This document provides guidance on antenatal care. It discusses the importance of preconception care, screening and risk assessment during pregnancy, and the essential components of antenatal visits. The goals of antenatal care are to ensure the best outcomes for women and babies by screening for problems, assessing risk, treating issues, providing medications and information. Key aspects covered include taking a medical history, conducting physical exams, estimating gestation, performing essential screening tests, discussing medications and vaccines, creating a management plan, and covering topics for subsequent routine prenatal visits.

1. ANTENATAL CARE
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. Intro
• Antenatal care attempts to ensure, by antenatal preparation, the best
possible pregnancy outcome for women and their babies.
• This can be achieved by:
• Screening for pregnancy problems
• Assessment of pregnancy risk
• Treatment of problems that may arise during the antenatal period
• Giving medications that may improve pregnancy outcome
• Provision of information to pregnant women

3. PRECONCEPTION CARE
• This is the optimisation of a woman’s health or knowledge before she
plans or conceives a pregnancy.
• All health workers who care for women in the reproductive age group
need to consider the possible effect of pregnancy on women.
• If pregnancy is not desired, appropriate counselling and advice on
contraception may be offered.

4. PRECONCEPTION CARE
The following considerations will assist in preparing:
• The presence of any medical conditions controlled or uncontrolled
• If HIV positive consider viral load values
• Medication or radiation needed
• Family history and genetic risks,
• Possible occupational and environmental exposures
• Use of tobacco, alcohol, cocaine and other recreational drugs
• Social, economic and family issues (include paternal involvement)
• The past obstetric history, nutritional issues, e.g. under weight or obesity
• Immunity to rubella by previous exposure or vaccination
• Mental health issues
• The value of peri-conceptual folate

5. RISK FOR GENETIC DISEASE AND
TERATOGENICITY
Red alert for health worker if following exposures have occurred:
• Mother over age 35 years
• Alcohol and recreational drug, traditional substances and smoking
• Parents closely related
• Family history of genetic disorders
• Medical conditions in pregnancy (e.g. diabetes, epilepsy) - especially if
poorly controlled
• Teratogenic medications during pregnancy
• Maternal infections, e.g. rubella and syphilis, during pregnancy

6. THE MATERNITY CASE RECORD
• All pregnant women that present to a healthcare facility, should have,
or should receive, the latest version of the Maternity Case Record
(MCR)
• This standardised national document is the principal record of the
pregnancy, and it must be completed at each antenatal clinic visit and
retained by the mother until delivery, after which it will be kept at the
place of confinement or final referral.
• Only a record of attendance, with results of special investigations,
needs to be kept at the antenatal clinic for audit and backup
purposes.
• The MCR serves as official communication tool between the different
levels of care and health facilities

7. THE FIRST ANTENATAL VISIT
• A woman should visit her healthcare provider as soon as she suspects
pregnancy, even as early as the first missed menstrual period.
• Urine pregnancy tests must be available at all healthcare facilities.
• Women who present to primary care clinics and are found to be
pregnant must be issued with a MCR and receive the first visit
• Those who request termination of pregnancy should be appropriately
counselled and referred

8. HISTORY TAKING
Take a full and relevant history including:
• Current pregnancy
• Previous pregnancies, any complications and outcomes
• Medical conditions and previous operations
• Familial and genetic disorders
• Allergies
• Use of medications
• Use of alcohol, tobacco and other substances
• Family and social circumstances
• Experience of violence

9. PHYSICAL EXAMINATION
• Ask permission to do a physical examination. Ensure privacy.
• Do a general examination including weight, height, heart rate, colour
of mucous membranes, blood pressure, a check for oedema, and
palpation for lymph nodes.
• Do a systemic examination including teeth and gums, breasts, thyroid,
and heart and lungs.
• Examine the pregnancy including inspection and palpation of the
pregnant uterus; with measurement of the symphysis-fundal height
(SFH) in centimetres

10. MID-UPPER ARM CIRCUMFERENCE
• The MUAC gives useful information on nutritional status and
pregnancy risk and is easily done
• MUAC is advantageous over body mass index because height does
not need to be measured, accurate scales are not required, the
woman does not have to stand up straight, no calculations need be
done, and MUAC, unlike weight, does not normally increase
significantly during pregnancy.
• A MUAC ≥33 cm: suggests obesity
• A MUAC <23 cm: suggests malnutrition or a chronic wasting illness

11. ESTIMATION OF GESTATIONAL AGE
• The first estimation of gestational age, should be used for the
remainder of the pregnancy and must not be changed unless
important new information becomes available.
• Last menstrual period: This is valid if the woman is sure of her dates,
and where SFH measurement is compatible with the given dates
• Symphysis-fundal height (SFH): This is used for estimation of
gestational age after 24 weeks if the dates from the last menstrual
period are unknown or wrong, in the presence of a normal singleton
pregnancy
• Ultrasound: Requested for women who are unsure of dates with SFH
measurement less than 24 cm.

12. ESSENTIAL SCREENING
• HIV serology, using rapid test kits (routine counselling and voluntary
testing).
• TB screening at each antenatal visit.
• Syphilis serology: Rapid tests are preferable, as results are immediately
available.
• Rhesus (D) blood group, using a rapid test.
• Haemoglobin (Hb) level, using a portable haemoglobinometer or copper
sulphate screening method. Repeat Hb measurements at 30 and 38 weeks
of gestational age.
• Urine dipstick testing for protein and glucose at each antenatal visit.
• Mental health screen

13. SCREENING TESTS THAT ARE NOT OFFERED
ROUTINELY
Indicated in some circumstances:
• ABO blood group
• Screening for Down’s syndrome
• Rubella serology
• Blood glucose screening
• Cervical (Papanicolaou) smear
• Urine culture
• Ultrasound scan

14. MEDICATIONS AND VACCINES
• Ferrous sulphate tablets 200 mg daily, to prevent anaemia
• Calcium tablets 1000 mg daily, to prevent complications of pre-
eclampsia (e.g. calcium carbonate (168 mg) two tablets orally, three
times daily with food. This is best taken four hours before or after iron
supplements.
• Folic acid tablets five milligram daily
• Covid-19 vaccine
• Influenza vaccine
• Tetanus toxoid (TT) immunisation, to prevent neonatal tetanus

15. MANAGEMENT PLAN
The final assessment should include:
• Check-list for risk factors (use the ‘BANC Plus Clinic Checklist)
• A best estimate of gestational age
• A plan for management or appropriate referral for any problems

16. INFORMATION FOR PREGNANT WOMEN
• Five danger signs and symptoms of pregnancy
• Self-care in pregnancy
• A delivery plan
• Newborn and infant care

17. SUBSEQUENT ANTENATAL VISITS
• A Basic Antenatal Care plus schedule of 7 follow-up visits (8 visits in
total) is provided for women without any risk factors.
• Following the early booking visit (preferably <12 weeks), return visits
should be scheduled for 20, 26, 30, 34, 36,38 and 40 weeks, and 41
weeks if still pregnant by then
• This is not applicable for women with risk factors or who develop a
risk factor during pregnancy.

18. CONTENT OF SUBSEQUENT ANTENATAL
VISITS
• Ask about general well-being, fetal movements, danger symptoms and any
problems.
• Check the blood pressure, heart rate and colour of the mucous
membranes.
• Measure the symphysis-fundal height (SFH) in cm. Plot the SFH
• Palpate the presenting part from 34 weeks
• Test the urine for protein and glucose at each visit.
• Repeat syphilis test at 34 weeks for all women who tested negative at
initial testing.
• Repeat HIV test every routine BANC+ visit for all women who tested
negative at initial testing.
• Repeat blood tests: Hb at 30 and 38 weeks

19. CONTENT OF SUBSEQUENT ANTENATAL
VISITS
• Repeat information for danger signs of pregnancy, and review delivery
and transport plans, as well as feeding and contraception choices.
• Repeat mental health screen, in second and third trimesters
• At 38 weeks, remind the woman to bring her MCR with her when she
presents to the clinic or hospital in labour.
• At 36/38 weeks, prepare person for what to bring for labour and
delivery (KMC wrap, woolen hat and booties)
• Link and arrange Ward Based Community Outreach Teams home visits

23. THANK YOU