This document discusses the history and evolution of antenatal care (ANC), current practices, limitations, and ways to improve ANC. It notes that while ANC has significantly reduced maternal and infant mortality rates, the maternal mortality rate in India remains high. It identifies limitations like low coverage, inadequate home care, and an overreliance on predicting risks rather than detecting current issues. The document recommends strengthening continuity of care, screening for common diseases, universal ultrasound screening, and developing birth preparedness plans to ensure earlier access to emergency care. The goal is to make pregnancy a normal physiological event and further reduce mortality rates.

1. Antenatal Care
Dr. Rabi Narayan Satapathy
Assistant Professor
Dept. of Obst. & Gyn.
S.C.B. Medical College,Cuttack.
Mail; drrabisatpathy@yahoo.com
Mob; 9861281510/8270088880

2. Evolution of ANC

3. “ Hints to Mothers for the Management of
Health during the Period of Pregnancy and
in the Lying-in Room with an Exposure of
Common Errors in Connection with these
Subjects”
Thomas Bull (1937)

4. ● 1901  Paper by Ballantyne entitled “A plea for
a pro-maternity hospital”
Led to establishment of the first
antenatal bed at the Edinburgh Royal
Maternity Hospital.
● 1915  First antenatal clinic at Edinburgh.
● 1950  2000 antenatal clinics in England &
Wales

5. ● ANC as we know it today emerged in the 1960s.
● Sought to prevent or cure most of the
hazards of pregnancy.
● Promised to make pregnancy and subsequent
delivery as smooth as possible
● Development of new technologies aided this
aim

6.  Early incorporation into India’s MCH services
 ANC now became more streamlined
 Benefits felt immediately in succeeding years
 MMR  from 2000/100,000 live births in 1938
1000/100,000 live births in 1959

7.  Promote,protect & maintain the physical,
mental and social well-being of both mother
& child.
 To detect high-risk cases
 To foresee complications
 To remove the anxiety & dread associated
with delivery

8.  To educate mother regarding child care, nutrition,
personal hygiene, environmental sanitation etc.
 To sensitise the mother to the need for family
planning.
 To reduce MMR & IMR
To maintain the “normal” status of a
normal physiological event.

9. Components of ANC

10.  A set of professional check-ups
 Tetanus & other immunizations
 Iron & folic acid prophylaxis
 Regular blood-pressure check-ups
 Risk-approach
 Advice regarding delivery methods,
nutrition, personal hygiene etc.
 Maintenance of records
 Home visits.

11. Successes OF ANC
Routine antenatal care is an example of
preventive health care at its best
Drastic reduction of MMR in the last five
decades
Considerable improvement in PNMR
High cost-effectiveness

12. Successes of ANC…contd.
78%women covered by tetanus prophylaxis
Introduction of screening & early detection of
foetal abnormalities using biochemistry &
ultrasound.
( detection of anomalies by USG AT 19 wks. Had
85% sensitivity & 99.9% sensitivity)

13. AT THE CROSS-ROADS
 The MMR,though dipping in the past decades has
not reached an ideal figure. It still stands at an
alarming 407/100,000 live births.
MMR in some countries :
UK – 13
USA -17
Bangladesh – 380
Sri Lanka - 92

14. At the Cross - roads
40% maternal deaths due to haemorrhage, sepsis
12% maternal deaths due to eclampsia
 20% due to indirect causes (notably anaemia)
29%
19%
16%
10%
9%
8%
9%
Hemorrhage Anemia
Sepsis Obstructed labour
Abortion Toxemia
Others

15. At the Cross-Roads
 ANC reaches out to 20-70% of pregnant
women,depending on area surveyed,
(urban,semi-urban or rural)
 About 80% of these have only one visit,3/4ths
receive their first visit between 6th to 8th month
of pregnancy
 About 25% of women who receive ANC have a
complication during labour and delivery

16. At the Cross-Roads
 300 women die every day in India during
childbirth or due to pregnancy related causes
 MMR in developing countries remains 100
times more than in the developed countries

17. At the Cross- Roads
 Majority of maternal deaths take place after
delivery, most within 24 hrs. after delivery. Yet,
only 17% of deliveries taking place outside of a
health institution are followed up by PP check-
ups; only 14%within the critical two-day period.

18. Limitations of current ANC Practices
● Low-Outreach – Inability to bring all
pregnant women into its fold.
Reasons :a)Not thinking check-ups were
necessary (60%)
b) Inability to meet costs (15%)
c)Family or peer pressure (9%)
d)Lack of knowledge about ANC
e)Long distances to health centre
f) Lack of transportation

19. LIMITATIONS … contd.
● Competency of health care provider
● Home deliveries unattended by trained
health professional
● Disregard for basic hygienic environment
● No change in incidence of preterm
labour,despite increased awareness of risk
factors and sophisticated diagnostic
procedures
● Limited usefulness of high-risk approach

20. Limitations…contd.
● 70% of adverse perinatal outcomes cannot
be predicted by existing assessment
methods
● Only 44% of IUGR correctly diagnosed
● 30% of women developing PET presented
for the first time in labour
● Despite existing ANC services, emergency
admissions far outweigh elective admissions

21. Limitations…contd.
● Though figures are hard to come by; for
every maternal death, there are 10-15 women
who survive only to suffer from the sequelae
of pregnancy and neglected childbirth
●Onset of unpredictable complications even
with full antenatal supervision eg.
PROM, vag.bleeding, HTN, cord
prolapse, shoulder dystocia etc.

22. A Way Forward
Safe Motherhood Programme in 1992
RCH Programme in 1997.Provision of care for
the pregnant woman became a major thrust
.JSY in 2005

23. A Way Forward…contd.
■ In its Annual Report 2001-2002,the GOI
Planning Commission notes that both the lack
of universal screening for risk factors and the
lack of appropriate referral are the major reasons
that maternal and child mortality and morbidity
have not declined in the past two decades.

24. Future Policy
Goals of the National Population Policy 2000
■ Reducing MMR to <100/100,000 live births
■ Achieving 80% deliveries within health
institutions
■ Delivery of all births by trained personnel
■ Adressing the unmet needs for basic
reproductive and child health services,
supplies and infrastructure

25. A Way Forward
● Continuity of ANC by health care provider.
The set of competencies necessary for
adequate ANC is more important than the
cadre of the health care provider
● Screening and detection of existing diseases
(eg. HTN, TB, HIV, DIABETES )will have
a direct impact on pregnancy and perinatal
outcome

26. .
Antenatal Visits 
*once / month till 7 mths
*twice / month in the 8th mth
*weekly thereafter
Revised visit schedule 
*1st visit as soon as pre detected/20th
wk
*2nd visit at 32 wks
*3rd visit at 36 wks

27. Aims of Pre-pregnancy Care
 To bring the woman to pregnancy in the best possible health.
 To provide the means of ensuring that preventable factors are
attended to before pregnancy starts, e.g., Rubella
 To discuss relevant issues.
 To give advice about the effect of:
Preexisting disease and its treatment on the pregnancy—Diabetes ,
Hypertension
the effect of pregnancy on preexisting disease and its treatment
 To consider the likelihood and effects of any recurrence of
events from previous pregnancies and deliveries.

28. Aims of Antenatal Care
1. Management of maternal symptomatic
problems.
2. Management of fetal symptomatic problems.
3. Screening and prevention of fetal problems.
4. Preparation of the mother for childbirth.
5. Preparation of the couple for childbearing.

29. Booking appointment
 Ideally by 10 weeks of gestation
 Identify women who may need additional care
and plan the pattern of care.
 Measure the weight (Wt) and height (Ht)
 Measure blood pressure (BP) and check urine
for proteinuria.
 Determine risk for gestational Diabetes and Pre-
eclampsia

30. Booking Visit
 History
 Age
 Parity
 Menstrual history
 Medical history
 Surgical history
 Socio-background
 Obstetric history

31. Booking Visit
 Examination
 Face; complexion, eyes, teeth
 Thyroid gland
 Chest, lungs, Heart and breasts
 Abdomen, changes of pregnancy, any scars
Uterine size
Fetal heart
 Pelvic ???/ vagina

32. Booking Investigation
 Offer blood tests:
 Blood group and Rhesus status
 Screen for anaemia and haemoglobinopathies
 Hepatitis B Virus
 Rubella susceptibility
 Syphilis
 Toxoplasmosis
 Mid stream urine
 Offer early ultrasound, for gestational age, structural anomalies
 Offer screening for Down syndrome???

33. Supportive Information
 Give information supported by written
information.
 Give an opportunity to discuss issues and ask
questions.
 Be alert to any factors, social that may affect the
health of both mother and fetus/baby.
 Offer ante-natal classes

34. Specific Information
 How the baby develops during pregnancy
 Nutrition and diet, including Iron supplement.
 The pregnancy care pattern
 Planning the place of birth
 breastfeeding

36. Ultrasound Scan (USS)
 USS to determine gestational age using:
 Gestational sac
 Crown-rump measurement, 10-13 weeks
 Bipareital diameter (BPD) 14 18 weeks
 Fetal Biometry: BPD, Head Circumference (HC),
Femur length (FL), Abdominal Circumference (AC) 18-
24 weeks
 USS to determine fetal growth:
 using fetal biometry variables
 USS to determine fetal wellbeing Using:

37. USS to determine anomalies
 10-12 weeks
 20 weeks

38. Down’s syndrome screening
 Combined test, 11-14 weeks of gestation
 Serum screening (Triple or quadruple test) 15-20
weeks.

39. Main purpose of visits
 History and examination, clarification of
uncertain gestation, identification of risk factors
for the pregnancy.
 Booking blood tests

40. Subsequent Visits
14-16 weeks
 Review history, discuss and record screening
tests,
 Measure BP and test urine,
 Check Hb level if < 11gm/dl consider Iron
supplement.
 Examine the fundal height and listen to the fetal
heart.

41. 18-20 weeks
 Measure BP and test urine,
 Examine the fundal height and listen to the
fetal heart.
 Discuss the structural anomaly scan
 If placenta extends across the internal cervical
os, offer another scan at ??????

42. 24 weeks
 Measure BP and test urine for?????
 Measure the plot symphysis-fundal height for
nulliparous

43. 28 weeks
 Measure BP and test urine
 Offer another screening for anaemia and
atypical red-cell alloantibodies
 Investigate a Hb <10gm/dl
 Offer anti-D prohylaxis to a women who are
Rhesus D-negative
 Offer screening for gestational Diabetes
 Measure symphysis fundal height

44. 32 weeks of gestation
 Check the dates from LMP.
 Review, discuss and record the results
undertaken at 28 weeks.
 Measure BP and test urine
 Measure S-F height

46. 34-36 weeks
 Check the dates from LMP.
 Review, discuss and raised issue.
 Measure BP and test urine
 Measure S-F height
 Offer a second does of anti-D prophylaxis
 Arrange an USS if low-lying placenta at 20 weeks
 Give specific information on preparation for labour

47. 36-37 weeks
 Check the dates from LMP.
 Review, discuss and record the results undertaken at 28
weeks.
 Measure BP and test urine
 Measure S-F height
 Check the presentation, if breech offer external cephalic
version(ECV)
 Give specific information on preparation for labour
 Information on breastfeeding

48. 38 weeks
 Check the dates from LMP.
 Measure BP and test urine
 Measure S-F height
 Check the presentation, if breech offer external
cephalic version (ECV)
 Give specific information on preparation for
labour
 Information on breastfeeding

49. 40 weeks
 Check the dates from LMP.
 Measure BP and test urine
 Measure S-F height
 Check the presentation, if breech offer external
cephalic version(ECV), can be difficult
 Give specific information on preparation for
labour
 Information on breastfeeding

50. 41 weeks
 Check the dates from LMP.
 Measure BP and test urine
 Measure S-F height
 Give specific information on preparation for
labour
 Information on breastfeeding
 Offer membrane sweep
 Offer induction of laour

51. Clinical assessment of bony pelvis
 It is not important. However if done should
include checking the:
 Anteroposterior diameter, from the symphysis pubis to
the sacral promontory.
 Curve of the sacrum.
 Promimance of the ischial spines.
 The angle of the greater sciatic notch
 Subpubic angle

52. .
Prenatal Advice:
● Diet and Nutrition
● Personal hygiene
● Drugs
● Radiation risk
● Warning signs
● Child care

53. .
Specific Health Protection :
 Anaemia
 Other nutritional deficiencies
 Toxaemias of pregnancy
 Tetanus immunization

54. A Way Forward
■ Modification of the “Risk- Approach”.
Current literature strongly suggests that the
focus of obstetric care should be shifted
from predicting complications to
identification of risk factors and detection of
signs and symptoms of current problems

55. A Way Forward
■ Birth-preparedness or a Birth-action plan
* Who attends,who accompanies
* Transportation,decision-makers,finance
* Complication preparedness
* Potential blood donors
The action plan to be made after discussion
with the woman and her family members

56. A Way Forward…contd.
■ Easy access to Emergency Obstetric Care
■ To provide useful information to the
pregnant woman and her family
■ Universal USG screening
■ ? Universal HIV screening
■ ? Genetic screening

57. Conclusion
• The current day ANC, though serving an extremely
useful purpose, has not met the expectations of the
nation. •
Since it is nearly impossible to predict which woman will
develop a complication, it is important to work with all
women to recognize complications and to establish a
plan of action in case they arise.
•This will ensure that they arrive earlier at points in the
health care system where they can receive appropriate
care. Only then can we reach much nearer to the goals
we have set for ourselves.