antenatal care

Antenatal Care

Asheber Gaym M.D. January 2009

Asheber Gaym, 2009 2

Outline

• Describe the objectives of antenatal care• Discuss different models of antenatal care• Describe activities of antenatal care • Detail essential diagnostic work-up during

antenatal care• Outline ANC fetal well being assessment

strategies • Discuss health interventions during ANC


Objectives of Antenatal Care

• Antenatal care refers to the health care provided to a pregnant woman throughout pregnancy until labor.

• Basically a screening program intended to detect complications early; provide health education and implement effective health promotive and preventive interventions

• Objectives– Overall- reduce maternal and perinatal morbidity and mortality – Timely detection and management of complications – Ensure the birth of a healthy child – Ensure the health of the mother – Provide essential health education to the mother including

information on the danger signs of pregnancy


Models of Antenatal Care Provision

• Traditional ANC model(s)– Began two hundred years ago and instituted programs and

interventions that were traditionally thought to benefit the mother and her fetus

– Activities were not scientifically tested as to their effectiveness or benefit

– Followed a visit pattern of 4 weeks until 28th week; then every 2 weeks until 36th week and a weekly visit with many interventions at each visit

– Led to upto 14 visits and cost incurred for many investigations that were not necessarily warranted

– It has recently been suggested that the traditional ANC practice be replaced by new models of focused ANC programs


Models of ANC – Continued

• Focused ANC- also called “new” or “WHO” models – Followed large randomized multicenter trials between

the traditional and focused ANC programs that identified evidence based interventions and visit patterns that benefited mothers and their fetus and were cost effective as well

– Suggested four routine visits only at different gestations with a few evidence based diagnostic and intervention modalities performed at each visit

– Visits were at 16,28,32 and 36 weeks – Additional visits were individualized on an individual basis


Focused ANC Program Activities Visit First Visit Second visit Third visit Fourth visit

Gestational age

<16 weeks 28 weeks 32 weeks 38 weeks

Activities •Classification to either the basic or specialized component •Clinical exam•Hgb test •Gestational age determination•Blood pressure •Weight/Height •Syphilis/STIs•Urinalysis•ABO/RH•TT administration•Iron supplementation•Document on ANC card

•Clinical exam for anemia•Gestational age; FH; FHB exam•Blood pressure•Weight- only if underweight at initial visit •Urinalysis- for nullipara or previous preeclampsia•Iron supplement•Complete on ANC card

•Hgb test •TT second dose •Instructions for birth planned •Recommendations for lactation/contraception •Document on ANC card

•Examine for breech presentation•Document on ANC card


Visits of Antenatal Care – Objectives

• Initial visit – – Detailed evaluation through history, physical exam and

laboratory work-up as required – Based on the results further work up and a program of care

is planned on individual basis – Maternal or fetal factors that may require special care for

the specific mother are identified and noted • Subsequent visits- – Are conducted based on the plans made at initial visit– Newly developing situations during follow up are also noted

and management plans modified accordingly


Initial visit- History

• Present pregnancy-– Accurate dating of gestational age– Any symptoms – minor or major complaints – Fetal movement perception – ANC details – investigations and interventions if the mother is referred from other

facilities – Presence of any of the danger signs

• Past obstetric history – Details of any obstetric complications in previous pregnancies

• Family history – Any familial medical conditions – Family history of congenital anomalies; multifetal gestations and hypertensive disorders

of pregnancy • Personal history

– History of medical illnesses – History of smoking, alcohol intake and habitual drugs use


Initial visit- Physical Exam

• Vital signs and anthropometry (weight and height)• Detailed physical exam for medical or surgical illnesses • Abdominal exam –objectives

– Fundal height by symphysis-fundal height measurement by the tape method– 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 34th week• Pelvic examination - objectives

– For uterine size measurement if gestation is less than 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


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

• 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


Diagnostic work-up during antenatal careDiagnostic 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 visit


Assurance of fetal well being at ANC- Strategies

• 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 (specific timing

of follow up initiation depends on the individual risk profile concerned) – Non stress test– Contraction stress test – Fetal biophysical profile score – Doppler ultrasound velocimetry

• Ultrasonographic fetal scan for anomalies


Health Interventions during ANC

• Health education – topics– Prompt reporting of danger signs of pregnancy – Balanced diet – Labor and delivery preparation – Basics of family planning, child rearing and

immunization • Iron supplementation • Psychological support

antenatal care

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