Antenatal Care

Introduction
The provision of special care for women during pregnancy through the public health services was a relatively late development in modern obstetrics. In recognition of the potential of care during the antenatal period to improve a range of health outcomes for women and children, the World Summit for Children in 1990 adopted antenatal care as a specific goal, namely Access by all pregnant women to prenatal care,trained attendants during childbirth and referral facilities for high-risk pregnancies and obstetric emergencies. The International Conference on Population and Development in 1994, the Fourth World Conference on Women in 1995, their five-year follow-up evaluations of progress, and the United Nations General Assembly Special Session on Children in 2002 all share similar views. Source: WHO 2003, Antenatal Care in Developing Countries - Promises, Achievements and Missed Opportunities.

DIAGNOSIS OF PREGNANCY
y Symptoms y Nausea y Irritation of the breasts y Increased frequency of micturation y Amenorrhea

DIAGNOSIS OF PREGNANCY
y Signs y fullness of the breasts y Darkening of the areola y Montgomerys tubercles in the areola y Uterine enlargement before 12weeks on bimanual

examination and after 12 weeks on abdominal examination y Cervical softening and cystic, soft general feeling of uterus by 8 weeks on bimanual examination

Montgomerys tubercles

DIAGNOSIS OF PREGNANCY
y Pregnancy tests y Detects HCG in the urine or blood y Based on colour change occurring if HCG binds to

monoclonal antibody embedded in the absorbent paper y HCG alpha subunit is similar to that of TSH, FSH and LH y HCG beta subunit is immunologically specific hence the term HCG.

DIAGNOSIS OF PREGNANCY
y HCG is secreted by the synciotrophoblast of fertilised

ovum and definitive placenta y Interpretation of results: y Positive results if double band of blue or central spot of pink y Negative results if single band of blue or absence of pink spot

Pregnancy test

BOOKING VISIT
y After pregnancy has been diagnosed y Longest but most important visit y Ideally should take place between 8-12 weeks of

gestation y Womans medical state assessed to place current pregnancy into appropriate part of a risk spectrum y Baseline data obtained from history, examination and relevant investigations

HISTORY
y Date y time y name y age y parity y blood group y PC y HPC

HISTORY
y Menstrual history y First day of LNMP y Certainty of date of LNMP y Regularity of cycles(usually 28 days) y Number of days bleeding lasts y Use of oral contraception or ovulation induction

agents y Calculate EDD using Naegeles rule (add 7 days and 9 months to the first day of the LNMP) y Calculate the POG

HISTORY
y Obstetric history y Previous miscarriage and TOP- SOG, any illnesses

afterwards y Previous pregnancies dates, number, duration, medical complications of pregnancy, type of delivery, complications of labour, features of the baby

HISTORY
y Medical history y Illnesses and operations of the past especially those

that will require continuation of treatment during pregnancy. Eg. Diabetes, epilepsy y Drug history y Medications taken during pregnancy

HISTORY
y Family history y Conditions among first degree relatives that may be

y y y y y

reflected in current pregnancy. Eg. Diabetes, twinning Social history Social class Race of woman Smoking and alcohol consumption Occupation of woman and her partner

EXAMINATION
Brief general examination Height correlates loosely with pelvic size Weight Clinical presence of anemia (mucuous membranes) Dental inspection Thyroid gland Auscultation of heart and lungs BP, pulse rate State of hydration breasts Spine for kyphosis and scoliosis, which might affect pelvic development y Legs for edema and varicose veins
y y y y y y y y y y y

EXAMINATION
y Speculum examination note condition of cervix

and presence of any vaginal discharge y Bimanual examination o Assess adequacy of the pelvis o Search for ovarian tumors or uterine fibroids o To determine whether uterine size corresponds with gestational age

INVESTIGATIONS
y Full blood count y Sickle cell test and hemoglobin electrophoresis y ABO blood group and rhesus type y VDRL y Other hematological tests rubella antibodies, HIV

and hepatitis screening, antibodies against Dantigen in rhesus negative women and glucose screen

INVESTIGATIONS
y Urinalysis proteinuria, glycosuria, ketonuria y Mid-stream urine collection for microscopy, culture

and sensitivity if indicated

RISK ASSESSMENT
y Maternal age teenage or advanced maternal age y Parity primigravida or grandmultiparity y Uncertain gestation y Previous obstetric problems  medical disorders of pregnancy  Preterm deliveries  IUGR  Fetal anomalies  Caesarean section  Perinatal loss

FURTHER ANTENATAL VISITS

y General state of health y Minor complaints y Abdominal pain y Vaginal bleeding y BP y Urinalysis y Weight gain y Uterine size - SFH

FURTHER ANTENATAL VISITS

y Haematinics prescribed from 16 weeks gestation

(folic acid, iron supplements, calcitrate) y Fetal monitoring with daily fetal kick charts and the non-stress test y Repeat FBC and antibody screen at 28 weeks y Rhesus negative mothers receive routine antenatal anti-D prophylaxis at 28 and 34 weeks gestation

FURTHER ANTENATAL VISITS

y Determine presentation and lie of fetus, and assess

liquor volume in 3rd trimester y Assess engagement of head in late 3rd trimester y Plan the mode and time of delivery

EXAMINATION
y Abdominal examination y Inspection y Scars of previous operations laparoscopy scars below y y y y y y

umbilicus and pfannenstiels incision above pubis Striae gravidarum Linea nigra Distension Umbilicus Hair distribution Fetal movement

PFANNENSTIELS INCISION

EXAMINATION
y Palpation y Ask if pain any where y Soft palpation to feel for any unusual masses, tenderness or

tenseness, rebound tenderness and guarding y Leopolds manuveur

 facing patient, place both hands laterally on abdomen towards

fundus of uterus. Measure height of the fundus from symphysis pubis from 20 weeks the SFH can be obtained. against one side while the finger tips of the other hand are used to feel for irregularly shaped parts or a smooth persistent regular surface

 lower hands on sides of the abdomen, holding one hand firmly

EXAMINATION
 place thumb and first two fingers of the right hand

over lower abdomen just above symphysis ( Pawliks grip) to determine what pole of the fetus is presenting and whether it is engaged or not. Place other hand at fundus of uterus to stabilize it.  face feet of patient and place four fingers of each hand over lower abdomen just above symphysis pubis and apply deep pressure downwards to feel features of the presenting part.

EXAMINATION- Leopolds Manoeuvres

EXAMINATION
y Percussion y To detect presence of a fluid thrill (common finding

with polyhydramnios)

EXAMINATION
y Auscultation y After 24th week of gestation, fetal heart sounds

listened for at every visit using the Pinards stethoscope (110-160bpm is normal) which is particularly uncommon today since the advent of the doppler ultrasound.

Conclusion
Antenatal visits offer entry points for a range of other programmes such as nutrition, malaria, HIV/AIDS and TB as well as for obstetric care. Greater efforts are needed to improve the content and quality of services offered. In addition, increased attention is needed to ensure that particular groups of women, specifically those living in rural areas, the poor and the less educated, obtain better access to antenatal services.