ANTENATAL CARE
DR. Fardowso Dahir Warsame
MMED OBGYN/Reg:2022-08-11029
Tutorial with HOD DR IRENE
Definition
• Systematic supervision (examination and advice) of a woman during
pregnancy is called antenatal (prenatal) care.
• It is actually the care in continuum that starts before pregnancy and
continues to delivery and after.
• It can also the be defined as the routine health evaluation of
presumably healthy, pregnant women without symptoms
(screening), in order to diagnose diseases or complicating obstetric
conditions, and to provide information about lifestyle, pregnancy and
delivery.
Problem
• Globally, 529,000 deaths occur annually, with 99% occurring in sub-Saharan
Africa.
• Uganda, has a typically high neonatal and maternal morbidity and
mortality statistics:
• Maternal mortality ratio: 435: 100,000 live births
• Neonatal mortality ratio:29:1000 live births
• Most women in Uganda record late ANC attendance, averaging 5.5 months
at date of first visit.
• Rural women are 2X LESS LIKELY to attend ANC than Urban women
• Globally, developing countries face challenge of poorly implemented ANC
programs.
Aims of Antenatal care
• To screen “high risk” patients
• To prevent, detect and treat complications at the earliest opportunity
• To provide ongoing risk assessment and provide primary preventative
health care
• To educate mother on the physiology of pregnancy and labor
• To create a birth plan: place, time, mode of delivery. Decisions may
also be made on specific doctors/nurses to be involved.
• To provide advice on Family planning, spacing and safe sex practices.
Objective
• To ensure a normal pregnancy and deliver a
healthy baby from a healthy mother.
HOW TO ACHIEVE THESE AIMS AND
OBJECTIVES
• Through timely and appropriate, evidence-based actions related to
health promotion, disease prevention, screening, and treatment
• These act to:
• Reduce complications to the mother arising from pregnancy and childbirth
• Reduce stillbirths and perinatal deaths
• Provide integrated care throughout delivery
What do Women Want?
• A POSITIVE EXPERIENCE FROM ANC!!
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A healthy pregnancy for the mother and baby: screening, prevention and rx
physical and sociocultural normality during pregnancy
Effective transition to positive labor and birth
Positive motherhood, including maternal self esteem, competence and
autonomy
All this is achieved by proper medical care, timely information and good
emotional support/advice.
NEW: ANC models with a minimum of eight contacts are recommended to reduce
perinatal mortality and improve women’s experience of care.
WHY THE CHANGE?
• Evidence suggesting increased perinatal deaths in 4-visit ANC model
• Evidence supporting improved safety during pregnancy through increased
frequency of maternal and fetal assessment to detect complications
• Evidence supporting improved health system communication and support
around pregnancy for women and families
• Evidence indicating that more contact between pregnant women and respectful,
knowledgeable health care workers is more likely to lead to a positive pregnancy
experience
• Evidence from HIC studies indicating no important differences in maternal and
perinatal health outcomes between ANC models that included at least eight
contacts and ANC models that included 11 to 15 contacts.
FIRST VISIT
• Recommended during first trimester (up to 12 weeks)
• Preferably accompanied by husband or caregiver
• Aims:
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Assess health status of the mother and fetus
To calculate fetal gestational age
To obtain baseline investigations
To organize for continued obstetric care and risk asssesment
FIRST VISIT: ACTIVITIES
• History taking: see KIU chart
• Physical Exam (general):
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Height ,Weight ,MUAC
Blood pressure
Pallor, jaundice, neck swelling(thyroid enlarges in 50% of pregnancies)
Oedema: Medial malleolus and anterior lower third of tibia
• Physiological due to pressure of the uterus on pelvic veins
• Pathological due to pre-eclampsia, anaemia, hypoproteinemia, nephrotic syndrome or
cardiac failure
FIRST VISIT: ACTIVITIES
• Abdominal exam: previous scars, distention ,skin changes in
pregnancy, leopolds manouvres, FHR, epigastric/ lower
abdominal/iliac tenderness.
• Systemic exam: necessary to rule out any other illnesses
FIRST VISIT: investigations
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CBC
RPR
BLOOD GROUP AND Rh factor
Malaria: slide for MPs or MRDT
HIV: determine used at our facility
Urinalysis:
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strip; proteins, glucose, nitrites and leucocytes
Microscopy: pus cells, casts etc
• Hepatitis B surface antigen in some facilities
• Obstetric ultrasound: the WHO recommends one ultrasound before 24 weeks (early gestation) for dating.
However, stakeholders may consider a later ultrasound scan to identify the number of fetuses, fetal
presentation, and placental location if an early ultrasound scan has not been performed.
• If husband is accompanying woman, then a HIV test, RPR, blood group +RH factor are done.
First Visit: Primary prevention
• Issue of insecticide-treated mosquito net
• Intermittent preventive therapy for malaria (if past 1st trimester): 3
tabs of SP given at least one month apart. Aim is at least 3 doses.
• TT first dose: two doses in pregnancy at least 1 month apart. 2nd given
at least 2 weeks to delivery
• Provide daily oral iron and folic acid supplementation with 30 to 60
mg of elemental iron and 400 μg (0.4 mg) of folic acid to prevent
maternal anemia, puerperal sepsis, low birth weight, preterm birth.
• Anthelminthic treatment if past the first trimester: mebendazole.
NUTRITIONAL ADVICE TO MOTHER: Recommended in all settings
• In poor resource countries, malnutrition is common and associated with
poor pregnancy outcomes. So is obesity/being overweight
• A healthy diet provides energy, protein, vitamins, and minerals, obtained
from a variety of foods.
• A healthy diet includes green and orange vegetables, meat, fish, beans,
nuts, whole grains, and fruit.
• Normal gestational weight gain occurs after 20 weeks gestation.
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Underweight
Normal
Overweight
Obese
(BMI <18.5)
(BMI 18.5-24.9)
(BMI 25-29.9)
(BMI>30)
12.5 to 18kg
11.5 -16kg
7-11kg
5-9kg
OTHER WHO RECOMMENDATIONS:ALL SETTINGS
• That each pregnant woman carries her own case notes during pregnancy
to improve continuity, quality of care, and pregnancy experience.
• Task shifting the promotion of health-related behaviors for maternal and
newborn health to a broad range of cadres.
• Task shifting the distribution of recommended nutritional supplements and
(IPTp)to a broad range of cadres.
• Ask about tobacco and alcohol and other substances use as early as
possible in pregnancy and be ready to provide intervention
• Provide a seven day antibiotic regimen for pregnant women with
asymptomatic bacteriuria (ASB) to prevent persistent bacteriuria, preterm
birth, and low birth weight.
Danger signs
• Headache, blurred vision, epigastric pain
• Gush of fluid PV
• Any vaginal bleeding however slight
• LAP increasing in frequency and intensity, radiating to the back
• Loss or reduction of fetal movement.
Common problems and their management
• Nausea and vomiting: chamomile, ginger, dry toast/biscuits in the morning. High protein
foods good. Fatty food and other triggers avoided. Frequent small meals helpful.
• Heartburn: due to relaxation of LES and hiatus hernia. Advice on dietary changes, eating
early before going to sleep and semi reclining position during sleep. Liquid antacids may
be helpful.
• Leg cramps: may be due to lack of diffusible calcium or increase in serum phosphorous:
Ca2+ supplementation, massage may be useful
• Lower back pain: massage, painkillers, exercise, rest, well-fitted pelvic girldles, better
posture and avoiding high heels
• Constipation: high fibre diet, milk, fluids, activity. If unsuccessful give stool softeners
• Varicose veins/edema: elevation of the limbs, crepe bandage for varicosities, stool
softeners/replacement for hemorrhoids. Avoid specific treatment. Improve markedly on
delivery. No diuretics.
• Vaginal discharge: advice on hygiene, local clotrimazole.
• THANK YOU FOR LISTENING
REFERENCES
• https://www.ncbi.nlm.nih.gov/books/NBK32799/table/summary.t1/?report=
objectonly.
• DC Dutta’s textbook of obstetrics, 7th edition
• World Health Organization Recommendations on Antenatal Care for a Positive
Pregnancy experience: January 2018 summary