Principles of

Antenatal Care
DR LENROY BRYAN
MBBS,DM(O&G), MRCOG,FACOG
CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST
20/6/17.
OUTLINE
Goals of antenatal care
Overview symptoms, signs and diagnosis
of pregnancy.
Screening for maternal and fetal
complications.
Assessment at antenatal clinic.
Example
Challenges in delivering antenatal care
Antenatal (prenatal ) Care
Comprises medical, educational, and
psychological efforts made during
pregnancy to the end that the gravid
woman and her fetus arrive at term in
good health, well prepared for childbirth.

Historically dates back to the beginning of

20th century ( Ballentyne 1902)
(Campbell 1920)
Goals of antenatal care
Reduce maternal and perinatal mortality and
morbidity rates
Screen for and Identify fetal complications.
Screen for and Identify maternal complications
Assess maternal and fetal wellbeing throughout
pregnancy
Provide advice and education on the normal
symptoms of pregnancy.
Preparation of the mother and her family for the
birth experience and parenthood
Procedures in antenatal care
Diagnosis of pregnancy
Initial evaluation
hx: reproductive
medical/surgical
social/family
exam: general
abdomen
pelvic
Investigations
routine
indicated
Diagnosis of pregnancy
Symptoms in the 1st trimester
Amenorrhea
Nausea & vomiting
Fatigue
Breast tingling and fullness
Urine frequency/nocturia
Constipation
Signs in the 1st
trimester
Signs & Symptoms in 2 nd & 3 rd

trimesters
Quickening = maternal perception of fetal
movements
1st pregnancy; 18-20 wk
2nd or > ;16-18 wk
Dermatologic changes
Chloasma
linea nigra
striae
Backache
Obstetrical abdominal
examination
Signs in the last two trimesters
Enlargement of the abdomen
Uterine contractions
Palpation of fetal parts
Auscultation of fetal heart
pinard
bell of regular stethoscope
doppler pocket size
Measuring
symphysio-
fundal height
Palpation of abdomen &
fetal parts
Symphysio-fundal height
chart
Detection of fetal
heart
 Pinard fetoscope

Bell ended
fetoscope
 o
s
c
o
p
e

Combined ear
and forehead
fetoscope

Place on
forehead

Place on
abdomen
Pocket fetal
heart
detector
Doppler umbilical cord blood
flow monitor
Ancillary aids to the diagnosis of
pregnancy
1st trimester
urine pregnancy test ( total HCG)
blood pregnancy test ( subunit HCG)
assay
trans-vaginal ultrasound
2nd trimester
trans-abdominal ultrasound
7 weeks
fetus
Measurements
taken during
an ultrasound
study to
determine fetal
size/age in the
2nd trimester
BPD
Commonly used terms in
pregnancy
Reproductive history
gravida: all previous and current pregnancies
parity : all pregnancies in the past beyond the
period of fetal viability (> 24 weeks or > 500 g
birth weight regardless of gestational age)
Nullipara,
primipara, 1 beyond 24w
multipara, more than 1 beyond 24w
grand multipara, 5/ more beyond 24w (sig. risk of
post partum hemorrhage)
Terms describing pregnancy length

Pregnancy length ( gestational age; GA)

quoted in weeks
Trimester
1st : LMP to 12 weeks
2nd : 13 27 weeks
3rd : 28- Term (37-42) weeks
Preterm >24 but < 37 weeks
Postterm >42 weeks
INITIAL VISIT ( BOOKING)
Assessment to determine those
pregnancies at high risk
-History.
-Physical examination.
-Laboratory data.
History
Welcome patient.
Build rapport
Name , age ,
Ensure woman is comfortable
No disturbance( phones off)
History
Menstrual Hx to establish estimated date
of delivery LMP, Cycle regularity and
freguency,Contraception Use
Calculate estimated date of delivery ( Edd)
Using Naegeles rule- add 7 days, subtract
3 months and add 1 year to LMP.
Eg. LMP 1/12/15 . EDD = 8/9/16
LMP 1/01/16. EDD = 8/10/16
History
Problems in current pregnancy
- nausea ,vomiting,
- abdominal pains
- vaginal bleeding
- urinary frequency
- backache
Past Obstetric History
Provides information that may impact
decision in current pregnancy
- Gravidity ,Parity, Miscarriage
- Previous complications( GDM,PIH)
- Gestational age at delivery
- Type of delivery( C/S vs Vaginal)
- Birth weights, neonatal or maternal
complications
Medical and surgical History
These may impact risk of current
pregnancy
- DM (high risk of neural tube defect), HTN,
SLE
- Previous Caesarean section
- Medication ,
- Allergies
Family History
Some conditions that runs in family may
put pregnancy at high risk
- DM ,HTN,
- Cardiac disease.
- Sickle cell disease.
- Mental disorders
 Social History
Identifies factors that increase risk to
pregnancy
- Occupation, religion (can they get blood? )
- Support, Housing
- smoking, alcohol use.
Physical exam
Detailed
General skin ,mm pallor, BP,PR, BMI
Thyroid
Breast
Chest ,CVS (can be tipped over the edge by pregnancy =>
needs termination)

Abdomen
Vagina if indicated.
BOOKING LAB TESTS (routine screening tests)
Management at booking
1st trimester U/S confirm gestation age
- identify multiple gestation
Papsmear - If missed schedule pap.
Supplemental Iron therapy
Folic acid( 400mcg /day ) until 12 weeks
gestation
Education.
Management at booking
Pregnancy assessed High or Low risk
High risk- followed up at high risk clinic(
obsetrician led)
Low risk - followed up at any clinic(
midwife led, General practitioner or
Obstetrician)
NB!! Low risk patients may become high
risk and need to be referred to high risk
clinic
Subsequent visits
Address concerns
Ask about fetal movements ,abdominal
pains, vaginal loss ( blood , discharge)
Check BP,PR, Urine dipstick
Check Symphysio-fundal height( SFH)
assess growth of fetus.
Continued education.
Local Antenatal clinic schedule
Booking ideally prior to 12 weeks
Every 4 weeks until 28 weeks then every 2
weeks until 36 weeks. Then weekly until
delivery
20 weeks Fetal anomaly scan ( detect
fetal structural abnormalities on
ultrasound)
24 28 weeks- Osullivans glucose test
screen for gestational diabetes
36 weeks- preparation for labour and
delivery.
A) Amniocentesis, B) Chorionic villus sampling (CVS)
Perinatal database

This serves as a risk-based

evaluation for continued care
Health education
To Improve health reduce harm
Hygiene
Diet
Exercise
Breast care
Travel , sexual activity.
Health education
Danger signs in pregnancy
- Headaches,flashing lights,epigastric pains
- Vaginal bleeding
- Reduce fetal movements
- Persistent abdominal pains.
- Fever
Example
Mrs Jane
26 yo Gravida 2 Para 1
Presented to midwife led booking clinic for
routine care
LMP 2/3/15. Sure of dates.
Regular 5 /28 cycle
No hormonal contraception.
Example
EDD 9/12/15. GA 7 /40
No chronic illness. Except for mild nausea
she was fine.
No significant past medical or surgical
history.
Past obstetric history uncomplicated.
Spontaneous vaginal delivery at 38 weeks.
Birth weight 3.5kg. No neonatal admission.
Example
Last papsmear 6/12 prior result normal
Married. Live home with modern
conveniences
Teacher
Nil Smoke Nil Alcohol use
Not on medication
Allergies
Example
General Examination MM pink, BP
100/70mmhg, urine dipstick normal.
Systemic exam- unremarkable.
MX - Patient education
- Booking blood test
- Dating Ultrasound
- Iron supplementation
- Folic acid.
Example
Test results
HB 11.5 g/dl
Gp O Rhesus +ve
Sickle - ve, Hiv -ve,VDRL-ve
Ultrasound Edd 10/12/15. Live Intrauterine
pregnancy 8 weeks gestation.
Assessed as low risk continue follow up in
low risk clinic.
Example
20 weeks routine anomaly scan
normal
24 weeks Osullivans test 6.9 ( normal
<7.8mmol/l)
32 weeks VDRL ,HIV ve. HB, 10.6g/dl.
36 weeks . Routine clinic visits. Nil
complaints. BP noted elevated 155/94 and
urine dipstick- 3+ proteinuria.
referred to hospital for further care.
Example
Patient admitted for blood pressure control
and delivery
Repeat BP 160 /100mmhg urine diptick 3+
proteinuria
Assessed as severe pre-eclampsia.
Placed on aldomet ( methyl dopa) for
blood pressure control
Labour induced
Delivered healthy baby. Birthweight 3kg.
Problems in the delivery of
antenatal care
Cost
Accessibility
distance
timings of institutions
Crowding/poor attention
Personel
skills
attitudes
Personal beliefs
Results of inadequate antenatal care
Raised perinatal mortality
Raised perinatal morbidity
Risk of long term sequelae e.g. growth
deficits, neurological handicap
Raised maternal mortality
Maternal morbidity i.e. complications are
increased.
Everyone must encourage antenatal
care
 Obstetrics by Ten Teachers (18th
edition)
Ash Monga and Phil Baker

Suggested reading: Chapters 2, 7-8