antenatal care

Dr Mekdes Bahru (R4)

 objectives
• Good care during pregnancy is important for the health of
the mother and the development of the unborn baby.

• Pregnancy is a crucial time to promote healthy behaviours

and parenting skills.

• Good ANC links the woman and her family with the formal
health system, increases the chance of using a skilled
attendant at birth and contributes to good health through
the life cycle.

• Inadequate care during this time breaks a critical link in the

continuum of care, and effects both women and babies:
 History
• Prenatal care started in Edinburgh at the turn of the
20th century, but clinics for the checking of
apparently well pregnant women were rare before the
first world war.
• Janet Campbell, one of the most farsighted and clear
thinking women in medicine, started a national
system of antenatal clinics with a uniform pattern of
visits and procedures; her pattern of management
can still be recognised today in all the clinics of the
Western world.
 Definition
• General health care given to pregnant women to
promote and maintain optimal health of the
mother throughout the pregnancy, labor and
puerperium with having and rearing of healthy
baby

• Prenatal care is an excellent example of

preventive medicine.
• The quality of antenatal care (ANC) is dependent on

• the qualifications of health providers and the number and

frequency of ANC visits.

• The content of services received and the kinds of information

given to women during their ANC visits are also important
components of quality care.

• These services raise awareness of the danger signs during the

pregnancy, delivery, and postnatal period, improve the health-
seeking behaviour of women, orient them to birth preparedness
issues, and provide basic preventive and therapeutic care.
 where and by who
• Prenatal care is provided at a variety of sites, ranging
from referral Hospitals , the private health institutions,
health centres, to the patient’s home.
• Most pregnant women are healthy, with normal
pregnancies, and can be followed by an obstetrical
team including nurses, nurse practitioners, and
nurse- midwives, with an obstetrician available for
consultation.
• The goal of the ANC package is to prepare for birth and
parenthood as well as prevent, detect, alleviate, or
manage the three types of health problems during
pregnancy that affect mothers and babies:

• complications of pregnancy itself

• pre-existing conditions that worsen during pregnancy

• effects of unhealthy lifestyles

 Types

• Routine/Traditional ANC

• Focused ANC
 Routine/Traditional ANC

• Based on high risk / low risk approach.

• Emphasis on frequent visits:
For high risk mothers
• every 4 weeks for the first 28 weeks of pregnancy, every 2 to
3 weeks until 36 weeks, and weekly thereafter, if the
pregnancy progresses normally.
 risk approach

A strategy to identify risk factors for undesirable

outcomes, with care to be delivered according to
individual needs
1. high levels of false positive and false negative
2. No amount of screening will separate those women
who will from those who will not need emergency
medical care .
Advantage

high maternal satisfaction with care, as well as decreased maternal

anxiety.

Disadvantage
•quantity was emphasised than quality

•not suitable for resource limited setup

•difficult to predict most obstetrical complication

•Risk factors are usually not direct cause of complications

•It fails to distinguish who will develop complications and who will not
•women may have a false sense of security and may not be prepared
for an emergency
For ANC to be effective in reducing maternal mortality, it must
be
• goal oriented and
• focused on “screening to detect a problem rather than
screening to predict a problem” and on treating any
problem that can complicate a pregnancy.
Focused ANC
• Focused or goal oriented ANC services provide
specific evidence-based interventions for all
women, carried out at certain critical times in
the pregnancy.
• The new model had median of 4/5 goal oriented\
visits vs 12 visits in the standard.
• Hospital admission diagnosis rate of LBW, UTI,
Eclampsia, PE similar between the two groups.
Individualized, woman-centered care based
on each woman’s:
• Specific needs and concerns
• Circumstances
• History, physical examination, testing
• Available resources
advantage

• goal oriented

• every pregnancy is risk

• low cost

disadvantage

• less maternal satisfaction

• more perinatal mortality

 principles of FANC
• The model should include simple format
• Identification of women with special health conditions
or risk factors should be done very carefully
• Health care providers should make all pregnant
women feel welcome at their clinic
• Only examinations & tests that serve an immediate
purpose that have been proven to be beneficial should
be performed.
• Whenever possible rapid & easy to perform test
should be used, treatment should be initiated at the
clinic the same day.
The essential elements of a focused approach to antenatal
care
1. Identification and surveillance of the pregnant woman
and her expected child
2. Recognition and management of pregnancy-related
complications, particularly pre-eclampsia
3. Recognition and treatment of underlying or concurrent
illness
4. Screening for conditions and diseases such as anaemia,
STIs (particularly syphilis), HIV infection, mental health
problems, and/or symptoms of stress or domestic violence
5. Preventive measures, including tetanus toxoid
immunisation, de-worming, iron and folic acid, intermittent
preventive treatment of malaria in pregnancy (IPTp),
insecticide treated bednets (ITN)
6 . Advice and support to the woman and her family for
developing healthy home behaviours and a birth and
emergency preparedness plan to:
o Increase awareness of maternal and newborn health
needs and self care during pregnancy and the postnatal
period, including the need for social support during and
after pregnancy
o Promote healthy behaviours in the home,
including healthy lifestyles and diet, safety and injury
prevention, and support and care in the home, such as
advice and adherence support for preventive interventions
like iron supplementation, condom use, and use of ITN
 o Support care seeking behaviour, including recognition
of danger signs for the woman and the newborn as well as
transport and funding plans in case of emergencies
o Help the pregnant woman and her partner prepare
emotionally and physically for birth and care of their baby,
particularly preparing for early and exclusive breastfeeding
and essential newborn care and considering the role of a
supportive companion at birth

o Promote postnatal family planning/birth spacing

 goal of FNAC

To promote maternal and newborn health and

survival through:
• Early detection and treatment of problems and
complications
• Prevention of complications and disease
• Birth preparedness and complication readiness
• Health promotion
 Timing of ANC Visits
• First visit: By 12 weeks or when woman first thinks she is
pregnant
• Second visit: At 24–28 weeks or at least once in second
trimester
• Third visit: At 32 weeks
• Fourth visit: At 36 weeks
• Other visits: If complication occurs, follow up or referral is
needed, woman wants to see provider, or provider changes
frequency based on findings (history, exam, testing) or local
policy
 first visit

• The first assessment in ANC is to distinguish pregnant

women who require standard care, such as the four-visit
model, from those requiring special attention and more
visits. Depending on the setting, approximately 25-30
percent of women will have specific risk factors which
require more attention. These women need more than four
visits.
goals

first visit second visit third visit fourth visit

Confirm pregnancy Assess maternal Assess maternal and Assess maternal and
and EDD, classify and fetal well-being. fetal well-being. fetal well-being.
women for basic Exclude PIH and Exclude PIH, anaemia, Exclude PIH, anaemia,
ANC (four visits) or anaemia. multiple pregnancies. multiple pregnancy,
more specialized Give preventive Give preventive malpresentation.
care. Screen, treat measures. measures. Give preventive
and give preventive Review and modify Review and modify measures. Review and
measures. birth and emergency birth and emergency modify birth and
Develop a birth plan. Advise and plan. Advise and emergency plan. Advise
and emergency plan. counsel. counsel. and counsel.
Advise and counsel
 activities
• history taking

• physical examination

• screening and testing

• Treatments

• Preventive measures

• Health education, advice, and counselling

 first visit activities
• history taking - detailed obstetric , medical and psychosocial Hx

• physical examination - complete examination

• screening and testing - Haemoglobin Syphilis ,HIV , Proteinuria

Blood/Rh group* Bacteriuria*

• Treatments - Syphilis ,ARV if eligible Treat bacteriuria if indicated

• preventive measures - tetanus toxoid Iron and folate+

• Health education, advice, and counselling -Self-care, alcohol and

tobacco use, nutrition, safe sex, rest, sleeping under ITN, birth and
emergency plan
 second visit activities
• history taking -Assess significant symptoms. Check record for previous
complications and treatments during the pregnancy. Re-classification if
needed

• physical examination - Anaemia, BP, fetal growth, and movements

• screening and testing - bacteriuria

• Treatments - Antihelminthic**, ARV if eligible Treat bacteriuria if

indicated*

• Preventive measures - Tetanus toxoid, Iron and folate IPTp , ARV

• Health education, advice, and counselling -Birth and emergency plan,

nutrition , reinforcement of previous advice
 third visit activities
• history taking -Assess significant symptoms. Check record for previous
complications and treatments during the pregnancy. Re-classification if needed

• physical examination - Anaemia, BP, fetal growth, and movements , multiple

pregnancy

• screening and testing - bacteriuria

• Treatments - ARV if eligible Treat bacteriuria if indicated*

• Preventive measures - Iron and folate IPTp , ARV

• Health education, advice, and counselling -Birth and emergency plan, infant
feeding, postpartum/postnatal care, nutrition, pregnancy spacing, reinforcement of
previous advice
 fourth visit activities
• history taking -Assess significant symptoms. Check record for previous complications
and treatments during the pregnancy. Re-classification if needed

• physical examination - Anaemia, BP, fetal growth, and movements , multiple pregnancy ,
malpresentation

• screening and testing - bacteriuria

• Treatments - ARV if eligible Treat bacteriuria if indicated , If breech, ECV or referral for
ECV

• Preventive measures - Iron and folate , ARV

• Health education, advice, and counselling -Birth and emergency plan, infant feeding,
postpartum/postnatal care, pregnancy spacing, nutrition , reinforcement of previous
advice
 Birth Preparedness and Complication
Readiness

Objectives
• Develop birth plan—exact plan for normal birth
and possible complications:
• Arrangements made in advance by woman and
family (with help of skilled provider)
• Usually not a written document
• Reviewed/revised at every visit
• Minimize disorganization at time of birth or in
an emergency
• Ensure timely and appropriate care
 Birth Preparedness and Complication
Readiness

Objectives
• Develop birth plan—exact plan for normal birth
and possible complications:
• Arrangements made in advance by woman and family
(with help of skilled provider)
• Usually not a written document
• Reviewed/revised at every visit
• Minimize disorganization at time of birth or in an
emergency
• Ensure timely and appropriate care
 …Birth Plan

• Family and Community Support: Care for family in

woman’s absence and birth companion during labor

• Blood Donor: In case of emergency

• Needed Items: For clean and safe birth and for newborn
care

• Danger Signs/Signs of Advanced Labor

 Essential Elements of a Birth
Plan
• Facility or Place of Birth: Home or health facility for
birth, appropriate facility for emergencies
• Skilled Provider: To attend birth
• Provider/Facility Contact Information
• Transportation: Reliable, accessible, especially for
odd hours
• Funds: Personal savings, emergency funds
• Decision-Making: Who will make decisions, especially
in an emergency

Berhanu M
 Record Keeping
Record all information on the ANC chart and clinic card:

Subsequent ANC Visits

• Interim history
First ANC Visit
• History • Targeted physical

• Physical examination examination, testing

• Care provision,
• Testing
• Counseling, including birth
• Care provision
• Counseling, including birth plan
plan and use of ITNs (and
relevant information on how
• Date of next ANC visit
client obtained and used
ITN)
• Date of next ANC visit
 Barriers to effective antenatal care

• Inadequate infra-structural resources

• Poor quality of care and treatment of clients

• Ignorance of the importance and value of ANC

• Not customary, In most societies there is no tradition of

antenatal care

• Cultural, traditional and religious practices

 ….Barriers

• Lack of women’s autonomous decision-making on their

own health care seeking

• Poverty – fear of costs of transport and medical care

• Household responsibilities

• Illiteracy
 reading assignment

• nutrition during pregnancy

• immunisation during pregnancy

• weight gain during pregnancy