Antenatal care
Dr. Andrew Kumwenda
BSc.(HB), MBChB (UNZA), Pg. Dip., MPhil.(Stellenbosch), MPH (Western Cape),
MMed. (Obs-Gyn.) (UNZA), PhD candidate (Witwatersrand)
MBChB lecture
28th February, 2022
Introduction
Most women progress through pregnancy in an
uncomplicated fashion and deliver a healthy infant
requiring little interventions.
Unfortunately, a significant number will have medical
problems that will complicate their pregnancy or develop
serious conditions threatening the lives of both
themselves and their unborn children
2
Introduction
The antenatal period allows the opportunity for women,
especially those in their first pregnancy, to receive
information regarding pregnancy, childbirth and
parenthood
3
Definition of antenatal care (ANC)
ANC is a systematic supervision (examination & advice)
of a woman during pregnancy.
The WHO defines ANC as the care provided by skilled
health-care professionals to pregnant women and
adolescent girls in order to ensure the best health
conditions for both mother and baby during pregnancy
4
Definition of antenatal care (ANC)
ANC is also defined as a package of regular medical
and nursing care services recommended during
pregnancy
The services comprise of preventative strategies aimed
at providing regular checkups that allow skilled
personnel to identify, treat, and prevent potential health
problems throughout the progression of pregnancy
while promoting a healthy lifestyle
ANC comprises of careful taking of history &
5
examination and advice given to the pregnant woman
Aims of ANC
To screen the high risk cases
To prevent or to detect and treat at the earliest any
complications
To ensure continued risk assessment and to provide
ongoing primary preventive health care
To educate the mother about the physiology of
pregnancy and labour so that fear is removed and
psychology improved 6
Aims of ANC
To discuss with the couple about the place, time and
mode of delivery provisionally and care of the newborn
To motivate the couple about the need of family
planning
Note: according to WHO, what women want and expect
from ANC is to have a “positive pregnancy
experience”.
7
Defining a positive pregnancy experience
Maintaining physical and sociocultural normality
Maintaining a healthy pregnancy for mother and baby
(including preventing and treating risks, illness and
death)
Having an effective transition to positive labour and birth
and
Achieving positive motherhood (including maternal self-
esteem, competence and autonomy) 8
Confirmation of pregnancy
Confirm pregnancy prior to commencement of antenatal
care
Amenorrhoea is most often a sign of pregnancy, but
other causes must be excluded
A pregnancy test, ultrasound confirmation of intrauterine
pregnancy or abdominal examination with auscultation
of FH are usually adequate
9
Timing for ANC visits
Minimum of 8 ANC contacts are recommended
throughout the pregnancy period in order to reduce
perinatal mortality and improve women’s experience of
care.
1st contact to take place in the 1st trimester (up to 12
wks)
Two contacts in the 2nd trimester (at 20 & 26 wks) and
10
Timing for ANC visits
Five contacts scheduled in the 3rd trimester (30, 34, 36,
38 & 40 weeks).
The timings of the 8 contacts are aimed at optimizing
the delivery of specific interventions in order to achieve
maximum impact of ANC.
This new model, presents a shift from the focused
antenatal care (FANC) model which recommended 4
visits.
11
FANC vs 2016 WHO ANC model
WHO FANC model 2016 WHO ANC model
First trimester
Visit 1: 8 – 12 weeks Contact 1: Up to 12 weeks
Second trimester
Visit 2: 24 – 26 weeks Contact 2: 20 weeks
Contact 3: 26 weeks
Third trimester
Visit 3: 32 weeks Contact 4: 30 weeks
Contact 5: 34 weeks
Visit 4: 36 – 38 weeks Contact 6: 36 weeks
Contact 7: 38 weeks
Contact 8: 40 weeks
12
Return for delivery at 41weeks if not given birth
Procedure at first visit i.e. booking clinic
Assessment of risk begins when the woman is seen
early - best within first 8 weeks
First hospital booking visit should take place within first
12 weeks and not later than16 weeks gestation
Procedure at first visit i.e. booking clinic
Administrative details, including age, marital status and
gravidity are recorded
History taking:
Socio-demographic data
Period of gestation – count from the first day of the LNMP
Any complaints
History of present illness if any
Procedure at first visit i.e. booking clinic
Obstetric history (only applicable to multigravidas).
Record the events chronologically - detailed
Menstrual and contraceptive history –
LNMP, cycle, duration, amount of blood flow etc
Recent contraceptive history,
Calculate the EDD using Naegele’s rule and
estimate current gestation
Add 9 calendar months and 7 days to the 1st day of the
LNMP
Procedure at first visit i.e. booking clinic
Alternatively, subtract 3 months from 1st day of the LNMP
and then add 7 to get the EDD
The former method is commonly used
Past medical & surgical history – all previous major
illnesses and operations must be listed
Family history - ask about DM, HTN, multiple
pregnancy, etc
Procedure at first visit i.e. booking clinic
Social history
Examination
General physical examination
Systemic examination
Obstetrical examination
Clinical examination
General observations
Height, Weight – calculate BMI
Temp, pulses, Face, Mouth,
Physical examination: Examine the following:
Thyroid
Breasts
Respiratory system
Cardiovascular system
Abdomen
18
Clinical examination
Abdominal examination
Inspection
Palpation – obstetric
Obstetric palpation – critical
SFH
Presentation
Fundal palpation
Lateral palpation
Auscultation
19
Routine investigations
FBC and check for haemoglobinopathy when indicated;
Blood grouping - ABO and Rh group
Serology (antibody) screening is done in selected cases;
For diagnosis of syphilis - RPR
HIV
Hepatitis B surface antigen
Blood glucose
Routine investigations
Urine
Urinalysis
Presence of nitrites and / or leukocytes by dipstick
indicates UTI
Mid-stream urine (MSU) for culture and sensitivity – test
for asymptomatic bacteriuria
Routine investigations
Ultrasound examination – 1st trimester either by TVS or
TAS
This is done for:
Dating,
Detecting early pregnancy,
Number of fetuses,
Checking for gross fetal anomalies and any uterine or
22
adnexal pathology
Procedure at subsequent visits
Every subsequent visit:
Urinalysis
Blood pressure
Exclude peripheral oedema
Measure and record fundal height (in centimetres above
symphysis pubis)
Procedure at subsequent visits
Continuing antenatal care
Traditional pattern of care involved the woman being
seen in clinic every 4 weeks up to 28 weeks; every 2
weeks from 28 to 36 weeks, and weekly thereafter
This should be more flexible depending on the need and
convenience of the patient
Procedure at subsequent visits
Every visit in third trimester
Fetal lie and presentation
Presence of fetal heart
Record patient awareness of fetal movement
At 28 and 36 weeks ( as a minimum)
Full blood count
Rh-D antibodies in Rh-negative women and other
antibodies if necessary
Procedure at subsequent visits
Presence of adverse features demands closer
attention.
Among risk factors that can arise during pregnancy
are:
Vaginal bleeding, Hypertension, proteinuria
Persistent glycosuria, UTI and other infections
Oligohydramnios, polyhydramnios, reduced fetal
movements, IUGR, malpresentations
Ultrasound in antenatal care
Clinical situations in which it is useful
Assessment of PVB and/or abdominal pain in early
pregnancy
Accurate assessment of GA- menstrual history can be
unreliable in up to 45% of women
Exclusion of multiple pregnancy
Exam of fetus for severe congenital anomaly
Ultrasound in antenatal care
Check fetal size and liquor volume when the uterus is
small or large for dates
Monitoring fetal growth in high-risk pregnancies
Ascertaining placental site and identifying the source of
some APH
Determination of fetal presentation if unclear by
palpation
Discovering fetal attitude, weight, type of breech
Ultrasound in antenatal care
If ultrasound is offered the suggested optimal
programme is:
First scan around 12 weeks’ gestation can confirm
continuing pregnancy and GA
A second scan at 20 weeks has the best predictive value
in the detection of serious malformations (earlier
scanning is more likely to miss serious cardiac
anomalies)
Other aspects of care
This is important time to provide health education and
advice e.g.
Diet
Habbits - (avoid alcohol, smoking, substance abuse)
Preparation for labour and breastfeeding should be given
in advance)
Other aspects of care
Rest and sleep – may continue usual activities but avoid
excessive & strenuous activities in 1st and last 4 weeks
Clothing, shoes & belt – loose but comfortable clothes
advised. Avoid high heeled shoes & constricting belts
Dental care – Good oral hygiene & dental care needed
Coitus – generally not restricted.
Those at risk of miscarriage or preterm labour should avoid
if they feel increased uterine activity
Other aspects of care
Travel – travel in vehicles having jerks is better avoided,
especially in 1st trimester and last 6 weeks
Travel in pressurized aircraft is safe up to 36 weeks
Summary of aspects of antenatal care
First visit
Complete detailed history
Full clinical examination
Special investigations
Establish duration of pregnancy
Risk grading
33
Summary of aspects of antenatal care
Second visit
Check results of the special investigations
Confirm risk grading
Follow up visits
Monitor maternal health
Monitor fetal growth and wellbeing
34
Summary of aspects of antenatal care
Late pregnancy
Determine and monitor fetal lie and presentation
Plan the place and method of delivery
35
End
36
