Antenatal care

Notes

## Basic introduction

  • Antenatal care (ANC) refers to the health care provided to a pregnant woman throughout pregnancy until labor
  • The objectives of ANC include the following:

_Identification, prevention and treatment of complications of pregnancy

_Screening for diseases and their subsequent treatment

_Provision of nutritional, social, emotional and physical support

_Health education and information to the mother-to-be in the following aspects:

||| Balanced diet

||| Need for prompt reporting of danger signs in pregnancy

||| Family planning

||| Child rearing

||| Immunization

||| Labor and delivery preparations

_Planning for labor and delivery

  • Clinical review of the expectant mother may include the following:

_Identification and Demographics:

||| Age

||| Marital status

||| Occupation

||| Education

||| Ethnic origin

||| Area of residence

_History of the current pregnancy:

||| Last menstrual period, LMP (i.e. first day of LMP)

||| Estimated Delivery Date, EDD (calculated quickly by adding 7 to the date of LMP and 9 to the month of LMP e.g. if the LMP was 2/02/2015 then the EDD was 09/11/2015)

_Past Medical History

||| Past pregnancies and gynecological history

||| Diabetes

||| Hypertension

||| Multiple pregnancy

||| TB

||| Any other disease

_Social History

||| Alcohol consumption

||| Smoking

||| Any use of drug of abuse

_Physical Examination

||| General physical examination

||| Weight

||| Blood pressure

||| Size of the liver and spleen

||| Fundal height

||| Fetal sounds and presentation

||| Presence of multiple presentation

||| Presence of other masses

||| Vaginal examination

  • Traditional ANC Model (not currently used):

_The following is the schedule of visit:

||| A visit pattern of 4 weeks until 28th week

||| Then every 2 weeks until 36th week

||| Then weekly

_The total number of visits amounted to 14

  • Focused ANC or “new” or “WHO” (currently used)

_The visits are at 16, 28, 32, and 36 weeks

_Additional visits are individualized on an individual basis after evaluating the risk of pregnancy

_The following checklist should be used to exclude a pregnant woman from the Focused ANC (and possibly institute more planned visits and care):

||| Previous stillbirth or neonatal loss

||| History of > 3 consecutive spontaneous ..  abortions

||| Birthweight of last baby <2500gm

||| Birthweight of last baby >4500gm

||| Last pregnancy experienced hospital …admission for hypertension or ....preeclampsia or eclampsia

||| Previous surgery on reproductive tract

||| Diagnosed or suspected multiple

    pregnancy

||| Age < 16yrs

||| Age > 40yrs

||| Isoimmunization Rh(-) in current  or in

   previous pregnancy

||| Vaginal bleeding

||| Pelvic mass

||| Diastolic blood pressure > 90mm Hg

||| Insulin-dependent diabetes mellitus

||| Renal disease

||| Cardiac disease

||| Known “substance” abuse (including

    heavy drinking)

||| Any other severe medical disease or

   condition

  • Focused ANC Program activities include the following:

_1st visit: < 16 weeks:

||| Clinical examination

||| Determination of gestational age

||| Hemoglobin test

||| BP monitor

||| Urinalysis

||| ABO/Rho

||| STIs / syphilis

||| Weight/Height

||| Administration of TT (1st dose)

||| Iron supplementation

||| Document on ANC card

_2nd visit: 28 weeks:

||| Clinical examination

||| Examination for anemia

||| Gestational age

||| Fetal heart (FH) beat and FHB

||| BP monitor

||| Weight (only if underweight at initial visit)

||| Urinalysis (for nullipara or previous preeclampsia only)

||| Iron supplementation

||| Document on ANC card

_3rd visit: 32 weeks:

||| Clinical examination

||| Hemoglobin test

||| Administration of TT (2nd dose)

||| Instruction for birth planned

||| Place and mode of birth agreed on

||| Recommendations for lactation and contraception (introducing the issue of postpartum voluntary surgical contraception among others)

||| Document on ANC card

_4th visit: 38 weeks:

||| Examine for breech presentation

||| Advice the expectant mother to report at the health facility in case of per vaginal bleeding, draining of the amniotic fluid, blurred vision and/or labor pain

||| Document on ANC card

  • Signs of a gestation that is progressing well:

_Maternal weight that is increasing progressively

­_Progressive fundal height or (McDonald's rule) growth

||| Gestational age of 12wks (Fundal height landmark: Pubic sympysis)

||| Gestational age of 20wks (Fundal height landmark: Umbilicus)

||| Gestational age of 36wks (Fundal height landmark: Xiphoid process of sternum)

||| Gestational age of 37-40wks (Fundal height landmark: Regression of fundal height between 36-32 cm)

_Normal fetal well-being tests that may include:

||| Fetal biophysical profile (BPP) test that may include a nonstress test with electronic fetal heart monitoring and a fetal ultrasound)

 _Satisfactory maternal perception of fetal movements (which should be >10 in 12hrs)

_Normal ultrasonographic fetal scan

_Contraction stress test

Reference

a. Villar, J., Ba'aqeel, H., Piaggio, G., Lumbiganon, P., Belizán, J. M., Farnot, U., ... & Langer, A. (2001). WHO antenatal care randomized trial for the evaluation Lancet, 357(9268), 1551-1564.

b. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

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