Antenatal care which is just the care given to a pregnant woman through out pregnancy from the time of conception until the time the woman goes into labor.

1. ANTENATAL CARE
HASTINGS MWABA
BSc NRS. RM. RN

2. Introduction
Antenatal care (ANC) plays an important part
in the care of pregnant women.
Women who remain healthy for longer
periods of time have a better outcome in their
pregnancies and are better able to care for
their children.
This in turn has an impact on the health of the
child.

3. Introduction
Health Education and counselling, disease
prevention and health promotion, planning
for delivery and postnatal period are critical in
the Antenatal care services
It is important to involve others in the process
of antenatal care, emphasising the need to
encourage women to involve their
husbands/partners, family members or other
support people in the process.

4. Introduction cont..
 The antenatal setting allows interaction
between health providers and the woman.

5. General objectives
At the end of the lecture, students should be
able to demonstrate an understanding of
antenatal care

6. Specific objectives
At the end of the lecture/discussion, students
should be able to:
Define terms
State the aims of antenatal care
explain the importance of antenatal care
Describe focused antenatal care
Discuss the activities that are carried out at
antenatal clinic
Offer IEC

7. Definitions
Antenatal care is the care given to pregnant
mothers from the time of conception to the
time they go into labour (Basavanthappa,
2003) or
These are all the health care services provided
to a pregnant woman and her unborn child
from the time pregnancy is confirmed to the
time she goes into labour

8. Definitions cont..
Lie: is the relationship of the long axis (spine)
of the fetus to the long axis of the mother’s
uterus, and the normal lie is longitudinal,
Abnormal are transverse, oblique and variable
(unpredictable)
Attitude: is the relationship of the fetal parts
to one another, and the normal attitude is
flexion, abnormals are extension and
deflection

9. Definitions cont..
Presenting part: is the part of the fetus felt at
the lower pole of the uterus and felt on
vaginal examination over the cervix
Presentation: is the part of the fetus in the
lower pole of the uterus and the normal
presentation is vertex, abnormal are breech,
face, brow and shoulder.

10. Definitions cont..
Denominator: The part of the fetus which
determines the position. (Vertex- occiput,
breach –sacrum, Face- Mentum).
Engaged: when the Bi-parietal diameters of
the fetal head passes through the pelvic brim.

11. Aims of antenatal care
To promote and maintain good physical and
mental health during pregnancy.
To monitor progress of pregnancy
To detect early and treat appropriately,
medical and obstetrical conditions that would
endanger life or impair the health of pregnant
woman or baby

12. Aims cont..
To ensure a safe delivery of a mature live and
healthy infant
To prepare the woman for delivery, breast
feeding and subsequent care of her child
To encourage the concept of having regular
antenatal care from the beginning by the
pregnant woman even in an apparently
normal pregnancy.

13. Importance of Antenatal care
To confirm pregnancy and assess the period of
gestation.
To facilitate health education regarding diet,
exercise, rest, avoidance of unnecessary travel
during pregnancy and preparation for delivery.
(Basavanthappa 2003.)
To provide physical, psychological, emotional and
spiritual care in order to ensure an enjoyable and
successful pregnancy and child bearing

14. Importance of ANC cont..
To be able to detect, prevent and treat early any
abnormalities in pregnancy in order to prevent
complications
To share the information, education and
communication with the parents on the
importance to keep health and remain happy
throughout pregnancy, childbirth and postnatal
To educate the parents on how to take care of
themselves and of the baby during pregnancy
and there after

15. Focused Antenatal care
Focused antenatal care is a new way of organising
ANC. The emphasis is on quality rather than
quantity of visit.
 Focused Antenatal is personalised care provided to
a pregnant woman which emphasises on the
woman’s overall health, her preparation for
childbirth and readiness for complications
[emergency preparedness]
It is timely, simple and safe service to a pregnant
woman.

16. Focused ANC AIM
To achieve a good outcome for the mother and
baby and prevent any complications that may occur
in pregnancy, labour, delivery and past partum.
Four comprehensive, personalised antenatal visits:
1st visit:<16 weeks
2nd visit: 16-28weeks
3rd visit:28-32weeks
4th visit:32-40weeks

17. WHO RECOMMENDATIONS
 ANC visits now referred to as ANC contacts
 Antenatal care model with a minimum of eight
contacts are recommended to reduce perinatal
mortality and improve women’s experience of care
 Term ‘contact’ implies an active connection between a
pregnant woman and a health worker

18. WHO RECOMMENDATIONS
INTERVENTIONS: There are 5 interventions
recommended:
1) Nutritional interventions
2) Maternal and fetal assessment
3) Preventive measures
4) Interventions for common physiological symptoms
5) Health systems interventions to improve the utilization
and quality of ANC

19. WHO RECOMMENDATIONS
 1st contact should be before 12 weeks .
 1st dose IPT at 13 weeks and one month apart
at least 3 doses but can go up to six doses.
 Iron 30 to 60mg and folic acid 0.4mg.
 Early ultrasound before 24 weeks gestation is
recommended for all pregnant women.
 Use of ITNs

20. ANC SCHEDULE
TRIMESTER GESTATION AGE CONTACTS
First Trimester 8-12 weeks Contact 1 : up to 12 weeks
Second
trimester
24-26weeks Contact 2 : 20 weeks
Contact 3 : 26 weeks
Third Trimester 32 weeks Contact 4 : 30 weeks
Contact 5 : 34 weeks
Contact 6 : 36 weeks
Contact 7 : 38 weeks
Contact 8 : 40 weeks
RETURN TO DELIVERY AT 41 WEEKS IF NOT GIVEN BIRTH

21. ROUTINE ANTENATAL CARE AND SERVICES
CONTACT GESTATIO
N AGE
PROCEDURES /SERVICES OFFERED
BOOKING Up to 12
weeks
Laboratory; FBC/HB, RBS, ABO and Rhesus typing,
RPR,HIV,
Imaging; Booking ultrasound,-fetal viability +
gestation age.
Medications; TT, FA,FeSo4, SP Dose1 to be taken
@13 weeks.
CONTACT 2 20 WEEKS
Review results on the ANC card, HB below 11g/dl
treat for anaemia.
Ultrasound - fetal anomalies.
Medication; SP dose 2, Deworming, Haematemics
CONTACT 3 26 WEEKS
Review ultrasound and record & record on ANC
Repeat RPR and HIV if initial tests were negative
SP dose 3, Haematemics.

22. ROUTINE ANTENATAL CARE AND SERVICES
CONTACT GESTATION AGE PROCEDURES /SERVICES OFFERED
CONTACT 4 30 WEEKS Repeat FBC SP Dose 4
CONTACT 5 34 WEEKS Review lab results SP Dose 5
CONTACT 6 36 WEEKS Ascertain presentation, Haematemics
CONTACT 7 38 WEEKS SP dose 6,
Haematemics
CONTACT 8 40 WEEKS Ascertain presentation,
Advise woman to return for delivery at
41 weeks if not delivered.

23. ROUTINE ANTENATAL CARE AND
SERVICES (Continue…)
• Routine activities at ALL contacts ; BP weight,
urinalysis, nutritional advise, various health
education messages on pregnancy, delivery,
danger signs and hygiene.

24. IPT AND EFFECTIVE TREATMENT
OF MALARIA
• Up to 12 weeks - No IPT
• 13 – 16 weeks –IPT dose 1 (additional contact)
• 20 weeks IPT dose2
• 26 weeks IPT dose 3
• 30 weeks IPT dose 4
• 34 weeks IPT dose 5
• 36 weeks No SP if last dose received less than a month ago.

25. Focused ANC objectives
Early detection and treatment of problems;
Identify existing medical, surgical or obstetric
conditions during pregnancy. Such as:
Severe anaemia (Hb<7gm/dl)
Vaginal bleeding
Pre-eclampsia (increased Bp, severe oedema)
STIs, HIV/AIDS,TB and Malaria
Chronic diseases (DM, Heart, Kidney problems)
Foetal malpresentation after 36weeks

26. Focused ANC obs..
Prevention of complications; By providing:
Tetanus toxoid to prevent maternal and neonatal
tetanus
Iron/folate supplementation to prevent anaemia
Use of IPT and ITNs to prevent Malaria/ anaemia.
Ensure environmental hygiene to prevent
intestinal worms.
Presumptive treatment of hookworm infection
with Mebendazole 500mg STAT any time after the
first Trimester.

27. Focused Antenatal cont..
 Birth preparedness and complication readiness- discuss
components of birth plan which include:
 Place of birth
 Skilled attendant
 Transportation
 Funds
 Birth companion
 Items for clean and safe birth and for new-born
 Knowledge of danger signs; what to do if arise
 Choose decision maker
 Emergency funds
 Emergency transport
 Blood donor.

28. Focused ANC
 Health promotion using health messages and counselling,-
encourage dialogue on the following:
 Nutrition
 Rest and hygiene
 Safer sex
 Care for common discomforts
 Use of IPT and ITN/LLINs
 Drug compliance
 Family planning/ health timing and spacing of
pregnancy
 Early and exclusive Breastfeeding
 New-born care.

29. Focused ANC obs..
Provision of skilled care at Birth:
Currently only less women receive skilled care
at birth.
A skilled attendant offers services at the
health facility or within the community
(domiciliary practice)
FANC provides an opportunity to increase
skilled care

30. Antenatal care activities
Registration and booking.
History taking
Physical examination
Investigations and tests.
Medications
Referrals
Advise and IEC
Recording

31. Activities cont..
These activities can be grouped into 3
contents i.e.
1) Assessment (History, Physical examination and
obstetrical examination).
2) Health promotion I.E.C
3) Care provision (treatment of problems)
referrals.

32. Booking visit
REGISTRATION: At the first visit the woman is
registered and given a number and a card.
During registration general data is gathered
and recorded for each client.
Most of the information entered in the
registration book is part of the social history.

33. History taking : it serves as a screening procedure
to identify high risk factors that may put a woman
and her unborn baby at risk and make them more
likely to become sick or die because of pregnancy
or child birth.
Its done in privacy and in a relaxed and
comfortable atmosphere. Technical terms which
the woman doesn’t understand should be
avoided.
Treat every woman with respect.

34. Booking cont..
SOCIAL HISTORY: This information is taken so that
the health care provider can better understand
the client and family (identity), offer appropriate
advice and also for follow-up.
OBTAIN THE FOLLOWING;
Name of client-spell it out correctly for identity.
Residential address and phone numbers for
follow up care.

35. Booking [social History]
Age of client-to exclude risk factor i.e. those that
are below 16 years and those above 35 years.
Marital status-for social and financial support.
Educational level-for communication purposes.
Occupation of client-to identify possible social
and financial problems as well as environmental
factors that could be harmful to growing fetus.

36. Booking cont..
Name of husband and his occupation and his
social habits for social support and to exclude
risk factors.
Religion-to exclude restrictions and harmful
practices e.g. food restrictions, blood
transfusion.
Hobbies-to exclude strenuous ones and risk
factors.

37. Booking cont..
Cultural taboos-to exclude harmful ones and
encourage good ones.
Social habits i.e. smoking, alcohol intake, this
may have effects on both mother and fetus.
Cigarettes have nicotine which constricts
blood vessels leading to poor blood supply to
the placenta-I.U.G.R.

38.  Accommodation: the type of house where
client lives, whether brick made or mud made
and how big i.e. number of windows, number
of occupants, number of rooms and type of
roofing and material used.

39. Social History cont..
Lighting system used. To rule out congestion
and collapse of house and allergic reaction to
the baby and ventilation.
Toilet facilities whether pit latrine, it’s
communal or not to rule out risk of diarrhoeal
disease.

40. Social History cont..
Water supply-type whether it’s tap, well, river,
and how she treats water for drinking i.e.
Boiling or adds chlorine.
Refuse disposal system if rubbish pit and how
far is it from the well

41. Social History cont..
Environmental factors i.e. Surrounding area
whether they have a small garden or have tall
grass around the house to exclude possibility
of being beaten by mosquitoes that cause
malaria

42. Family medical History
This history is useful in identifying or
predicting familial or genetic conditions.
This could affect both the mother and baby if
they occurred during pregnancy putting them
at risk.

43. Personal Medical History
This is to identify previous illnesses that the
woman suffered from that may influence the
present pregnancy.
You find out if the woman has had any
admissions to the hospital and why? I.e. DM,
hyptn, mental disease, some of these
conditions may be aggravated by pregnancy
and some could recur during pregnancy .

44. Personal surgical History
Any operation involving the abdomen,
especially the lower abdomen to rule out risk
of uterine rupture.
Any accidents involving the spine, pelvis and
lower limbs because these may alter the
pelvic diameters leading to difficult labour.

45. Personal surgical History
 Any deformities of the spine, pelvis and lower
limbs. E.g. lordosis, kyphosis, rickets etc.
Any history of blood transfusion to exclude
risk of rhesus I so-immunization, malaria, HIV
and hepatitis.

46. Menstrual History
Find out age at menarche to determine the
fertility period.
Type of menstrual cycle, whether it’s regular
or irregular and duration i.e. 21 day or 28 day
to calculate the EDD.
Duration of bleeding and the flow i.e. amount
of blood loss to rule out the risk of anaemia.

47. Contraceptive History
The type of contraceptives used, i.e. pill,
Injectable and for how long? It helps us
calculate the EDD
Find out reasons for stopping the
contraceptive method to determine whether
the pregnancy was planned or not.

48. Past Medical History
This is to predict the outcome of the present
pregnancy e.g.
The parity, meaning the number of previous
viable pregnancies.
The gravida- which is the number of
pregnancies including the present pregnancy.

49. Past Medical History
For each pregnancy ask about the duration
and the outcome.
The number of living children, where each
child was delivered from, the method of
feeding of children.
Number of dead children, at what age? Cause
of death?

50. Past Medical History
Ask about number of abortions at what
gestation age did they occur?
Ask about number of still births
Any multiple pregnancies.
Birth weight of babies.

51. Past Medical Hist..
Health during pregnancies for each pregnancy.
Types of labour- whether SVD, C/S, forceps.
History of PPH, during puerperium.
Number of TT immunizations received.

52. Present Obstetrical History
The dates of the 1st day of the last normal
menstrual period, was it a normal one with
amount and length.
Calculate the EDD. There two methods;
1) Naegeles rule; you add 7 days to the 1st
day of the L.M.P and then add 9 months to
this date.

53. Present Obstetrical History
Add 7 days to 1st day L.M.P then subtract 3
months and add 1 year.
This method assumes that conception
occurred 14 days at the 1st day of the L.M.P.
This is only true when the woman has a
regular 28 days cycle and the last period of
bleeding was the menstruation.

54. EDD calculation
EXAMPLE
a) L.M.P = 13. 12. 2020
EDD = 13 + 7 = 20
=12 + 9 = 21 - 12 = 9
2020 + 1 = 2021
EDD = 20. 09. 2021
b) L.M.P = 13. 12. 2020
= 13 + 7 = 20
= 12 – 3 = 9
= 2020+ 1 = 2021
EDD = 20. 09. 2021

55. By Dates
 BY DATES CALCULATION
 These are calculated days and weeks of a gestational period. Examples;
 1) L.M.P = 04. 04. 2020.
 Calculated by dates today
 Months weeks days
 April 26 3 5
 May 31 4 3
 June 30 4 2
 July 21 3 0
 14 ____________ __________
 _____10 days /7 Gestation age:
15 weeks 3 days

56. Personal Obstetrical History cont..
 Asses the woman’s attitude towards this
pregnancy, was it planned or not?
Ask about any serious disorders i.e. P.V.B,
severe headaches, fever, blurred vision.
Ask about the health during this pregnancy.
Any medications taken or being taken or any
other treatment.

57. Personal Obstetrical History cont..
Asses the woman’s attitude towards this
pregnancy, was it planned or not?
Ask about any serious disorders i.e. P.V.B,
severe headaches, fever, blurred vision.
Ask about the health during this pregnancy.
Any medications taken or being taken or any
other treatment.

58. Physical Examination
This examination serves to screen the woman for
any existing abnormalities or high risk factors and
also acts as a base line for examination at future
visits to the antenatal care.
It also ascertains the fetal well being.
The woman’s psychological and emotional state is
assessed and noted if, she is co-operative and
communicative or dull or unresponsive, calm,
anxious, aggressive, whether she is happy or
depressed.

59. Physical Exam cont..
Note the stature as she walks in (height and
weight) because a small built woman is likely
to have a small pelvis.
Note the gait i.e. if the woman is limping, this
could be caused by an injury to lower limbs,
spine or to the pelvis because such may
indicate disproportion in the pelvic diameters.

60. Physical Exam cont..
Take the woman’s height. A woman who is
less than 150 cm tall should be regarded as
possibly having a small pelvis.
The shoe size. Less than 4 are suggestive of a
small pelvis.

61. Physical Exam cont..
Weigh the woman and record to compared
with the weights taken during subsequent
visit.
Check the BP. BP it is taken early in pregnancy
at the 1st booking in order to act as base line
reading for subsequent visits.
NOTE: BP may be falsely elevated if the
woman is nervous or anxious but in some
women it may be a warning of pre-eclampsia

62. Physical Exam cont..
Urinalysis- urine should be examined at each
visit for the following.
Proteins- This plus a high BP and oedema,
could indicate the presence of pre-eclampsia.
Glucose- This could be caused by high
circulation blood glucose levels, low renal
threshold or conditions i.e. DM.

63. Examination by Midwife
Let the woman lie comfortably on a firm bed
or couch.
Examination should be carried out
systematically so that no point is omitted.
Always start from head to toe.
1st observe the woman’s general appearance.

64. Head
Note the colour and texture of the hair for
nutritional status, alopecia and neatness.
Check for any signs of malnutrition and any
lice infestations.
State of hair gives an insight into the mother’s
personal hygiene.

65. eyes
 Note for any eye discharge, pallor and signs of
jaundice.
The eyes should be bright, alert and clear.
Oedema of eyelids and Surrounding areas may
indicate pre-eclampsia or renal disease. Pale
conjunctiva may indicate anaemia.

66. Nose
Note for any abnormalities i.e. broken nose,
nasal polyps, bleeding discharges from the
nose which could suggest the possibility of
infection.

67. Mouth
Check for sores on the tongue, oral thrush in
the mouth and any sores.
Note the dental status and note for any dental
carries and if present find out if they are
painful.
The breath should not be offensive and should
be free from other odours i.e. alcohol.
If you suspect any infection, take a throat
swab.

68. Ear
 Observe for any discharges and any other
abnormalities.
Palpate for enlargement of the lymph nodes.
Enlargement of lymph nodes suggest
infection, chronic illness i.e. HIV, TB.
Observe for undue pulsation of veins around
the neck.

69. Hands
Examine for signs of anaemia on the palms,
venous return on pressure nail beds, presence
of oedema and personal hygiene.
Examine for symmetrical because the
deformity would affect the mother with
feeding or taking care of the baby, otherwise
it’s of no obstetrical importance.

70. breast
Examine for presence of presumptive signs of
pregnancy.
Presence of abnormal lumps.
Palpate Axilla for any enlarged glands that
could be due to some illness i.e. TB or any
other chest infections and breast problems.

71. Abdomen
Before starting this procedure, ensure that the
woman has emptied the bladder within 30
minutes, this is to aid comfort of client and to
ensure accuracy during measurement of
H.O.F.

72. Abdomen cont..
Three senses are used in abdominal
examination i.e. Sense of sight, touch and
smell
Inspection
Palpation
Auscultation

73. On Inspection
Note the skin of abdomen by observation. For
probable signs of pregnancy i.e. Striae gravid
arum, linea nigra.
Observe for any surgical scars.
The size of abdomen in relation to gestation
age. Multiple pregnancy or Polyhydramnios
will enlarge both the length and breadth of
uterus, whereas a large baby increases only
the length.

74. Inspection cont..
Fetal movements- This is evidence of fetal life.
These could also help to identify the position
of the fetus because the back of the fetus
would be located on the opposite side of the
abdomen to that on which fetal limb
movement is seen.

75. On Palpation
The hands should be clean and warm because
cold hands tend to induce contractions of the
uterine muscles.
The pads and not the tips of the fingers should
be used with delicate precision.
The hands should be moved smoothly over
the abdomen in a stroking motion in order to
avoid causing contractions.

76. Palpation cont..
Assessment of H.O.F- the height of fundus is
assessed by pressing the left hand held out
straight as for a hand shake.
The fingers of the right hand are used to
measure the distance from the upper boarder
of symphysis pubis to the highest point on the
fundus of uterus.

77. Palpation cont..
You then note the number of finger breadths
which can be comfortably accommodated
between the two.
Up to 20 weeks the fundus raises about 2
finger breadths every 2 weeks.
After 20 weeks the fundus rises about 1 finger
breadth every 2 weeks. Therefore 1 finger
breadth represents 2 weeks.

78. HOF estimations
At 12 weeks - just above symphysis pubis.
At 16 weeks – half way between the upper
border of symphysis pubis and the lower
boarder of the umbilicus. At 20 weeks – level
of the lower boarder of the umbilicus.
At 22 weeks – at the centre of the umbilicus.
At 24 weeks – at the upper boarder of the
umbilicus.

80. Estimation
At 30 weeks – it will be half way between the
upper boarder of the umbilicus and the lower
boarder of xiphisternum.
 At 36 weeks – it will be at the lower boarder
of xiphisternum.
At 38 weeks to the onset of labour, it drops by
2 finger breadths and remains to the level of
32 – 34 weeks.

81. Fundal Palpation
 It’s carried out in order to determine whether
it contains the breech or head. This
information will help to diagnose the lie and
presentation of the fetus.
The buttocks feel rather firm but they are not
as hard, smooth or well defined as the head.

82. Fundal palpat cont..
 The breech cannot be moved independently
of the body as can the head.
The head is much more distinctive in outline,
being hard and round, it can be balloted by
the finger tips of the 2 hands because of the
free movements of the neck.

84. Lateral Palpation
Lateral palpation is used to determine position.
The midwife can steady the uterus with one hand
and using a rotary movement of the opposite
hand to map out the back as a continuous
smooth resistant mass from the breech down to
the neck, on the other side the same movement
reveals the limbs as small parts that slip about
under the examining fingers.

86. Pelvic Palpation
The sides of the uterus just below the
umbilical level are grasped by the palms of the
hands with the fingers, held close together,
pointing downwards and inwards.
If the head is presenting, a hard mass with a
distinctive round smooth surface will be felt.
At the same time determine if the head has
descended in the maternal pelvis.

88. Auscultation
The fetal heart beat should be listened to at
each ante natal visit.
From 20th week of gestation a pinnard
stethoscope is used.
Or 14th week if ultra sonic fetal pulse
detectors are available (Doppler ultra sound).
The normal rate of the FHR is between 120 –
160 beats per minute.

89. Legs
Note the shoes size
Check for symmetrical
Inspect for presence of varicose veins and
examination of calf tenderness.
Check for pitting oedema in the lower limbs by
applying finger tip pressure for 10 seconds
over the bone prominences e.g. the tibial,
ankle and pedal.

90. Vulva
Midwife should now wear surgically gloves
and explain the procedure to the client.
Inspect for presence of abnormal discharges,
cleanliness in general, warts, sores, oedema,
varicose veins and scars.
Abnormal vaginal discharges and offensive
odours may indicate infections like
gonorrhoea

91. Plan of Action
To do investigations e.g. Hb,RPR, urinalysis,
HIV counselling and testing. Abdomen scan.
To provide EMTCT (male involvement)
To give medication e.g. folate,iron,prophylasis
for Malaria.
To refer client to hospital e.g. it complications
present.

92. IEC
Counselling on :
 Danger signs.
 Individual birth plan.
 Complication readiness
 Nutrition
 Breastfeeding
 family planning
 safer sex
 hygiene
 EMTCT
 Return Date.

93. References
• Lowdermilk, D. L & Perry S. E (2004), Maternity &
Women’s Care, Eighth Edition, Mosby Inc. St.
Louis, USA.
• Central Board of Health, (2002), Integrated
Guidelines for Frontline Health Workers, 2nd
Edition, and Lusaka: Zambia.
• Williams M. & Booth D (1985), Antenatal Care
Education, 3rd Edition, Longman Group Ltd, New
York: USA.