak), beetroot, pomegranate (anaar), dates (khajur), and lentils (dal). Vitamin C (lemon, amla, oranges) helps absorption.
  • Better Iron Tips: Take IFA with lemon water; avoid tea/coffee within 1 hour; black stools are normal. If Hb is very low, doctor may advise IV iron.
  • "Are we taking one red iron tablet every day?"
  • "Do we remember which foods are good for increasing blood?"
  • "What was our last hemoglobin level?"
Hypertension (High BP) or Diabetes
  • Doctor's Plan is Key: Managing BP or sugar from the very beginning is critical. Follow doctor’s advice on medication and diet.
  • Diet: For high BP, reduce salt. For diabetes, reduce sugar and sweets.
  • Preeclampsia Prevention: If high risk, ask about low‑dose aspirin by 12–16 weeks (doctor decision).
  • "Have we had our blood pressure and sugar levels checked recently? What did the doctor say?"
  • "Are we taking any medication for BP or sugar? Are we able to take it regularly?"

Second Trimester (Months 4-6): Monitoring and Growth

🚩 Red Flags for this Trimester: Advise immediate doctor/hospital visit for: Leaking fluid from the vagina, severe headache or blurred vision, painful urination, reduced or no baby movements (after month 5).

Months 4-5

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
All High-Risk Patients
  • Anomaly Scan (Ultrasound): Special ultrasound around the 5th month to check if the baby is growing well and all organs are normal.
  • Fetal Movement: After the 5th month, they should start feeling the baby's movements—this is a good sign of the baby's health.
  • Continue Nutrition & IFA: Keep balanced diet and IFA tablets; start/continue calcium from 14 weeks.
  • Vaccines & Deworming: Td dose 1 at ~16 weeks, Td dose 2 after 4 weeks; albendazole 400 mg after 14 weeks per program.
  • If Placenta Low-Lying: Follow pelvic rest instructions and plan repeat scan later.
  • "Has the doctor told we about the TIFFA scan or 'level 2' ultrasound? Is it scheduled?"
  • (After 5 months) "Have we started feeling our baby move or kick? How often do we feel it?"
  • "Are we continuing to take our iron and calcium tablets daily?"
  • "Have we received our tetanus (Td) injection this month?"
Anemia
  • Managing Side Effects: If IFA causes constipation, drink more water and eat fruits. If nausea, take after a meal. Do not stop taking them.
  • Hemoglobin Check: Get blood checked for hemoglobin as advised. If Hb is 7–9.9, doctor may intensify treatment; if very low, IV iron/transfusion may be considered.
  • Absorption Tips: Avoid tea/coffee within 1 hour of IFA; take with lemon/amla; black stools are normal.
  • "Are we having any problems like constipation or feeling sick after taking the iron tablet?"
  • "When was the last time our blood was checked? What was the result?"
Hypertension (High BP)
  • Pre-eclampsia Signs: Teach warning signs: severe headache, vision problems (blurriness, flashing lights), sudden swelling of hands/face, right‑upper‑abdominal pain, breathlessness.
  • Regular BP Checks: Get BP checked at every ANC visit, or more often if the doctor advised; home BP checks if available.
  • "Have we had any severe headaches or problems with our eyesight recently?"
  • "Have we noticed any sudden swelling in our hands or face in the morning?"
  • "Any pain under the right ribs or new breathlessness?"
  • "What was our last blood pressure reading?"

Month 6

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
Gestational Diabetes (GDM)
  • GDM Screening: The test for pregnancy diabetes (GCT/GTT) is usually done between 24-28 weeks. Advise them to complete this test.
  • If Diagnosed: GDM can be managed. Emphasize diet control (avoid sugar, sweets, juice) and regular walks. If the doctor advised monitoring blood sugar, check if they are able to do it.
  • Later & Postpartum: Remind that good control now helps the baby; plan a postpartum sugar test (OGTT) at 6–12 weeks after delivery.
  • "Has the doctor asked we to do a test for sugar by drinking a glucose liquid?"
  • (If diagnosed) "What has the doctor advised about our diet? Are we finding it difficult to follow?"
  • "Do we have a plan for checking sugars if advised by the doctor?"
Previous C-Section (LSCS)
  • Scar Health: Inform the doctor if there is pain or pulling at the old scar.
  • Delivery Planning: The doctor will discuss normal delivery vs repeat C-section.
  • Safety Note: Scar pain alone is not reliable. Come early in labor. Continuous, severe abdominal pain with bleeding is an emergency.
  • "Do we feel any discomfort or pain near our previous operation scar?"
  • "Have we discussed our delivery plan with the doctor yet?"

Third Trimester (Months 7-9): Preparation for Birth

🚩 Red Flags for this Trimester: Advise immediate doctor/hospital visit for: All previous red flags PLUS: regular, painful contractions before the due date (preterm labor), and a noticeable, sustained decrease in baby's movements.

Months 7-8

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
All High-Risk Patients
  • Fetal Kick Count: Lie on the left side after a meal and count movements. About 10 in 2 hours is reassuring—but more important is noticing a clear drop from the usual. If much less, contact the doctor immediately.
  • Birth Preparedness: Prepare hospital bag, arrange transport, identify a support person.
  • Signs of Labor: Explain true vs false pains.
  • Vaccines: Consider Tdap between 27–36 weeks if available.
  • Positioning: Avoid lying flat on the back; rest on the left side.
  • "How are the baby's movements? Are we able to feel the baby move every day?"
  • "Have we thought about how we will travel to the hospital when the time comes?"
  • "Do we know who will accompany we to the hospital?"
Anemia
  • Final Hemoglobin Boost: This is the last chance to improve blood levels before delivery. Good hemoglobin reduces the risk of heavy bleeding after birth (PPH). Encourage strict adherence to IFA tablets and diet.
  • Absorption Tips: Keep iron and calcium 2 hours apart; avoid tea/coffee around IFA; black stools are normal.
  • "Are we taking our iron and calcium tablets without fail? It is very important now."
  • "Has the doctor planned for a final blood test before our delivery?"
Hypertension (High BP)
  • Highest Risk Period: Re-emphasize the danger signs of pre-eclampsia—headache, vision changes, right‑upper‑abdominal pain, breathlessness. This is the most common time for it to become severe.
  • Immediate Action: Do not ignore any warning signs; go to the hospital immediately, even at night.
  • "How has our blood pressure been? Are we checking it regularly?"
  • "Let's review the danger signs one more time. What would we do if we had a severe headache that won't go away?"

Month 9

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
All High-Risk Patients
  • Finalizing Birth Plan: Confirm they know which hospital to go to. All high-risk patients should deliver at a hospital with facilities for surgery and newborn care (like an NICU).
  • Post-Delivery Care: Rest, nutrition, and breastfeeding after the baby is born.
  • Newborn: Birth‑dose vaccines (BCG, OPV, Hep B) and skin‑to‑skin care.
  • Family Planning: Discuss postpartum contraception options (e.g., PPIUCD) if desired.
  • "Is our hospital bag ready? Do we have the hospital's contact number?"
  • "Are we prepared for the delivery? Do we have any final questions for the doctor at our next visit?"
  • "Have we decided on a postpartum contraception method?"
Gestational Diabetes (GDM)
  • Fetal Growth: The doctor will monitor the baby's size; GDM can lead to a large baby, potentially affecting the delivery plan.
  • Blood Sugar Control: Good control in the final weeks is very important for the baby's health immediately after birth.
  • Postpartum: Schedule OGTT at 6–12 weeks after delivery to check that sugars have settled.
  • "What did the doctor say about the baby's growth in our last check-up?"
  • "How has our blood sugar control been in the last few weeks?"
  • "Can we plan our postpartum sugar test date now?"
Advanced Maternal Age or Teenage Pregnancy
  • Support System: Reconfirm they have a strong support system in place for after the birth, for both mother and baby care.
  • Postpartum Care: Emphasize the importance of the postpartum check-up for themselves, not just the baby.
  • "Who will be there to help we with the baby and around the house after we deliver?"
  • "Do we feel ready and supported for the arrival of our baby?"

Additional High‑Risk Modules

High-Risk Condition Key Advice & Topics to Discuss Important Questions to Ask
Rh‑Negative Mother
  • Carry blood group card. Anti‑D injection at 28 weeks and within 72 hours after delivery if baby Rh‑positive; also after any bleeding, miscarriage, or abdominal injury.
  • "Have we received the Anti‑D injection at 28 weeks?"
  • "Any bleeding, falls, or abdominal injury recently?"
Hypothyroidism
  • Take levothyroxine every morning on an empty stomach; avoid food for 30 minutes; do not take with iron/calcium.
  • TSH monitored and dose adjusted by doctor.
  • "When was our last TSH test?"
  • "Are we taking the thyroid tablet before breakfast every day?"
Multiple Pregnancy (Twins)
  • Expect more frequent visits/scans; higher calorie and protein needs; more rest. Higher risk of preterm—know signs of early labor.
  • "Are we getting more frequent scans?"
  • "Do we know when to come if pains start early or water leaks?"
Short Cervix / Previous Preterm Birth
  • Progesterone or cerclage if advised; reduce heavy work; report contractions, pelvic pressure, or watery discharge immediately.
  • "Any cramps every 10 minutes, pelvic pressure, or watery discharge?"
Placenta Previa / Antepartum Bleeding
  • Pelvic rest (no intercourse, no internal exams outside hospital). Plan delivery at a CEmONC facility.
  • "Any fresh red bleeding or clots now?"
Fetal Growth Restriction (IUGR) / Low Fluid
  • Attend all growth scans and NSTs; maintain adequate diet and hydration; do daily kick counts; rest on left side.
  • "Are we doing daily kick counts? Any days with fewer movements?"
Hypertension / Preeclampsia (Expanded)
  • Medication adherence; home BP checks if available; know red flags (headache, vision change, RUQ pain, breathlessness, swelling, reduced urine).
  • "Any new headache or vision changes?"
  • "Are we taking our BP medicines regularly?"
Gestational Diabetes (Expanded)
  • Diet (plate method), avoid sweets and juice; 20–30 min walk after meals; record sugars if advised; plan postpartum OGTT at 6–12 weeks.
  • "Do we have our diet plan? Are post‑meal walks happening most days?"
  • "When is our postpartum sugar test planned?"
Severe/Moderate Anemia
  • Strict IFA adherence; take with Vitamin C; separate from calcium/tea/coffee; IV iron or transfusion per doctor if needed; plan delivery at facility prepared for PPH risks.
  • "What is our latest Hb? Any dizziness, breathlessness, or palpitations?"
Previous C‑Section (Expanded)
  • Discuss VBAC eligibility; deliver at CEmONC; come early in labor; continuous severe abdominal pain is an emergency.
  • "Have we discussed VBAC vs repeat C‑section? Which hospital is ready for us?"
Chronic Diseases (Kidney/Heart/Asthma/Epilepsy)
  • Never stop meds without doctor advice; bring all meds to ANC; some anti‑epileptics need higher folate; avoid valproate if possible (doctor decision).
  • "Any recent admissions? Are meds running out?"
Infections (HIV, Hep B, Syphilis, TB)
  • Early treatment protects baby; partner testing/treatment for syphilis; if Hep B+, baby needs vaccine + HBIG within 12 hours of birth.
  • "Have we received and understood our test results and next steps?"
  • "Has partner testing been discussed (if applicable)?"
Underweight / Overweight / Obesity
  • Target weight gain: underweight 12.5–18 kg; normal 11.5–16 kg; overweight 7–11.5 kg; obese 5–9 kg. Emphasize protein and vegetables; monitor BP and sugars closely if overweight.
  • "Have we checked our weight this month? Are we including dal/egg/milk at least twice daily?"
Teen or >35 years
  • Extra support at home; nutrition; mental health check‑ins; plan hospital delivery with pediatric support.
  • "Who is our support person? Do we feel safe and supported at home?"

Simple Call Triage Script (for Your Team)

  1. Confirm basics: name, GA (weeks), EDD, risk tags, last visit date, current meds.
  2. 7 must‑ask screening questions:
    • Any bleeding or leaking?
    • Headache/vision changes/right‑upper‑abdominal pain?
    • Painful, regular contractions or back pain every 10 minutes?
    • Baby movements okay today?
    • Fever, burning urine, or foul‑smelling discharge?
    • Severe vomiting—can we keep water down?
    • Any injury, fall, or severe breathlessness/chest pain?
  3. Action:
    • Any red flag → immediate hospital/108 or local emergency; inform ASHA/ANM if applicable.
    • Mild issues → book VOPD/doctor within 24–48h; reinforce home care.
    • Routine → reinforce month‑wise checklist; confirm next visit/tests due.
  4. Close: repeat plan; confirm transport and support person; log the call.

Ambulance: 102/108 (India). Keep facility numbers handy.

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