ANTENATAL CARE.pptx

OBJECTIVES
General objectives
• Understand the management of
pregnancy
Specific objectives
• Define terms used.
• Outline the aims of antenatal care.
• Discuss the components of Focused
Antenatal care.

MANAGEMENT OF PREGNANCY
INTRODUCTION
• Management of pregnancy, also
called antenatal care is the care given
to a pregnant woman from the time
of conception to beginning of labour.

INTRO CONT,
• Appropriate management would reduce
the maternal mortality rate which is
currently at 298/100 000 live births.
• To achieve this, the Ministry of Healthy
promotes an updated approach to
antenatal care that emphasizes quality
over quantity of visits called Focused
Antenatal Care.

INTRO CONT’
Focused Antenatal Care, has four main
objectives which include:
• Early detection, treatment and referral of
abnormalities.
• Disease prevention and ensure safe
delivery
• Birth and complication preparedness and
• Health (IEC) promotion of pregnant
women (MoH, 2004).

DEFINITION OF CONCEPTS
1. Antenatal Booking (first visit): This is
the first visit a pregnant woman makes
to the clinic to seek medical advice. This
visit should take place as soon as the
woman notices that she is pregnant.
2. Revisit: These are subsequent or follow-
up visits that the woman will make after
Booking for her pregnancy.

To receive maximum benefits from antenatal
visits, it is desirable that the woman receives at
least four (4) visits spread out the entire
pregnancy (Now called antenatal contacts-
minimum 8 contacts or visits):. Depending on
the individual needs, a woman may require
additional visits. At each visit, ask about her
wellbeing and that of her family. Discuss
individual birth plan, do observations.

Do abdominal examination. From 34
weeks, the size, Lie, position and
Presentation of the fetus is cardinal. Pelvic
assessment should be done. Also do a
Pelvic Ultrasound scan to determine these
aspects. Do a repeat of Hb, RPR and take
appropriate action.
IEC according to needs identified. IEC on
labour also to be given.

3. Focused Antenatal Care (Now called
antenatal contacts-minimum 8 contacts or
visits): This is an updated approach to ANC
where a woman has frequent routine visits
that are standard and a woman is classified
according to their risk of complications to
determine the level of care they should
receive.
It emphasizes the quality of visits over
quantity of visits.

4. Antenatal care-refers to the care that is
given to a pregnant woman from the time
that conception is confirmed until the
beginning of labour (Fraser & Cooper,
2003).
Ante means before and Natal means
Birth: Hence antenatal care means the
care given to a pregnant woman before
delivery or before birth of baby.

SCHEDULES OF VISITS
– First visit at or before or by 16 weeks (by the end of
four months)
– Second visit at 24-28 weeks (5-7 month)
– Third visits at 32-34 weeks (8 months)
– Fourth visit at 36-40 weeks (9 months) (MoH, 2004).
– NOTE: Now a pregnant woman can make an average
of 8 contacts/visits/appointments to the clinic (normal
pregnancy). Nulliporous=10 maximum, parous=7
maximum depending on the prenancy findings.

Activities that are considered at each
visit
First visit (before or by 16 weeks).
-History taking.
-counselling for HIV,
-Health education on what the clinic or
hospital offers, investigations done, the
activities e.g comprehensive history
taking, full physical examination (long
palpation), observations, birth
preparedness, danger signs.

-Screen and treat for anaemia, malaria,
syphilis in pregnancy, malaria in pregnancy,
nutrition in pregnancy.
-Order for Pelvic Ultra sound Scan to
determine Gestational Age (G/A), Expected
Date of Delivery (EDD), Placental location,
Viability of fetus. Any anomaly, if
interested, Sex of baby.

-Give TT (if did not finish 5 doses),
Fansida first dose (SP1) only if quickening
has occurred. Also give Ferrous sulphate
and Folic acid.
-Establish LMP and EDD.
-Full and thorough Physical examination is
done (Head to Toe) i.e Long Palpation.
-Give appropriate next visit.

ACTIVITIES cont’
Second visits (24-28 weeks).
• Review what occurred on the first visit
(assess and continue treatment started on
first visit). Reinforce birth plan, ensuring
if the woman has received: fansidar, iron
supplement, deworming (if did not get on
first visit) medication and tetanus toxoid.
IEC e.g on importance of ANC, minor
disorders of pregnant, nutrition, hygiene.

ACTIVITIES cont’
Second visit cont’
• Women reminded on the importance
of rest, danger signs, delivery, and
postnatal care whether HIV and
syphilis test were done. Any side
effects from the drugs being taken.

-If Pelvic Ultra sound Scan was not done on
the first visit, order to determine
Gestetional Age (G/A), Expected Date of
Delivery (EDD), Placental location, Any
anomaly, if interested, Sex of baby.
A quick Physical examination is done (Short
Palpation).
Give appropriate next appointment.

Third Visit (32-34 weeks).
-Provide client with information on stage of
pregnancy.
-Screen for Anaemia (repeat FBC for Hb
and other blood indices), also do second
test for syphilis.
Review with client danger signs of
pregnancy.

-Remind client of baby and mother layette.
Give fansida 3, feso4, f/acid.
-Order for Pelvic Ultra sound Scan to
determine the Lie, Position, Presentation
and Attitude of fetus. Fetus should be
cephalic. Also to assess the volume of
liquor amni to rule out Polyhydramnious,
Viability of fetus, Any anomaly e.g cord
around the fetal neck .

-Give IEC on true signs of labor.
-A quick Physical examination is done
(Short Palpation).
-Give appropriate next appointment.

ACTIVITIES cont’
Fourth visit (36-40 weeks).
-Review of child birth, screen for anaemia,
infant feeding, postnatal care and family
planning and physical examination is done.
-Give IEC on true signs of labour. Review date
now should be in line with EDD. At least 2
weeks after EDD. Fetal head should engage by
36 weeks in G1. If not could be a case of CPD.

COMPONENTS OF FOCUSED ANTENATAL CARE
Early detection of complications and
prompt treatment:
• Thorough history taking, physical
examination and investigation.

Disease prevention :
• Thorough IEC, after quickening, give
Intermittent Presumptive Treatment
with Fansidar against malaria,
deworming with vermox.

• immunization against Tetanus
• provision of ferrous sulphate and
folic acid to prevent anaemia and
mebendazole to prevent worm
infestation.

COMPONENTS OF FOCUSED
ANTENATAL CARE... cont’
Birth preparedness and complication
readiness:
• achieved through provision of
information.
Health promotion :
• This is achieved through discussing
various health topics.

1. HISTORY TAKING
The history provides information that will
help the medical provider ( Midwife, Nurse
Military Medical Assistant or Doctor),
target the Physical examination and testing
as well as individualize her plan of care.
The History will include the following:

• Social history
• Personal medical history
• Family medical history
• Surgical history
• Past obstetric history
• Present obstetric history

a. Social History
Name- for identification and rapport.
Age- women who are 18 – 35 years have
the fewest problems in giving birth. Very
young women below 18 years and older
primigravida are at increased risk and
maternal and perinatal mortality and
morbidity due to complications such
anaemia, obstructed labour etc.

Adolescent women may have lack of access
to basic healthy care and ANC services, lack
of support system, resources etc.
Address/phone number- this information
can be used to contact the mother. Also for
follow-up.
Marital status- singleness may present an
added risk mostly because the family
abandons them. This leads to stress.

Occupation (of self and partner)- knowing
these details can help to understand the
woman economically for financial support
and also to rule out other factors, like,
exposure to radiation that may affect both
the mother and the baby.
Religion- to identify any religious beliefs
that could be detrimental to health
thereby giving council to the woman.

Habits- e.g smoking, drinking alcohol or
the use of potentially harmful substances.
This information helps to individualize care
and giving of IEC. Alcohol as a fact,
predisposes her to malnourishment, and
accidental falling due to alcohol
intoxication.

Cultural taboos- e.g avoidance of certain
nutritious foods like eggs. Educate the
mother that eggs are necessary and gives
both the mother and unborn child the
proteins required for growth and
replacement of body tissues.

Next of king- helps to identify the kind of
support she is getting. Also for easy contact
in case of an emergency.
Education levels- to assess the level of
understanding.
Hobbies- as some of them do not promote
rest, like sports

Social habits- if she smokes cigarettes, as it
predisposes her to respiratory tract
infections and placental insufficiency
leading to small for dates babies.
Also ask about type of accommodation,
water supply, type of toilet, refuse disposal
etc.

b. Family Medical History
Is useful in identifying conditions such as
cardiac disease, diabetes mellitus, asthma,
hypertension, epilepsy, psychosis,
pulmonary tuberculosis contact and
multiple pregnancies.

These conditions tend to run in
families and they make pregnant
women prone to them if present in the
family. It can also help the midwife to
act timely in case of problems.

c. Personal Medical History
The woman is asked about her health.
Some medical conditions such as
Hypertension, malaria, urinary tract
infections, heart diseases, asthma,
anaemia, epilepsy, diabetes mellitus,
mental illness and sickle cell disease are
ruled out.

These conditions tend to recur in
pregnancy and complicate pregnancy while
some can be complicated or be
exaggerated by pregnancy causing
permanent damage to the vital organs of
the body.

Women with chronic illnesses may require
services beyond the scope of basic care.
The woman is asked about previous
hospitalization and for any child hood illnesses,
to rule out condition that can affect pregnancy.
Ask the woman if she is taking any drugs like
Anti retro viral, antihypertensive, anti Diabetics,
Anti Epileptics or anti malarial.

• Some drugs are not supposed to be taken in
pregnancy because of teratogenic effects
hence need to change for example if a diabetic
woman is on Suphonylureas e.g Daonil,
substitute and give or prescribe Insulin for her
until after delivery.

Medication history is very important
because it will help a midwife give
appropriate health education on the need
to continue taking the drugs or
discontinue, for some dugs may be toxic to
the pregnancy, or there may be need to
modify the dosage.

Dietary habits
History about the type of food she
likes, number of meals per day and
eating of non foods, like soil, so that
appropriate health education on good
dietary habits can be given.

d. Surgical History
History about any injury or operation
involving the pelvic bones, spine or the
lower limbs is obtained to rule out
alteration of the pelvic diameters and
angle of inclination leading to cephalo-
pelvic disproportion.

History of operation involving the
lower abdomen especially the uterus
is taken to exclude the possibility of
uterine rupture during pregnancy or
labour

Major abdominal operation that could lead
to adhesions is also ruled out.
History is obtained about blood transfusion
to rule out the possibility of iso-
immunization if the mother is rhesus
negative and also to rule out the possibility
of HIV infection.

e. Past Obstetric History
History about the number of previous
pregnancies, children and their health status,
year of birth, health during pregnancy, duration
of labour, weight of the babies at birth, whether
the children were alive or dead. If dead, find
out the cause of death and at what age.

Type and duration of feeding is inquired.
Past history on childbearing helps to predict the
likely outcome of the current pregnancy, in
addition discussion of the past complications
provides an opportunity to emphasize the
importance of having a birth and complication
readiness plan.

f. Present Obstetric History
Obtain history of her first day of the last normal
menstrual period, age at menarche, type of the
cycle duration and the flow of her menses.
Find out about the contraceptive method used,
when and why it was stopped.

Present Obstetric History
This history can assist the provider in calculating
the gestational age of the pregnancy as well as
the estimation (expected) of the date of delivery
(EDD) and help the care provider give
appropriate health education to the woman and
family in terms of preparation for labour and
delivery.

Calculation of Estimated or Expected Date of
Delivery (EDD) by Using the Naegele’s Rule
Find out when she last had her normal menstrual
period and calculate the expected date of
delivery as follows:-
Add 7 days to the date
Add 9 months to the month e.g
If her LNMP was 10.03.2020
Add 7 to 10 and you will have 17

Calculation of Estimated or Expected Date of
Delivery (EDD) by Using the Naegele’s Rule -
contd
Then add 9 to the month and you will have 12
So your EDD will be 17.12.2020. Now always
consider + (plus) or – (minus) 14 days to your
calculated EDD. Meaning the client can deliver
14 days before this Due date or 14 days after
the Due date but still consider it to be within
normal range. The client should not worry.

Another example to calculate EDD (Estimated or
Expected date of Delivery). LMP was 27. 9. 20.
Calculation: 27. 9
+7 9
34 18
Since September ends with 30 days hence subtract 30
from 34 = 4 and a year has 12 months hence subtract
12 from 18 = 6
Now on the days we went past the month of September
into October by 4 days hence add 1 month to the
months therefore our EDD = 04. 07. 2021.

Calculation of Gestation age (Age of
pregnancy) by-date.
LNMP 10.11,2020. Date of Visitation to clinic for
antenatal is 28. 01. 2021
• Calculation is as follows:-
Month number of days weeks days
November 20 2 6
December 31 4 3
January 28 4 0
=10 =9
Gestation Age =11 weeks, 2 days By Date.

Calculation of Gestation age (Age of
pregnancy) by-date -cont’d
• When you add all the days you will have 9
days.
• Divide by 7 to turn them into weeks you will
have 1 week 2 days
• Add this week to the number of weeks which
is 10 weeks you will have 11 weeks 2 days
• So the gestational age today the 28th January
for this woman is 11weeks 2 days

OTHER METHODS TO CALCULATE DUE
DATES AND GESTATION
1. CALENDAR METHOD: Take the first day of the
last normal menstrual period and count
backwards by three (3) months, then add 7 days
e.g if her LMP (bleeding) started on the 06. 05.
20. count back 3/12 ( i.e April 6, March 6 and
February 6). Then add 7 days (February 6+ 7
days = February 13 is her due date i.e 13. 02. 21.
NOTE: Remember also the Naegele’s rule where
you add 7 days to the days and 9 to the
months……to calculate EDD

DATES AND GESTATION
2. Gestational Wheel: This is a special wheel
which has three columns indicating the Month
(outer column), Days of each month (middle
column) and Age of pregnancy in weeks (inner
most column). The Wheel has two arrows or
pointers i.e the first one indicates the First day
of LMP and further, the second pointer indicates
the Full term of pregnancy at 40 weeks.

DATES AND GESTATION
3. Using Tape Measure (McDonald’s Rule): The
measurement is called Symphysio-Height. This is
because the measurement is taken by placing the
zero line of the tape measure on the superior
border of the symphysis pubis and then the tape is
stretched across the contour of the abdomen to the
top of the fundus ( from Symphysis pubis to the
fundus hence the term Symphysio-height). The tape
is only used when pregnancy or height of fundus is
above the ambilicus ( 22 cm or 22 weeks and
above).

DATES AND GESTATION
4. Finger breadth or width: Each finger i.e
fingerbreadth (the three middle fingers) each finger
is equal to 2 cm or 2 weeks. Finger breadth is only
used when the pregnancy or height of fundus is 22
cm or 22 weeks and above. With the woman lying
flat on the couch or bed, the measurement is
always taken from the middle of the fundus to the
top of the fundus hence the measurement is called
Height of Fundus (HOF). Counting starts from the
middle of the umbilicus which is 22cm until to the
top of fundus.

DATES AND GESTATION
5. Use of Landmarks (Bartholomew’s Rule): This
method is only used in two instances to determine
age of pregnancy when:
-the LMP is not known or
-when height of fundus is below the umbilicus.
NOTE: Never use tape measure or fingerbreadth to
estimate age of pregnancy when HOF is below the
Umbilicus!!!!!!! Just let the woman lie on the couch
or bed and use your eyes and Landmarks to
estimate the age of pregnancy.

Inquire about her health during pregnancy and any
problems, such as fatigue, drowsiness, and
headache, loss of appetite, nausea, vomiting,
oedema and blurred vision.
Ask the woman about social support and record the
main support such as husband and mother in law.
Ask about availability of money for food,
transportation, and baby layette and supplies
(Sellers, 2009).

Current problems
Obtain history on current problems before
obtaining the whole history such as;Vaginal
bleeding , Severe headache or visual changes,
Shortness of breath, Fever, Draining of liquor
If any of these danger signs are present, then
the client should receive special attention. After
history taking then conduct Physical
examination.

2. PHYSICAL EXAMINATION
After thorough History taking, a full Physical
Examination is conducted.
Physical examination helps the attendant to
identify special needs, abnormal signs and
other potential problems as well as areas where
the client is doing fine.

They also provide information to consider when
giving health messages and counselling. A
thorough physical examination is performed
during the first visit and in subsequent visits, a
shorter or rather a more targeted examination
may be sufficient depending on the woman’s
needs, unless otherwise.

Objectives of examination
To screen the woman for any existing
abnormalities or high risk factors.
To have a baseline data for follow up visits.
Types
General examination
Specific examination

General examination
a. OBSERVATIONS
• Vital signs,
• Weight- as baseline. Total weight gain is
12.5kg. In the first 20weeks its about 2.5kg.
Last 20 weeks its 10kg. In the last 20weeks,
weight gain is about 0.5kg per week.

• Height- If less than 150cm and shoe size of
less than 4.
• Woman’s movement, gait, facial expressions
and general cleanliness, Stature.

Specific examination
b. Head to Toe examination
• General Appearance.
• Head: Texture of the hair, colour and
distribution of hair to rule out malnutrition and
other chronic illnesses. The general hygienic
status of the hair is also assessed for
appropriate individual education. The scalp is
also assessed for rush and nits to rule out
infections and Pediculi infestations.

Eyes: Check for abnormalities like discharges to
rule out infection, yellow pigmentation of sclera
which may indicate jaundice, pale conjunctiva
which may indicate anaemia, oedema of the
eyelids and surrounding areas may indicate
hypertensive disorder such as pre-eclampsia and
renal condition.

Nose: It is assess for blockage, discharges,
bleeding, growths or polyps.
Mouth: Examined for signs of anaemia on the
lips, mucus membranes of the mouth, gums and
the tongue. Fissures on the tongue, oral thrush
or sores may indicate lowered immunity due to
other medical condition such as HIV if present.

Dental status: Check for dental carries, if
present give appropriate education.
Ears: They are examined for any discharge,
growths and enlargement of peri-auricular
lymph nodes which may indicate infection.

Glands: Palpate for lymphadenopathy behind
the ears, under the jaw (submandibular),
cervical glands around the neck and thyroid
gland. Lymphadenopathy suggests infection,
chronic illness or may be due to the effect of
oestrogen on the glands.

Neck: Enlargement of the cervical and
submandibular lymphnodes. Enlargement of the
thyroid gland.
Upper limbs: Examine the hands for hygiene,
signs of anaemia on the palms, poor venous
return on pressure of the nail bed and examine
for signs of knuckle oedema by asking the
woman to make a fist

A feeling of tightness in the knuckles when
undoing the fist in absence of pitting oedema
would suggest occult oedema. At times
tightness of the wedding ring will also suggest
occult oedema.
Symmetry: The disability of the upper limbs is
also assessed. It has no obstetric importance but
it would affect the mother during breast feeding
or care of the baby.

Breast examination- It comprises of inspection
and palpation of the breast:
Inspection- is done to note differences in shape
and size, skin dimpling, sores and rash of both
breast to rule out infection and breast cancer.

The signs of pregnancy are also observed such
as Montgomery’s tubercles at 12weeks and
darkening of the primary and the secondary
areola at 8 and 16weeks respectively.
Inspection for orange peel appearance may be
indicative of the breast cancer.

Nipples are also inspected for flatness,
depression or inversion which may cause
challenges in breast feeding. Therefore
appropriate intervention should be done for
instance pulling of the nipples.

Palpation - Lumps or tenderness are noted to
rule out infection and cancer of the breasts. The
findings are explained and what needs to be
done. Assess the axillary lymph nodes for
enlargement. The woman is also taught how to
perform a self breast examination.

Abdominal examination
• The abdominal examination determines the
relationship between the foetus and the uterus
and the pelvis.
• Aims of abdominal examinations
• To confirm pregnancy.
• To assess presentation and the lie of the foetus.
• To assess the foetal well being.

The abdominal examination is divided into 4 parts: Inspection,
HOF or Symhysio-height, palpation and auscultation
Inspection
On inspection the size of the abdomen in relation to the
gestation age and shape of the abdomen is noted to ascertain
the lie of the foetus. An ovoid shaped abdomen denotes a
longitudinal lie while a wider than its length shape abdomen
indicates a transverse lie. Abdominal scars involving the
operation to the uterus are noted to rule out risk of uterine
rupture and adhesion.
Signs of pregnancy such as darkening of linear nigra, presence
of striae gravidarum and foetal movements are noted. Foetal
movements are positive signs of pregnancy.

HEIGHT OF FUNDUS OR SYMPHYSIO-HEIGHT
If using finger breadth, the pregnant abdomen is
measured from the center of the abdomen
hence the name HOF. But if using the tape
measure, the pregnant abdomen is measured
from the Symphysis pubis hence the name
Symphysio-height (SOH). On the other hand if
pregnancy is below the umbilicus use the land
marks.

Palpation
Palpation uses the landmarks on the symphysis
pubis, umbilicus and the xiphisternum.
Palpation comprises of fundal, lateral and pelvic
palpation. The presence of uterine contractions
indicates labour.

Height of fundus(HOF): This is done to estimate
the period of gestation by measuring the height
of the abdomen by using finger widths in 2nd
and 3rd trimester. It is done to assess the height
of fundus in relation to the gestation of the
pregnancy.

Number of centimeters should be approximately
equal to the number of weeks of gestation after
22nd -24th weeks gestation.
1 finger= 2 weeks/ 2 centimeters after 22 weeks.
Palpation has four aspects: fundal, two lateral
and pelvic palpation.
Fundal palpation, noting size, shape, consistence
and mobility of what is in the fundus.

Lateral palpation is done to determine where
the back is, which helps in determine the Lie and
position of fetus after 26 weeks of gestation.
Pelvic palpation is done to determine
presentation and engagement (3rd trimester).
Lastly you do auscultation (late 2nd and 3rd
trimester). This is done to assess fetal wellbeing
by using fetal scope or Doppler.

Normal fetal heart is 120-160bpm or new World
Health Organization Guideline is 110 to 180
bpm. The fetal heart sounds are heard at their
maximum or loudest at the point over the fetal
back. They sound like a tickling watch under the
pillow.

Before the 12th week of pregnancy the uterus
remains a pelvic organ. After this period of
gestation the fundus can be palpated above the
symphysis pubis. From 12-20weeks gestation
the fundus rises two finger’s breadth every 2
weeks. After 20 weeks the fundus rises about
one finger’s breadth every 2 weeks (Sellers,
2009).

Approximate height of fundus at various weeks
of pregnancy.
THE LAND MARKS (Bartholomew’s Rule).
12 weeks : just above the symphysis
16 weeks: half-way between the upper border
of the symphysis pubis and the lower border of
the umbilicus. Quickening or foetal movements
can now be felt by the

mother. The Uterine soufflé, the sound of the maternal blood
coursing through the large uterine vessels can be heard on
auscultation.
20 weeks: At the lower border of the umbilicus. The foetal
parts and foetal movements can be felt on palpation.
22 weeks: At the centre of the umbilicus
24 weeks: At the upper border of the umbilicus
30 weeks: half-way between the upper border of the
umbilicus and the lower border of the xiphisternum.
36 weeks: the lower border of the xiphisternum.
38 weeks to the onset of labour:

This time the uterine ligaments and the pelvic
viscera become more vascular and soften. The
cervix ripens and there is partial effacement of the
cervical canal, causing the presenting part to
descend and may even pass through the pelvic brim
into pelvic cavity. This will then cause the height of
fundus to drop about 2 finger’s breadth and to
reduce to the level of about 32-34weeks.This is
known as lightening. It usually takes place in the
primegravida but may occur in the multigravida
with tight abdominal muscles (Seller, 2009).

Using a tape (McDonald’s method), the height of
fundus is also measured then the duration of
gestation in weeks should correspond to cms
with a maximum difference of 2 weeks/cms.
Fundal palpation: Palpate shape, size,
consistency and mobility. The foetal breech will
feel irregular, larger or bulkier than the head and
is not well outlined or readily moved or balloted

If it’s the head presenting, it feels round and hard
and can be balloted between the hands or the
thumb and finger of one hand. Palpate for the
shape, size, consistency and mobility of the foetal
head.
Lateral palpation is done to determine the position
of the back and the limbs of the foetus. The foetal
back feels like a firm, curved, continuous smooth
mass extending from the breech to the neck

The front will have feet, hands, knees and the
elbows felt as being small, knobby and irregular and
mobile on pressure.
Pelvic palpation -determines the part of the foetus
that is presenting at the pelvic brim. If it’s the head
presenting, it feels round and hard and can be
balloted between the hands or the thumb and
finger of one hand. Palpating for the shape, size,
consistency and mobility of the foetal head helps to
rule out cephalo pelvic disproportion.

It can also determine if the head has descended
into the maternal pelvis. This is calculated in fifths
of the foetal head above the pelvic brim. From 36
weeks lightening takes place due to softening of the
cervix.
Engagement of the foetal head is also determined
to rule out cephalo pelvic disproportion, this usually
occurs in prime gravidae while in multiparous
women engagement occurs when in labour.

Auscultation: Foetal heart sounds are assessed
for foetal viability .This is done from the side
where the foetal back was felt. The normal
ranges between 120 -160 beats per minute or
the new according to WHO is 110 to 180bpm.
The foetal heart beat must be regular and of
good volume.

Lower limbs– Inspect the symmetry of the
limbs. The shoe size if less than four may
indicate a small pelvis. The soles and the feet
are inspected for pallor to rule out anaemia.
Calf's are palpated to rule out deep vein
thrombosis.

Tibial and pedal oedema is assessed by applying
pressure. The woman is asked if she experiences
the oedema which disappears in the morning
after a good rest.

This will help to rule out the oedema associated
with raised blood pressure and proteinuria,
which is pathological. If the oedema is coupled
with proteinuria, the woman should be refered
to the Obstetrician for further examination and
management.

The Vulva
On Inspection: warts, sores, oedema, varicose
veins, abnormal discharge etc.
Anal region
Check for haemorrhoids and fissures, fistulae,
rectocele etc

The Back
Ask the woman to lie on her left side. Check for
the curvature, lordosis, scoliosis, kyphosis, sacral
oedema.
PROBLEMS IDENTIFIED
From history taking, physical examination and
observations.

PLAN OF ACTION
1. To do investigations
2. To give medication
3. To give IEC
4. To refer client to the hospital etc.

INVESTIGATIONS DONE
-RPR
-FBC
-Grouping and cross-match
-HIV testing. Done after counselling.

MEDICATION GIVEN
e.g
-Ferrous sulphate and rationale
-Fansida and rationale
-Folic acid and rationale
-Mebendazole and rationale
-Septrin and rationale

IEC given: This should be individualized to the
woman’s needs at each visit and will depend on the
woman’s medical, surgical , obstetric history and
any other concern. Health messages and counselling
should include guidance on the following topics:
Birth plan/preparedness, hygiene, nutrition,
medication, use of ITN, danger signs, minor
disorders, signs of labour, exclusive breast feeding,
family planning etc.
Review date.

INVESTIGATIONS
• Haemoglobin level estimation is done
to rule out anaemia at booking and
repeated at 28-32 weeks when the
physiological effects of haemodilution
are marked. Normal values are
10.5g/dl to 16g/dl (Fraser et al, 2006).

INVESTIGATIONS cont’
• Urinalysis is done to rule out urinary tract
infections, diabetes mellitus and hypertensive
disorders such as pre- eclampsia.
• Test for HIV infection.
• Rapid Plasma Reagin (RPR) is also done to
rule out syphilis.
• Rhesus factor is also done

MEDICATION
• The following medication may be given:
• Fansida 1 is given at 16 weeks or when
quickening has occurred, then after 1 month
give SP2, and 3rd SP to be given 1 month after
SP2 to prevent malaria (IPT).
• Ferrous sulphate 200mg od and folic acid 5mg
od will be given to boost the haemoglobin
levels. Dose for Feso4 can be increased if Hb
is less than 10.5g/dl.

• Tetanus toxoid to prevent the mother and the
baby from tetanus.
• Mebendazole 500mg p.o start is given
together with SP1 (after quickening) to
prevent worm infestation and malaria.

MEDICATION cont’
In HIV positive women the following regime
is given:
• A woman who is HIV positive, regardless of
the CD4 count, is started on Option B+.
• If the CD4 is below 350cells/mm3 the woman
will also receive Septrin until the CD4 is above
350cells/mm3.

BIRTH PREPAREDNESS AND
COMPLICATION READINESS
• It allows for time to develop a birth plan
which includes making arrangements for
normal childbirth, such as:
• Skilled provider to attend the birth.
• Place of birth
• Transportation of the pregnant woman to the
skilled provider.

BIRTH PREPAREDNESS AND
COMPLICATION READINESS
• Funds
• Support person or birth companion.
• Items needed for a clean and safe birth and for
the newborn.

DANGER SIGNS IN PREGNANCY
• Vaginal bleeding
• Severe headache
• Fever
• Severe abdominal pains
• Reduced and caesation of foetal movements.
• Discharge or sores on the private part,
• Fatigue and pallor.

HEALTH PROMOTION AND
COUNSELLING
• Information on the following topics is
discussed:
• Importance of subsequent antenatal visits.
• Preparing a birth plan.
• Common (minor) disorders of pregnancy.
• Recognizing danger signs in pregnancy and
during childbirth.

HEALTH PROMOTION cont’
• Mother –To Child –Transmission of HIV
• Nutrition during pregnancy
• Exercise and rest
• Childbirth
• Infant nutrition including breastfeeding
and replacement feeding
• Postnatal care

• Newborn care (according to individual needs)
• Immunization and other preventive measures
from conditions that can adversely affect the
women and newborn.
• Prevention malaria using insecticide treated
mosquitoes nets and Intermittent preventive
treatment (IPT) of malaria.
• Personal hygiene.
• Family planning
HEALTH PROMOTION cont’

COUNSELLING
• Techniques for successful breastfeeding
(according to individual need).
• Counselling on HIV and other sexually
transmitted diseases is done and the use of
condoms for disease prevention is done.
• Availability of testing services and their
benefits and specific issues related to mother-
to-child transmission and living with HIV
(after a positive test result) is also explained.

ACTIVITIES DURING ANTENATAL VISIT
1. ORIENTATION: Orient mothers on the activities of the
clinic or hospital in terms of services offered e.g delivery
services, theatre, blood transfusion days of antenatal
Booking and revisits etc.
2. HEALTH EDUCATION: Educate mothers on importance of
antenatal clinic, birth preparedness, minor disorders of
pregnancy, danger signs during pregnancy, complications
during pregnancy, nutrition, hygiene & infection
prevention, medication, signs of labour, mother & baby
layette etc
3. GROUP AND INDIVIDUAL COUNSELLING: Do a group
counselling on HIV/AIDS and finally conduct an individual
or couple counselling and observe privacy and
confidentiality. Educate that this test is mandatory.

ACTIVITIES DURING ANTENATAL VISIT
4. INVESTIGATIONS: Do Blood pressure, height, weight, history taking,
physical examination, malaria test, syphilis test (Rapid Plasma Reagen), Full
bood count, Blood group and Rhesus factor, gravidex, pelvic ultrasound scan,
HIV test and if HIV positive do CD4 and CD8 count, viral load, Creatinine, Liver
function tests, urea and electrolytes etc.
5. HISTORY TAKING: Conduct thorough history on First visit (Booking) and a
confirmatory on the subsequent visits. Collect Social, medical ( personal &
family), Surgical, Present Obstetrical and Past Obstetrical history
6. PHYSICAL EXAMINATION: Do a full physical examination on the first
(Booking) visit and a Short Palpation on the subsequent visits. Do Head to Toe
examination.
7. DRUGS AND OTHER SUPPLEMENTS: Give prophylactic medication against
malaria and worm infestation as required or guided. Give haematinics as well.
Prescribe and give antibiotics if having any bacterial infection. if HIV positive
commence or continue with ARV’s.

Conclusion
• Quality management of pregnancy is essential
to pregnant women as it ensures early
detection and management of complications,
disease prevention, birth preparedness and
complication readiness and health promotion.

Conclusion.
• Antenatal services should be available and
acceptable to all mothers regardless of status
in society. It is therefore important to
encourage women to seek professional health
care as soon as they are pregnant to ensure
good health.

REFERENCE
• Central Statistical Office (CSO) Zambia and
Macro international Inc (2009) Zambia
Demographic and Health Survey (ZDHS)
Key Findings (2007), Lusaka, Zambia.
• Fraser M.D, Cooper M.A and Nolte A.G.W
(2006) Myles Text book for midwives,
African edition, Elsevier. Philadelphia.

References cont’
• Fraser M.D and Cooper M.A (2003) Myles
Text book for midwives, 14 edition, Elsevier,
Philadelphia.
• Ministry of Health, Integrated prevention of
Mother-to-Child Transmission of HIV (2010)
National protocol Guide lines, Lusaka Zambia.
• Ministry of Health, Introduction to Focused
Antenatal Care (2004) Lusaka, Zambia.

REFERENCE cont’
• Sellers P.M (2010) Midwifery volume 1, 12th
impression, Juta and Co limited, Lansdowne.

ANTENATAL CARE.pptx

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