Antenatal care

1. ANTENATAL CARE
Ephrem Yohannes (MSc in
Maternity and Neonatology)
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2. Outline
 Historical back ground
 Organization of prenatal care
 Describe the objectives of antenatal care
 Discuss different models of antenatal care
 Describe activities of antenatal care
 Outline ANC fetal well being assessment
strategies
 Discuss health interventions during ANC
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3. Historical back ground
 in US was introduced by social reformers and
nurses
 An outpatient prenatal clinic was established
in 1911
 In 1954, Nicholas J. Eastman "done more to
save mothers' lives in our time than any other
single factor"
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4. …Con
The antenatal period presents opportunities
– Inform about danger signs and symptoms
– The risks of labor and delivery
– Delivery with skilled healthcare provider
– Information on birth spacing
– Intervention-
• Tetanus immunization
• Prevention and Rx of malaria, anemia, STI
• HIV prevention and care
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5. Organization of Prenatal Care
 Essence of ANC as described by ACOG
The contents include;
1.Preconceptional care
2.Prompt diagnosis of pregnancy
3.Initial prenatal evaluation
4.Follow-up prenatal visits
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6. Aim of ANC
• The goal of antenatal care is to
have a healthy mother and baby
by monitoring their well
beingness during pregnancy
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7. Objectives
 Timely detection and management of cpx
 Ensure the birth of a healthy child
 Ensure the health of the mother
 Provide essential health education to the mother
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8. Models
• Two models of prenatal care provision
1.Traditional ANC model /Routine
2.Focused ANC
3.New WHO recommendation
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9. Routine ANC
• Begin almost two hundred years ago.
• Based on European models developed in the
early 1900s.
• that were traditionally thought to benefit the
mother and her fetus.
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10. Routine ANC
Components of Traditional ANC model
• Frequent visits
• Routine screening
• Monitoring of Ht, Wt, ankle edema
• Risk approach
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11. Routine ANC
 Visit pattern
Every 4 weeks till 28 weeks
Every 2 weeks from 28-36 weeks
Every week from 36 weeks till delivery
 Total number of visits 12-14
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12. WHO Recommendations
• Goal oriented and
• Focused on “screening to detect a problem
rather than screening to predict a problem”
and on treating any problem that can
complicate a pregnancy.
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13. WHO Recommendations
Final Recommendations
1. four focused visits as sufficient for normal
pregnancy (now 8)
• Goal-directed visits by skilled provider
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14. WHO Recommendations
2. Birth Preparedness
• Skilled attendant
• Place of delivery
• Finance
• Nutrition
• Essential items
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15. WHO Recommendations
3. Readiness for Complications
• Early detection
• Designated decision maker(s)
• Emergency funds
• Communication
• Transport
• Blood donors
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16. WHO Recommendations
4. Counseling
• Nutrition
• Family planning
• Breastfeeding
• Danger signs
• HIV/STIs
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17. WHO Recommendations
5. Detection and management of existing
diseases and conditions
• HIV – Voluntary counseling and testing
• STIs, including syphilis
• Tuberculosis
• Malaria
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18. WHO Recommendations
6. Detection and management of complications
• Severe anemia
• Vaginal bleeding
• Pre-eclampsia /eclampsia
• Malpresentation after 36 weeks
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19. WHO Recommendations
7. Prevention
• For all women
- Tetanus toxoid
- Iron and folate supplementation
• In select populations
- Malaria - intermittent preventive treatment
- Routine hookworm treatment
- Vitamin A supplementation
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20. 2016 WHO ANC
model
• FANC model, which was developed in the
1990s, is probably associated with more
perinatal deaths than models that comprise at
least eight ANC visits.
• More ANC visits, irrespective of the resource
setting, is probably associated with greater
maternal satisfaction than less ANC visits.
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21. • Prefers the word “contact” to “visit”, as it
implies an active connection between a
pregnant woman and a health-care provider
that is not implicit with the word “visit”.
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22. • The decision regarding the number of contacts
was also influenced by:
– Safety
– health system communication and support
– No differences between 8 ANC and (11–15)
contacts
– Contact between px women and knowledgeable,
supportive and respectful health-care
practitioners
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23. 12/2/2019 23

24. FOCUSED ANC
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25. Principles of focused ANC
1. Simple classifying form
2. Identification of high risk women and referral
3. Well coming all women at the clinic
4. Only necessary examinations and tests
performed
5. Rapid & easy test
6. Treatment should start the same day
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26. Focused ANC
• Intended only for pregnant women with out ----
- evidence of pregnancy-related complications,
- medical or major health-related risk factors.
• Two groups of px mother by using the
classifying form
- Basic model
- Comprehensive model
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27. WHO ANC Model
All women
first visit ANC
Classifying
form
Any condition or
risk factors detected
in applying
classifying form
NO
YES
Basic Component
of ANC
Program(25%)
Specialist care/
additional assessment
or follow-up if
needed in clinic or
elsewhere(75%)
Transfer of patients
between basic component
and specialized care is
possible throughout ANC
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28. CLASSIFYING FORM - Criteria
• OBSTETRIC HISTORY
1. Previous SB/ neonatal loss?
2. Recurrent abortions?
3. BWt of last baby < 2500g?
4. BWt of last baby > 4500g?
5. hospital admission for hdp?
6. Previous surgery on
reproductive tract?
• CURRENT
PREGNANCY
7. Diagnosed or suspected
multiple pregnancy?
8. Age less than 16 years?
9. Age more than 40 years?
10. Isoimmunization Rh (-)
11. Vaginal bleeding?
12. Pelvic mass?
13. DSP 90mm Hg or more at
booking?
GENERAL MEDICAL
14. Insulin-DM?
15. Renal disease?
16. Cardiac disease?
17. Known 'substance' abuse?
18. Any other severe medical
disease?
NB: yes to any one – Not
eligible
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29. Framework of Focused ANC
• Disease detection
• Counseling and health promotion
• Birth preparedness
• Complication readiness
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30. Basic component
Timing of visits
1st- up to 12 weeks
2nd- 24-28 weeks
3rd- at 32 weeks
4th- at 36 weeks
5th- 40-42 weeks- optional
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31. Contents of ANC visits
Disease detection / Screening
Care provision
Health promotion
• Each visit of ANC requires about 20-30
minutes.
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32. Initial visit
• Should occur in the 1st trimester at ≤12 weeks
or regardless of the GA at 1st enrolment.
• Irrespective of gestation at 1st visit, all
pregnant women should go through first visit
contents in addition…
• Expected to take 30– 40 minutes.
• Emphasis on medical/obstetric HX – eligibility
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33. Initial visit- History
Present pregnancy-
• Accurate dating of gestational age
• Any symptoms – minor or major complaints
• Fetal movement perception
• ANC details if mother is referred from other
• Presence of any of the danger signs
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34. Initial visit- History
Past obstetric history
• Details of any obstetric complication
Family history
• Any familial medical conditions
• DM, HDP, Congenital anomalies
Personal history
• History of medical illnesses
• Substance intaking
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35. Initial visit- Physical Exam
• Vital signs and anthropometry
• Abdominal examination
 Fundal height palpation in non obese women at 20
to 34 weeks gestation
 Fetal heart auscultation after 10th week by doppler
or 20th week by fetal heart stethoscope
 Fetal presentation after the 28th week but
malpresentations abnormal after the 36th week
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36. Initial visit- Physical Exam
• Pelvic examination
 For uterine size measurement if GA< 12th week
 Adnexal abnormalities or masses
 Early evidence of pregnancy on physical exam-
 cervical softening; Chadwick’s sign( bluish color of
vagina, cervix); Von-Fernwald’s sign( localized
softening of the fundus) and Hegar’s sign
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37. Assess for referral
• LMP and EDD
• Need for special care
– Diabetes
– Heart disease
– Renal disease
– HIV positive
– Severe anaemia, previous SB, Previous HDP, Previous
CS,
– High BP
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38. Implement interventions
• Iron & folate supplementation
• Treat STIs
• TT 1st injection
• IPT for Malaria
• PMTCT~ (asses for prophylaxis or HAART)
• Refer high-risk cases as above
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39. Advice, Q&A
• Safe sex
• Nutrition
• Whom to call for emergency
• Birth plan
• Invite partner
• Schedule next appointment
• Maintain complete records
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40. Subsequent visits – Activities
History
• Follow up on previous complaints
• Any new complaints since last visits
• Development of any of the danger
symptoms
• Fetal movements history
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41. Subsequent visits – Activities
Physical examination
• Brief detailed exam including the vital signs,
anthropometry and general examination
• Adequacy of weight gain since last visit
• Adequacy of fundal growth since last visit
• Presence of fetal heart beat
• Presence of other findings such as
generalized edema
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42. Diagnostic work-up during antenatal care
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Diagnostic procedure Gestational age
Hemoglobin/hematocrit determination Initial visit; repeat at 28-32 weeks
ABO and RH typing Initial visit
VDRL Initial visit; repeat at 28 weeks if negative
Urinalysis At each visit to detect proteinuria
Urine culture and sensitivity Initial visit to detect asymptomatic
bacteriuria
Indirect Coomb’s test Initial visit
Serum alpha-fetoprotein test 16-18 weeks
Routine ultrasonography 16-18 weeks
Screening test for gestational diabetes 24-28 weeks
Pap smear Initial visit
Cervical smear gram stain and culture Initial visit
HBsAg; HIV tests Initial visit12/2/2019

43. Assurance of fetal well being at ANC- Strategies
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Progressive increase in maternal weight
Progressive fundal height growth as per
expectations
Adequate maternal perception of fetal
movement (at least 10 in 12 hours)
Fetal well being tests – from 28 weeks onwards
• Non stress test
• Contraction stress test
• Fetal biophysical profile score
• Doppler ultrasound velocimetry
Ultrasonographic fetal scan for anomalies
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44. Record keeping
• At 4th visit give the client a copy of her
antenatal card to take to the unit of choice of
delivery.
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45. THANK YOU
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