ANTENATAL CARE

LKB
 DEFINITION
• Antenatal care is supervision and
management offered to a pregnant
woman from confirmation of
conception to the beginning of
labour (Henderson and Macdonald,
2004). 
 FOCUSED ANTENANTAL
CARE (FANC)
• According to MoH, 2003 this is the
basic antenatal care that is given to
all pregnant women that emphasizes
on the quality of care rather than the
quantity or frequency of visits, in
which every pregnancy is considered
to be at risk for complications. 
 CONT.
• Focused antenatal care is a way of
organising antenatal services with
emphasis on quality rather than
quantity of visits in an attempt to
improve maternal satisfaction by the
provision of holistic, individualised
care and organisational change in the
pattern of care.
 CONT.
• This is on the basis that every
pregnancy is a risk.
• It relies on evidence based and goal
directed interventions that are
appropriate to the gestational age
of the pregnancy.  
AIMS OF ANTENATAL
CARE
 CONT.
• To ensure a normal pregnancy
whenever possible by maintaining
and where necessary by improving
the general health of a pregnant
woman.
• To ensure early detection, referral
and management of complications.
 CONT.
• To ensure a normal labour
whenever possible by preparing
the woman for labour both
psychology and physically.
• To provide careful screening of all
women especially those who are
to deliver at the health centre.
 CONT.
• To prepare for a normal puerperium
and care of a health new born baby.
• To promote and prepare for
breastfeeding whenever possible.
 CONT.
• To promote health education and
family planning and in so doing
uplift the quality of life of all the
people.
 CONT.
• To give support to special clients
with special medical conditions e.g.
women living with HIV so that that
are able to undergo the effects of
pregnancy, labour and puerperium
to reach the end of pregnancy with
a positive outcome.
RECOMMENDED MINIMUM
ANTENATAL CARE
SCHEDULE
• Recommended Minimum Antenatal Care
Schedule
• Evidence shows that quality basic antenatal
care can be provided in four focused visits at
key times during pregnancy.
• First visit - Within the first 16 weeks of
gestation
• Second visit - 24 -28 weeks
 CONT.
• Third visit - 32weeks
• Fourth visit - 36 weeks
• NB: However, further visits can be
arranged depending on individual
client needs.
 CONT.
• Activities done on 1st ANC visit
• The first visit should be done at 8 -
16 weeks.
• During this period, the client is at
risk of hormonal changes which
cause minor disorders.
 CONT.
• It is a period of organogenesis so
advise the woman against taking
self-prescribed drugs or other drugs
that the client may be taking.
• This is a period most common for
abortions. 
 CONT.
• Detailed history is taken.
• Full physical examination which
include measuring of height,
weight, urinalysis and abdominal
palpation and BP
• Calculation of the expected date of
delivery (EDD) ,GA.
• Administration of Tetanus Toxoid
and Fansidar (1st doses if due).
• Counselling and testing for HIV and
giving of test result
• Route laboratory examination of
Hb, RPR, Rh factor, urinalysis.
• Discuss the Birth plan and the
preparation for labour.
• 2nd visit (24 & 28 weeks of gestation)
• The woman is at risk of developing complications of
pregnancy such as pre-eclampsia which occurs after
the 20th week of gestation characterised by raised
blood pressure and/or proteinuria.
• There is need to check for the fetal heart rate.
• The mother should be interviewed on her wellbeing
and that of the fetus and it is important to listen to
what she is saying
• Appropriate IEC is given to the mother on the
danger signs in pregnancy such as bleeding per
vagina, reduced fetal movements, severe headache
and blurred vision.
• Preparation on baby layette is discussed with the
mother and 2nd doses of Fansidar and Tetanus
Toxoid are given.
• 3rd Visit (30 & 34 weeks gestation)
• The mother is at risk of development APH which
occurs after 28 wks of gestation. 
• Investigations should be done to rule out multiple
pregnancy or abnormalities of the placenta and
also the adequacy of the pelvis (Pelvimetry).
• Reinforce on the danger signs of pregnancy.
• Monitor the fetal and maternal wellbeing.
• Third dose of Fansidar should be given.
• 
• 4th Visit at 36weeks gestation
• The main purpose is to detect complications such a
mal presentation e.g. breech and to refer such a
case to the obstetrician.
• Educate on signs of labour and repeat Hb and HIV
tests
• Perform pelvic assessment to rule out Cephalo
Pelvic Disproportion [CPD].
• Make a final and concrete Birth plan.
• The woman is advised to come when in labour but
if labour is not established from 38-40 weeks she
should report at 42 weeks for referral to the
obstetrician
• COMPONENTS OF FANC
• There are four components of Focussed antenatal
care (FANC) which are:
• Early detection of complications and prompt
treatment.
• Disease Prevention
• Birth preparedness and complication readiness
• Health promotion
• EARLY DETECTION AND TREATMENT
• Although most pregnancies are normal, early
detection and treatment of problems that can
complicate pregnancy is important.
• Focused ANC promotes targeted assessment during
which the skilled provider interviews, examines,
and tests the woman to detect signs and symptoms
of pregnancy.
• PREVENTION OF CONDITIONS/ COMPLICATIONS
• To prevent certain conditions safe, simple and cost-
effective interventions are carried out.
• These are Tetanus Toxoid immunization to prevent
tetanus and provision of iron/folate
supplementation to prevent iron deficiency which
may lead to severe anaemia and complications like
pre-term birth, congenital anomalies and
intrauterine growth restriction.
• Intermittent preventive treatment with Fansidar
and insecticide-treated bed nets for malaria.
• Intermittent Presumptive Treatment (IPT) for
hookworm infection through provision of either
albendazole or mebendazole doses.
• HEALTH PROMOTION
• Throughout Antenatal care health education and
counselling are done to make sure women are able
to take care of themselves.
• It is the duty of the skilled provider to ensure that
adequate information is given to these mothers.
• Health information
• Preparing a birth plan.
• Recognizing danger signs in pregnancy and during
childbirth.
• HIV and pregnancy
• Malaria in pregnancy
• Nutrition during pregnancy
• Activity and exercise
• Childbirth and infant nutrition including
breastfeeding and replacement feeding
• Postnatal care and family planning services.
• 
• BIRTH PREPAREDNESS AND COMPLICATION
READINESS
• If a woman is well prepared for a normal childbirth
and possible complications, she is more likely to
receive the skilled and timely care she needs.
• This can protect the mother and the newborn’s life.
• It allows for time to develop a birth plan which
includes making arrangements for normal
childbirth.
• 
• Developing a birth plan
• This includes;
• The skilled provider to attend the birth.
• Place of birth
• Transportation of the pregnant woman to the
skilled provider.
• Funds
• Support person or birth companion.
• Items needed for a clean and safe birth and for the
newborn.
• Some arrangements in case of complications
• Recognition and response to danger signs
• Decision-making in an emergency situation
• Emergency funds.
• Emergency transportation.
• ACTIVITIES THAT ARE CARRIED OUT IN ANTENATAL
CARE
• The activities carried out at the Antenatal clinic are
the following:
• Registration and booking.
• History taking
• Physical examination
• Investigations and tests.
• Medications
• Referrals
• Advise and IEC
• Recording
• Registration and booking
• When the woman reports for Antenatal Care
booking, she has to be registered for the purpose of
record keeping and documentation.  
• History taking
• The following are the preliminary points to note
during History taking:
• Prepare the necessary equipment.
• Greet the woman respectfully and introduce
yourself.
• Offer the woman a seat and ensure privacy.
• Explain the procedure and encourage her to ask
questions.
• Get her permission before you begin the
procedure.
• Listen to what the woman has to say.
• History taking is cardinal during ANC booking for a
Nurse/Midwife to get to know the client well.
• It is a means of assessing the health of the woman
to find out any condition which may affect child
bearing.
• Social History
• Name, age, marital status, religion, residential
address, occupation and education level for self and
spouse, social habits and environmental factors.
• Ask her how she is feeling and respond to danger
signs if any.
• This history is taken for identification, follow up
and health education.
• Family History
• Ask the woman if there is any history in the family
about diabetes mellitus, hypertension, asthma,
epilepsy, sickle cell disease and mental illness since
they tend to run in families.
• It also Include history of pulmonary tuberculosis
contact and history of multiple pregnancies.
• This kind of history is taken to know the genetic
predisposition to certain diseases.
• Personal Medical History
• Ask the woman if she has ever suffered from
diabetes mellitus, hypertension, asthma, epilepsy,
sickle cell anaemia, mental illness, cardiac disease,
STI, tuberculosis, hepatitis and UTI e.t.c.
• Former illnesses may have damaged certain
structures or organs which could give rise to
complications during pregnancy and labour. 
• Surgical History
• Ask the woman whether if she has had injuries or
operations involving the pelvic bones, spine or
lower limbs.
• These could alter the pelvic diameters and angle
of inclination that may lead to cephalo-pelvic
disproportion.
• Remember to ask about history of blood
transfusion to exclude iso-immunisation if the
woman is rhesus negative
• Past Obstetrical History
• Ask about Parity, Gravid, duration of pregnancies,
duration of labour, any complication during
pregnancy, labour and puerperium, weight of
babies, whether died or alive, breastfeeding and for
how long.
• This is taken to find out if there were any
complications during the previous pregnancies.  
• Menstrual history
• Ask about age at menarche, menstrual interval and bleeding
pattern
• How she was keeping the maternity pads
• This history is taken to rule out preconception anaemia and
the duration of the fertility period.
• Contraceptive history
• Ask about method of contraception, when and how long
and reasons for stopping.
• This history is taken to find out whether the pregnancy
was planned or not.
• Present obstetric History
• Ask the woman for the first day of the last normal
menstrual period and then calculate the gestational
age of the pregnancy and expected date of
delivery. 
• Health during pregnancy
• Ask the woman about health and other concerns
during pregnancy such as Fatigue, drowsiness,
headaches, sore tongue, loss of appetite, nausea
and vomiting and oedema.
• Diet during pregnancy
• Ask the woman about her dietary intake i.e. what
type of foods they eat, how many times a day and
any ingestion of non-food stuff.
• PHYSICAL EXAMINATION
• Tell the woman what is going to be done and
encourage her to ask questions.
• Listen to what the woman has to say prior to the
physical examination as a nurse note the following;
• Stature
• If a woman has a small built she is likely to have a
small pelvis.
• Gait
• As the woman walks in, observe any deformity,
stunted growth, limp etc., such may indicate
disproportion in the pelvic diameters.
• A pregnant woman tilting backwards with a large
abdomen may make one suspect multiple
pregnancy or a very large foetus etc.
• Height
• A woman of about 150 cm or less needs special
care.
• Weight
• The average weight gain during pregnancy is about
12-14 kg.
• In the first trimester a woman should gain 0.4 kg
per month and in the second and third trimester
she should gain 0.4 kg per week.
• Blood pressure, temperature, pulse and
respiration
• Checked and recorded at each visit.
• Urinalysis
• Ask the woman to pass urine and you should
perform Urinalysis.
• This should be done at every visit to rule out
proteins, sugar and acetone in urine.
• ACTUAL EXAMINATION
• It has to be done from head to toe
• Assist the woman to get onto the couch
• Wash your hands thoroughly with soap and water
and dry them, then start the examination.
• Head – look for under nourish hair and general
cleanliness
• Eyes – examine for pallor and jaundice on the
conjunctiva by asking the woman to look up.
• Nose – examine the nose for polyps.
• Ears – examine the ears for polyps and any
discharge.
• Mouth
• Ask the woman to open the mouth.  
• Check for signs of anaemia on the lips, mucus
membranes of the mouth, gums and tongue.
• Check also for fissures on the tongue, oral thrush
and sores on the tongue.
• Take note of dental caries, present find out if they
are painful.
• Glands
• Palpate for enlargement of the peri-auricular lymph
glands, submandibular lymph glands and cervical
glands around the neck.
• Palpate the thyroid gland too.
• Ask the woman to swallow while your fingers are
lightly placed just below the larynx.
• Enlargement of gland suggest infections, chronic
illness or may be to the effect of oestrogen on the
glands
• Hands
• Starting with the furthest arm, examine the arms
for signs of anaemia on the palms, poor venous
return on pressure of the nail beds.
• Examine for signs of oedema.
• Ask the woman to make a fist with each hand, a
feeling of tightness in the knuckles in the absence
of pitting oedema would be suggestive of occult
oedema.
• Check for any physical disability and symmetry of
the arms.
• Lastly palpate the axilla for any enlarged lymph
nodes. 
• Breast
• Examine the breast for:
• Presumptive signs of pregnancy i.e. Montgomery’s
tubercles, darkening of primary areola and
secondary areola.
• Suitability for breast feeding – this is more
significant in primigravida.
• Expression of fluid shows that the ducts are patent.
• Presences of clear fluid, milky fluid, colostrum, are
presumptive signs of pregnancy.
• Lumps or swelling in the breast. 
• Lower limbs
• Starting with the furthest leg, examine the legs for
signs of anaemia on the soles, poor venous return
on pressure of the nail beds.
• Examine for signs of tibia, pedal and ankle oedema.
• Check for any physical disability and symmetry of
the limbs.
• Also check for varicose veins and calf pain. 
• ABDOMINAL EXAMINATION
• Inspection
• Shape : Note the contour of the abdomen, is it
round, oval, irregular or pendulous.
• Size : Should correspond with the calculated
gestational age.
• Skin : Check for dark line of pigmentation (linea
nigra), Striae gravidarum, Scars and any skin
lesions. 
• Palpation
• Measure Height of Fundus to determine the how
old the pregnancy is.
• Do Fundal Palpation to determine lie and
presentation.
• Do Lateral Palpation to determine the lie, attitude
and position
• Do deep pelvic Palpation to determine the
Presentation.
• Auscultation:
• Listen to the Foetal heart rate and rhythm, count
for one complete minute to ascertain regularity. 
• Laboratory test
• Urine:- For Protein and glucose
• Blood Tests: Collect blood samples for - RPR, HIV,
Haemoglobin, Rhesus and blood grouping.
TREATMENT
• The following are the drugs given to the pregnant
woman;
• Intermittent Presumptive Treatment
• Three doses of Fansidar (SP) to be given at 1st, 2nd,
and 3rd visits to prevent malaria in pregnancy
and/or treat asymptomatic malaria.
• The SP is to be taken by the woman under Direct
observation by the Nurse.
• Tetanus toxoid injection to be given up to 4th dose
to prevent adult/neonatal tetanus.
• Mebendazole 500 mg per oral stat is given for
deworming.
• This is given as a single dose with a minimum
gestational age of 20 weeks.
• Daily doses of ferrous sulphate 200mg and Folic
acid 5 mg to prevent and correct iron deficiency
anaemia and folic acid deficiency anaemia.
• INFORMATION EDUCATION AND
COMMUNICATION (IEC)
• Give IEC on;
• Nutrition in pregnancy
• Hygiene in pregnancy
• Danger signs in pregnancy
• Minor disorders in pregnancy
• Birth preparedness and complication readiness,
• Malaria in pregnancy
• EMTCT
• Importance of ANC
• Signs of true labour
• Family planning
• Birth registration
• Child immunisation and many more.
• 
• Recording of findings
• Record or enter all the information gathered and
the care provided on the Antenatal Card and Safe
Motherhood Register.