ANTENATAL CARE

DR Elong Felix Adolphe

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 OBJECTIVES

1. Define prenatal consultation.

2. Discuss the diagnosis of pregnancy.
3. Carry out basic investigations in pregnancy.
4. Detect risk women .
5. List the four components of a good prenatal consultation.
6. List the danger symptoms and signs in pregnancy
7. Discuss the frequency and content of antenatal consultations
8. Describe essential elements of a delivery plan

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 PLAN
I. Introduction.
II. Diagnosis of pregnancy
Presumptive, Probable, positive manifestations
III. Paraclinical investigations in pregnancy
IV. Components of ANC
1. Health promotion
2. Preventive care
3. Curative care
4. Preparation for delivery
V. ANC schedule
VI. ANC content
1. Preconception consultation
2. First trimester consultation
3. Second trimester consultation
4. Third trimester consultation
VII.Conclusion
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 I INTRODUCTION1/2

• Pregnancy-related preventable morbidity and mortality

remains unacceptably high.
• It has been established that by implementing timely and
appropriate evidence-based practices, ANC can save lives.

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 I INTRODUCTION2/2

ANC can be defined as the care provided by

skilled health-care professionals to pregnant
women and adolescent girls in order to
ensure the best health conditions for both
mother and baby during pregnancy.

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 II DIAGNOSIS OF PREGNANCY

• PRESUMPTIVE
• PROBABLE
• POSITIVE

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PRESUMPTIVE PROBABLE POSITIVE
DIAGNOSISCHADWICK
AMENORRHOEA OF PREGNANCY
SIGN FETAL HEART TONE

NAUSEA AND VOMITING HEGAR SIGN PALPATON OF FETUS

BREAST SYMPTOMPS ABDOMINAL PREGNANCY TEST

ENLARGEMENT
QUICKENING UTERINE CONTRACTIONS ULTRASOUND

URINARY SYMPTOMS BALLOTEMENT OF THE X RAY

UTERUS
INCREASED BODY
TEMPERATURE
SKIN SIGNS; CHL, LNG,
SMK,
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 III PARACLINICAL INVESTIGATIONS IN
PREGNANCY

• BASIC TESTS
• OTHER TESTS (EXCEPT IF RISK FACTOR)

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 Other tests
BASIC TEST
FBC TOXOPLASMOSIS

BLOOD GROUP AND RHESUS RUBELLA

Hb ELECTROPHORESIS HERPES; little or no significance.

FBS CYTOMEGALOVIRUS; little significance

TPHA/VDRL
HBC Ab)
HBs Ag OTHER TESTS (clinical condition)
HIV SEROLOGY
VAGINAL SMEAR, STOOLS
URINE BACTRIOLOGY,
•
CYTOLOGY
SUGAR
ALBUMINE AND
Other test as indicated by the clinical condition of the woman.
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III PARACLINICAL INVESTIGATIONS IN
PREGNANCY

When should antenatal care clients be tested for HIV?

HIV testing routinely offered at 2 points in time during ANC:
• 1st antenatal consultation,
• A few weeks before delivery or during labour(if she tested
negative at 1st visit),
• To detect infection acquired after initial HIV test.

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 IV COMPONENTS OF ANC

Quality prenatal consultation: 4 components

1. Health promotion
2. Preventive: Prevention of complications and diseases
3. Curative, treatment of all medical illness that may hamper normal
progress of pregnancy.
4. Preparing for delivery, place of delivery, cost, route etc.

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 What topics are covered in antenatal
care health education?

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 IV COMPONENTS OF ANC
A) HEALTH PROMOTION
Educate the woman on:
1. Healthy lifestyles, personal hygiene, Diet and weight gain.
2. Primary prevention of diseases (malaria, helminthiasis)
3. Adherence, education and support for iron/folic acid, use
of IPT, for those taking ARVs
4. The danger symptoms and signs of pregnancy
5. Care of the baby, breast feeding
6. etc.

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 IV COMPONENTS OF ANC
A) HEALTH PROMOTION
1) Diet and weight gain

Undernourishment and overnourishment may have negative

consequences for pregnant women and their babies
to meet maternal and fetal needs, pregnancy requires a
healthy diet that includes an adequate intake of
• energy,
• protein,
• vitamins and minerals.

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 How much weight should a woman gain
while pregnant?

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 IV COMPONENTS OF ANC
A) HEALTH PROMOTION
1) Diet and weight gain

Monitor Pregnancy Weight

• Gain minimum of 1 kg/month in 2nd and 3rd trimesters;
or at least 7 kg total (including weight gained during 1st
trimester).
• Better to try to gain closer to 11 kg total (+/- 2
kilograms) over the 3 trimesters of pregnancy.
• At every ANC visit:
• Compare current weight to previous ones
• Assess food intake and appetite
• Provide nutrition counselling and education
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 IV COMPONENTS OF ANC
A) HEALTH PROMOTION
2) Danger symptoms and signs
• Fever,
• Headaches,
• Convulsion or coma,
• Contractions,
• Bleeding,
• Loss of liquor,
• Absence of foetal movement,
• Vomiting.
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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE1/6
1) Risk identification

A high risk pregnancy: fetus or mother runs a significantly increased

chances of death or morbidity either before, during or after birth.

GRAND MULTIPARITY
PREVIOUS CESARIAN SECTION, PREVIOUS MYOMECTOMY
HABITUAL ABORTIONS
COMPLICATED OBSTETRICAL HISTORY
16 YEARS OR UNDER
35 YEARS OR OLDER
HYPERTENSION, PREECLAMPSIA, DIABETES
OBESITY, DIABETES
TWIN, BREECH
HIGH LESS THAN 1,5 M
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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE2/6
2) Intermittent preventive treatment of malaria

In malaria-endemic areas in Africa, intermittent preventive

treatment with sulfadoxine-pyrimethamine is recommended
for all pregnant women.
Dosing should start in the second trimester, and doses
should be given at least one month apart, with the objective
of ensuring that at least three doses are received.

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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE3/6
3) Haematinics

• Daily oral iron and folic acid supplementation with 30 mg to

60 mg of elemental iron and 400 µg (0.4 mg) folic acid is
recommended for pregnant women to prevent maternal
anaemia, puerperal sepsis, low birth weight, and preterm
birth.
• Intermittent oral iron and folic acid supplementation with
120 mg of elemental iron and 2800 µg (2.8 mg) of folic acid
once weekly
• Take iron and folic acid until 42 days postpartum
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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE4/6
4) Preventive anthelminthic treatment

In endemic areas a preventive anthelminthic

treatment is recommended for pregnant women
after the first trimester as part of worm infection
reduction programmes.

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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE5/6
5) Supplementation of micro nutients

• In populations with low dietary calcium intake, daily calcium

supplementation (1.5–2.0 g oral elemental calcium) is
recommended for pregnant women to reduce the risk of pre-
eclampsia.
• Multiple micronutrient, vitamin B6, D, C, E supplementation are
not recommended for pregnant women to improve maternal and
perinatal outcomes.
• Vitamin A supplementation is only recommended for pregnant
women in areas where vitamin A deficiency is a severe public
health problem, to prevent
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 IV COMPONENTS OF ANC
B) PREVENTIVE CARE6/6
6) Tetanus toxoid vaccination

Tetanus toxoid vaccination is recommended for all pregnant

women, depending on previous tetanus vaccination exposure, to
prevent neonatal mortality from tetanus.

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 IVCOMPONENTS OF ANC
C) CURATIVE CARE

Treatment of all medical illness that may hamper normal progress

of pregnancy:
• Malaria
• Urinary tract infection
• Vulvovaginitis
• Ailments of pregnancy
• etc

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 IV COMPONENTS OF ANC
D) PREPARING FOR DELIVERY

Choose the place of delivery,

Prepare the Material, babies clothes
Be in contact with the medical team and the health care facility,
Identify people who will accompagny her to the hospital
Identify potential blood donnors
Be aware of the route of delivery,
Know the Cost of delivery or cesarian section,
have available means of transportation ,
etc.
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 How many antenatal consultation are
recommended for women whose
pregnancy is progressing normally?

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 What is the timing of these
consultations?

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 V ANC SCHEDULE
1) Comparing ANC schedule1/5
Focused ANC (FANC) Schedule: outdated?
Consultation Timing
1st consultation Before 16th week or when
pregnancy is diagnosed (ideally
before 12 weeks)
2nd consultation 24–28th weeks; or at least once in
2nd trimester
3rd consultation At 32 weeks (+/- 2 weeks)
4th consultation At ~36 weeks
Other If complications occur or if needed
consultations

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 V ANC SCHEDULE
1) Comparing ANC schedule2/5
Up-to-date evidence shows that the FANC model is
associated with more perinatal deaths than models that
comprise at least eight ANC visits.
Evidence shows that more ANC visits is associated with
better outcome than less ANC visits.
The GDG prefers the word “contact” to “visit”,as it implies
an active connection between a pregnant woman and a
health-care provider that is not implicit with the word “visit”.

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 V ANC SCHEDULE
1) Comparing ANC schedule3/5

WHO FANC model 2016 WHO ANC model

• Visit 1: 8–12 weeks • Contact1: up to 12 weeks

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 V ANC SCHEDULE
1) Comparing ANC schedule4/5
WHO FANC model 2016 WHO ANC model

• Visit 2: 24–26 weeks • Contact 2: 20 weeks

• Contact 3: 26 weeks

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 V ANC SCHEDULE
1) Comparing ANC schedule5/5
WHO FANC model 2016 WHO ANC model

• Visit 3: 32 weeks • Contact 4: 30 weeks

• Visit 4: 36–38 weeks
• Return for delivery at 41
weeks if not given birth.
• Contact 5: 34 weeks
• Contact 6: 36 weeks
• Contact 7: 38 weeks
• Contact 8: 40 weeks
• Return for delivery at 41
weeks if not given birth.

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 VI ANC CONTENT
1) Questions to answer at each ANC contact
• What is the goal of this contact?
• In terms of history-taking, what are we specifically going to
find out?
• What are we going to do during the examination?
• What screening and tests are we going to conduct?
• What treatments are we going to provide?
• What preventive measures are we going to make sure you
administer (e.g. immunisations)?
• And finally, what health promotion advice and counselling
are we going to discuss?
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 VI ANC CONTENT
2) Pre-conception consultation:

• Determine hereditary conditions (sicklers, ABO+Rh).

• Drug history (alcohol, cocaine consumption).
• Nutritional defficiencies (folic acid, fe, malnutrition).
• Exclude metabolic diseases, diabetes, thyrotoxicosis,
endocrine disorders.
• Infectious diseases, HIV, syphilis, chlamydia etc.
• Discuss fertile period, early symptoms of pregnancy.

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 VI ANC CONTENT
3) First trimester consultation:

• Objective, confirm pregnancy, determine localisation,

viability, number of embryo/foetuses.
• Do baseline work-up, including US
• No drug usage except indicated.
• Counselling possible risk factors, alarm symptoms and
signs.

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 VI ANC CONTENT
4) Second trimester consultation

• Objective, morphological studies, sex malformation,

(AMNIOCENTESIS; US; ßHCG, alpha fetoproteins, CVS,
amnioscopy etc).
• Routine prophylaxis, education
• Measurements: maternal weight, BP, UH.
• Foetal heart tones.

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 VI ANC CONTENT
5) Third trimester consultation:

• Objective: determine lie, presentation and mode of

delivery. Make contact with place of delivery, the staff,
information on cost etc.
• Repeat measurement of maternal parameters.
• Pelvic assessment
• Routine prophylaxis. US
• Referral if need be to higher health facility.
• Education on labour, frequency, loss of liquor, mucous plug,
transportation, term, post term, foetal movement count
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etc.
 VII CONCLUSION

The aim of ANC is to ensure the best health conditions for both mother
and baby during pregnancy.
For the diagnosis of pregnancy it is good to differenciate the
presumptive, probable and positive manifestations.
The paraclinical investigations in pregnancy are divided into basic and
OTHER investigations.
There are 4 components in quality ANC: health promotion, preventive
care, curative care, delivery preparation.
New evidence show that at least 8 ANC contacts are necessary to have
the best maternofetal outcome.
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 References
• WHO recommendations on antenatal care for a positive pregnancy
experience.ISBN 978 92 4 154991 2 World Health Organization 2016
WHO recommendations on antenatal care
• for a positive pregnancy experience WHO handbook for guideline
development, 2nd edition. Geneva: World HealthOrganization;
2014(http: //www.who.int/kms/handbook _ 2nd_ed.pdf, accessed 6
October 2016)
• Current OB/Gyn chapter 9 normal pregnancy and prenatal care

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