LECTURE ON ANTENATAL CARE FOR

THIRD YEAR HEALTH OFFICER STUDENTS

BIRHANE TEKLAY (GYN/OBS GP)

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• « To achieve the Every Woman Every Child vision
and the Global Strategy for Women's, Children's
and Adolescents' Health, we need innovative,
evidence-based approaches to antenatal care. I
welcome these guidelines, which aim to put
women at the centre of care, enhancing their
experience of pregnancy and ensuring that
babies have the best possible start in life. »
Ban Ki-moon, United Nations Secretary-General

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• INTRODUCTION
• OBJECTIVES
• IMPLEMENTATION OF FOCUSED ANC
• COMMON COMPLAINTS OF PREGNANCY
• NUTRITIONAL ADVICE ,BMI ASSESSMENT &
RECOMMENDED WEIGHT GAIN
• DANGER SIGNS DURING PREGNANCY
• DRUG EDUCATION & CLASSIFICATION
• INDICATIONS FOR ULTRASOUND
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 INTRODUCTION
• ANC is defined as the complex of interventions that a
pregnant woman receives from organized health care
services.
• ANC is an opportunity to advice women and their families on
how to :
 prepare for birth and potential complications
 promote the benefit of skilled attendance at birth
 and to encourage women to seek postpartum care
forthemselves and their newborn.
 counsel women about the benefits of family planning and
provide them with options of contraceptives.

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 The pregnant woman has the right to:
• Information about her health
• Discuss her concerns, thoughts, and worries
• Know in advance about any planned procedure
to be performed
• Privacy
• Confidentiality
• Express her views about the services she receives

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 Objectives of Focused ANC
• The new approach to ANC emphasizes the
quality of care rather than the quantity.
• For normal pregnancies WHO recommends
only four antenatal visits.

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• The major goal of focused antenatal care is to
help women maintain normal pregnancies
through:
• Health promotion and disease prevention
• Early detection and treatment of
complications and existing diseases
• Birth preparedness and complication
readiness planning.

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• Health Promotion and Disease Prevention:
• Counseling about important issues affecting a
woman’s health and the health of the
newborn is a critical component of focused
ANC.

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• Immunization against tetanus
• Iron and folate supplementation.
• How to recognize danger signs, what to do,
and where to get help
• Voluntary counseling and testing for HIV
• The benefit of skilled attendance at birth
• Breastfeeding

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• Establish access to family planning
• Protection against malaria with insecticide-
treated bed nets
• Good nutrition and the importance of rest
• Protection against iodine deficiency
• Risks of using tobacco, alcohol, local
stimulants, and traditional remedies
• Hygiene and infection prevention practices
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 Tetanus Toxoid Immunization Schedule
DOSE SCHEDULE
TT1 At first contact, or as early as possible
during pregnancy

TT2 Four weeks after TT1

TT3 Six months after TT2,

TT4 One year after TT3,

TT5 One year after TT4,

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• Early detection and treatment of
complications and existing Diseases
• the provider talks with the woman and
examines her for pre-existing health conditions
that may affect the outcome of pregnancy,
require immediate treatment or require a
more intensive level of monitoring and follow-
up care over the course of pregnancy.

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• Birth Preparedness and Complication
Readiness:
• A skilled attendant at birth
• The place of birth and how to get there
including how to access emergency
transportation if needed
• Items needed for the birth

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• Money saved to pay for transportation, the
skilled provider and for any needed
• mediations and supplies that may not been
provided for free
• Support during and after the birth (e.g., family,
friends)
• Potential blood donors in case of emergency.

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 Implementation of Focused ANC:
• It includes revised forms and checklists
needed to identify those women that can
follow basic care and those women with
special health conditions and/or are at risk of
developing complications that needs a special
care.

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• Keep in mind to:
- Make all pregnant women feel welcome at your clinic.
- Opening hours for your ANC clinic should be as convenient as
possible for mothers to come to the clinic.
- Make every effort to reduce client waiting time.
- However, women who come without an appointment should
not be turned away even when there is no emergency.
- As far as possible, any required interventions (for treatment)
or tests should be done at the women's convenience, for
example, on the same day of the woman’s visit.

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focused ANC model categorizes pregnant
women into two groups:
• those eligible to receive routine ANC (called
the basic component); and
• those who need specialized care based on
their specific health conditions or risk factors

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The classifying form has 18 components that are grouped in the three:
• Obstetric history – previous stillbirth/ neonatal loss, history of three or
more consecutive abortions, birth weight of less than 2500 or more
than 400 grams, admission in the last pregnancy for preeclampsia or
hypertension, previous uterine or cervical surgery.
• Current pregnancy – diagnosed or suspected multiple pregnancy ,age
less than 18 or more than 35, RH isoimmunization, vaginal bleeding,
pelvic mass, diastolic blood pressure of more than 90mmHg
• General medical condition – insulin dependent diabetes mellitus, renal
or cardiac disease, known substance abuse any other severe medical
illness

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Activities of the new WHO ANC model

I. First visit at 16 weeks

• diagnosis of pregnancy and determination of the gestational age;
• risk assessment and determination of the medical status of the
mother;
• health promotion by education on nutritional supplement,
danger signs of pregnancy
• care provision like malaria prophylaxis. Prevention of MTCT of
HIV, iron supplementation and immunization with tetanus toxoid.
• Individualize birth plan
• The first visit can be expected to take 30–40 minutes

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• History and physical examination.
• Laboratory tests
 Urine analysis preferably multiple dipstick test for
bacteriuria and test for proteinuria to all women.

 Blood: syphilis (rapid test - RPR if available or VDRL)

result while waiting in the clinic.
 Blood-group typing (ABO and rhesus).
 Hemoglobin (Hb) or hematocrit.
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 Perform HIV test if the woman does not say “NO”.
Encourage testing of partner
 Perform CD4 count for all HIV positive pregnant
women, If CD4 determination is unavailable, HIV
positive pregnant women should be staged clinically
and using total lymphocyte count for antiretroviral
treatment, ART, eligibility.
 Additional investigation that can be considered when
available and affordable include: urine culture and
sensitivity, ultrasound, Pap smear, HBsAg
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Implement the following interventions
• Iron and folate supplements to all women: one tablet of
60-mg elemental iron and 400 micrograms folate per day.
• If rapid test for syphilis is positive: treat, provide
counseling on safer sex, and arrange for her partner’s
treatment and counseling.
• Tetanus toxoid: give first injection.
• In malaria endemic areas provide ITN.
• Refer clients that need specialized care, according to
diagnosis

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II. Second visit between 24 – 28 weeks.
Major Activities are
• further health promotion and care provision and plan birth place.
• Similar to 1st visit
• It is expected to take 20 minutes.
III. Third visit at 32 weeks
Major activities are
• screening for hypertension, anemia, multiple pregnancy, diabetes
mellitus and RH sensitization; preterm,APH
• health promotion and care provision and plan birth place.
• Ascertain fetal growth and feta well being
• Develop individualized birth plan

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• It is expected to take 20 minutes.
• Ensure compliance of iron and folate and refill
as needed
• Tetanus toxoid injection as needed.
• Anti – D is given if the woman’s blood group is
Rhesus negative and Coomb’s test is negative

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• IV. Fourth visit at 36 weeks
Major activities are
• Screening for hypertension, antepartum hemorrhage, multiple gestations;
• check for fetal lie, presentation, growth and well being;
• health promotion and care provision and finally up date individualized
birth plan.
• Individualized birth plan
V. 5th 40-42(optional)
• Fetal lie , presentation, well being, growth
• Biophysical profile
• Bishops score
• Decide on termination /expectant managment

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Common Complaints of Pregnancy.
Nausea and Vomiting :
• About 50 percent of women have both nausea and vomiting, 25 percent have nausea only,
and 25 percent are unaffected .

• About two thirds of women with severe nausea in a prior pregnancy have similar symptoms
in subsequent pregnancies
• Research suggests that taking a prenatal vitamin before conception may reduce nausea in
pregnancy.

• Nausea severe enough to cause significant weight loss or hospitalization is seen rarely,
affecting 0.5 to 2 of pregnant women
• There are four main categories of interventions for nausea: dietary changes, behavior
modification, medications and acupressure.

• Non pharmacologic measures are usually recommended initially to treat nausea and
vomiting in early pregnancy.

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• Heartburn is a common complaint in pregnancy
because of relaxation of the esophageal sphincter.
• Overeating contributes to this problem. Pillows at
bedtime may help.
• If necessary, antacids may be prescribed. Liquid
antacids coat the esophageal lining more
effectively than do tablets.
• In a subset of patients, H-2 blockers may be
helpful.
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Backache
• Back pain is a common complaint in pregnancy affecting over 50%
of women.
• Numerous physiologic changes of pregnancy likely contribute to
the development of back pain including ligament laxity related to
relaxin and estrogen, weight gain, hyperlordosis, and anterior tilt
of the pelvis.
• These altered biomechanics lead to mechanical strain on the
lower back.
• Backache can be prevented to a large degree by avoidance of
excessive weight gain, and a regular exercise program before
pregnancy.

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• Exercises to strengthen back muscles can also be
helpful.
• Posture is important, and sensible shoes, not
high heels, should be worn.
• Scheduled rest periods with elevation of the feet
to flex the hips may be helpful.
• Acetominophen, narcotics, prednisone, and
rarely antiprostaglandins (if remote from term)
can be used.
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• Varicosities
• Hemorrhoids: varicosities of rectal mucosa
• Pica: There has been considerable historical interest in the
cravings (pica) of pregnant women for strange foods and, at
times, nonfoods such as ice (pagophagia), starch (amylophagia),
or clay (geophagia). This desire has been considered by some to
be triggered by severe iron deficiency.
• Ptyalism: Women during pregnancy are occasionally distressed
by profuse salivation. The cause of this ptyalism sometimes
appears to be stimulation of the salivary glands by the ingestion
of starch. This cause should be looked for and eradicated if found.
Most cases are unexplained

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• Constipation : is aggravated by the addition of iron
supplementation
• Headache: Non specific
• Leukorrhea
• Trichomoniasis: In as many as 20 % of women,
Trichomonas vaginalis can be identified during
prenatal examination.
• Candidiasis: Candidia albicans can be cultured from
the vagina in about 25 percent of women
approaching term.
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• Bacterial Vaginosis: prevalence of vaginosis during
pregnancy is 10 to 30 percent, and it is associated
with preterm birth.
-Treatment is reserved for symptomatic women who
usually complain of a fishy-smelling discharge.
Metronidazole, 500 mg twice daily orally for 7 days,
will achieve cure in about 90 percent of cases.
- Unfortunately, treatment does not reduce preterm
birth, and routine screening is not recommended

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• Exercise: Avoid excessive fatigued or risk injury. Avoid diving to swim

• Bathing: There are no contraindications to bathing during pregnancy or the

puerperium. Early pregnancy exposure to a hot tub or Jacuzzi at 100°F or
higher has been associated with an increased risk of miscarriage & neural-
tube defects

• Clothing: Comfortable and non constricting

• Coitus: Whenever abortion or preterm labor threatens, avoid coitus
• Dentition: Pregnancy is not a contraindication to dental treatment.

• Caffeine: Caffeine is not a teratogen. The risk of spontaneous abortion

related to caffeine consumption is controversial

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• Travel : ACOG has concluded that pregnant women can
safely fly up to 36 weeks
• The patient should be advised against prolonged sitting
during car or airplane travel because of the risk of
venous stasis and possible thromboembolism.
• The usual recommendation is a maximum of 6 hours per
day driving, with stopping at least every 2 hours for 10
minutes to allow the patient to walk around and
increase venous return from the legs.
• Hydration and support stockings are also recommended.

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Restless Legs Syndrome
• About one in 5 to 10 women will develop restless legs syndrome (RLS) during
the second half of pregnancy.
• RLS usually occurs as women fall asleep and is characterized by tingling or
other uncomfortable sensations in the lower legs, resulting in the
overwhelming urge to move the legs.

• Unfortunately, movement, walking around or other measures do not relieve

RLS.
• Iron deficiency anemia has been associated with an increased risk for RLS, and
in anemic women, iron supplementation may reduce leg restlessness.
• Avoidance of caffeine containing drinks like coffee, tea or sodas in the last half
of the day should also be recommended, as caffeine may increase symptoms.

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Sciatica
• Sciatica refers to nerve pain that shoots rapidly down from the
buttocks and unilaterally down one leg, usually ending in the foot.
• True sciatica is rare in pregnancy, affecting less than 1% of
pregnancies.
• True sciatica is caused either by a herniated disc, or less
commonly by uterine pressure on the sciatic nerve.
• In addition to pain, other signs of nerve compression include
numbness in the affected leg.
• True sciatica should prompt referral to an orthopedic surgeon for
further evaluation.

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Carpal Tunnel Syndrome
• The extra fluid retention of pregnancy can exacerbate carpal tunnel syndrome.
• Higher weight gain during pregnancy is also a risk factor.
• The most common symptoms of carpal tunnel syndrome are pain and numbness
in the thumb, index and middle fingers and weakness in the muscles that move
the thumb.
• Between 25 and 50% of pregnant women will notice some symptoms of carpal
tunnel syndrome.
• Treatment : nighttime splinting that may help reduce increased pressure on the
nerve that occurs when the wrist is bent; about 80% of women will notice
reduction in symptoms with splinting alone.
• severe cases of carpal tunnel syndrome can be treated with steroid injections
into the area around the carpal tunnel to reduce swelling and inflammation.
• After delivery, symptoms generally resolve within 4 weeks

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urinary incontinence :
• About 40–50% of women will experience urinary incontinence during their
pregnancy. Check for infection.
Round Ligament Pain
• Frequently, patients will notice sharp groin pains caused by spasm of the round
ligaments associated with movement.
• This is more frequently felt on the right side as a result of the usual dextrorotation of
the uterus.
• The pain may be helped by application of local heat such as with hot soaks or a
heating pad.
• Patients may awaken at night with this pain after having suddenly rolled over in their
sleep without realizing it.
• During the daytime, however, modification of activity with gradual rising and sitting
down, as well as avoidance of sudden movement, will decrease problems with this
type of pain. Analgesics are rarely necessary.

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Syncope
• Compression of the veins in the legs from the advancing size of the
uterus places patients at risk of venous pooling associated with
prolonged standing. This may lead to syncope.
• Measures to avoid this possibility include wearing support
stockings and exercising the calves to increase venous return.
• In later pregnancy, supine hypotension, a distinct problem when
undergoing a medical evaluation or an ultrasound examination.
• A left lateral tilt position with wedging below the right hip will help
keep the weight of the pregnancy off the inferior vena cava.

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 NUTRITIONAL ADVICE ,BMI ASSESSMENT & RECOMMENDED WEIGHT GAIN

Eat foods from each of the six major food groups:

1) Fat (sparingly)
2) Milk, yogurt, cheese
3) Vegetable
4) Meat
5) Fruit
6) Bread, cereals, and other carbohydrates
Drink plenty of liquids (especially water—8 to 10 large
glasses, or 2 liters), increase fiber, and increase calcium and
iron intake.
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10/26/20 41
 DANGER SIGNS DURING PREGNANCY

• Vaginal bleeding
• Sudden gush of fluid or leaking of fluid from vagina
• Severe headache not relieved by simple analgesics
• Dizziness and blurring of vision
• Sustained vomiting
• Swelling (hands, face, etc.)
• Loss of fetal movements
• Convulsions
• Premature onset of contractions (before 37 weeks)
• Severe or unusual abdominal pain
• Chills or fever

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 Drug Education and Drug Classification
The following are guidelines for the clinician who prescribes medication
during pregnancy or lactation:
• Try to avoid any medication during the first trimester.
• Use single, non-combination, short-acting agents.
• Choose topical (if available) over-the-counter medications.
• Use the lowest effective dosage of the safest known medication.

• Instruct breastfeeding mothers to use a single dose or short acting

medication so they can feed again, past the peak blood level to minimize
the risk to infants.
• Encourage breastfeeding mothers to watch and see whether the infant
seems to have any problems related to any medication the mother may be
taking

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 Drug category Risk in pregnancy
A
Drug Classification Table
Controlled studies show no risk
Adequate, well-controlled studies in pregnant
women have failed to demonstrate risk to the
fetus
B No evidence of risk in humans
Either animal findings show risk (but human
findings do not) or, if no adequate human
studies have been done, animal findings are
negative
C Risk cannot be ruled out
Human studies are lacking and animal studies
are either positive for fetal risk or lacking as
well. However, potential benefits may justify
the potential risk.
D Positive evidence of risk
Investigational or post marketing data show
risk to fetus. Nevertheless, potential benefits
may outweigh the risk
X Contraindicated in pregnancy

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 Indications for Ultrasound
• Ultrasound is an excellent means of assessing
fetal well being; however, it can be
inappropriately used, leading to excessive
reliance on technology and increasing health
care costs. Consequently, it is crucial to know
the indications for ultrasound, its true value
and limitations.

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• Estimated gestational age for clients with uncertain
dates of LMP.
• Evaluation of fetal growth.
• Vaginal bleeding of undetermined etiology in
pregnancy.
• Determination of fetal presentation.
• Suspected multiple gestation.
• A support to amniocentesis.
• Significant uterine size and clinical dates discrepancy
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• Pelvic mass.
• Suspected Hydatidiform mole.
• Suspected ectopic pregnancy.
• A support to special procedures; e.g., fetoscopy,
chorionic villus sampling, cervical cerclage placement.
• Suspected fetal death.
• Suspected uterine abnormality.
• Localization of IUD.
• Surveillance of ovarian follicle development
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• Biophysical evaluation for fetal well being.
• Observation of intrapartum events; e.g.,
extraction of second twin.
• Manual removal of placenta.
• Suspected polyhydramnios or oligohydramnios.
• Suspected abruptio placenta.
• A support to external cephalic version.
• Estimation of fetal weight
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• Abnormal serum alpha-fetoprotein value.
• Follow-up observation of identified fetal anomaly.
• Follow-up evaluation of placenta location for
identified placenta previa.
• History of previous congenital anomaly.
• Serial evaluation of fetal growth in multiple
gestation.
• Evaluation of fetal condition in late registrants for
antenatal care.
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