Important aspects of routine Antenatal care in primary care for women of child bearing age

1. ANTENATAL CARE
FAMILY MEDICINE DEPARTMENT
AKTH KANO
DR OGECHUKWU MBANU
AUGUST 11TH 2017
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3. OUTLINE
DEFINITION
INTRODUCTION
OBJECTIVE
GOALS
COMPREHENSIVE MATERNITY CARE
MODELS OF ANTENATAL CARE
ANTENATAL CARE
WARNING SYMPTOMS
MITIGATING FACTORS AGAINST ANC
REFERENCES
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4. DEFINITION
Antenatal care is a planned program of observation,
education, and medical management of pregnant
women directed toward making pregnancy and
delivery a safe and satisfying experience
OR
Antenatal care can also be defined as the care that is
given to an expected mother from time conception is
confirmed until the beginning of labor
4

5. INRODUCTION
Every year there are an estimated 200million
pregnancies in the world . Each of these
pregnancies is at risk for an adverse outcome for
the woman and her infant.
While risk cannot be totally eliminated ,they can
be reduced through effective ,and acceptable
antenatal care
Globally 85% of pregnant women access
antenatal care with a skilled health personnel at
least once.
 only six in ten (58%)receive at least four ANC
visits
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6. INRODUCTION CONT’D
The sustainable developmental goal 3 (SDG 3)
has the agenda to reduce the global maternal
mortality rate to less than 70% per 100000 life
births by 2030
As of 2015 developing regions account for
about 99% with sub –saharan africa
accounting for 66%
Nigeria and India are estimated to account for
over one third of all maternal deaths world
wide in 2015 with 19% and 15% respectively
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7. OBJECTIVE
The overall objective is to ensure a
normal pregnancy with delivery of a
healthy baby from a healthy mother
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8. GOALS
To reduce maternal mortality and morbidity
rates
To improve the physical and mental health of
women and indeed the entire family
To prevent and identify maternal and fetal
abnormities that can affect pregnancy
outcome
To decrease financial burden for care of
mothers especially in developing countries
To remove the fear about the delivery and to
gain confidence before labour 8

9. GOALS (CONT’D)
These goals can be achieved by
1. Early screening tests
2. Prevention, detection and treatment at any
earliest complication
3. Continued medical surveillance and
prophylaxis
4. Educating the mother about the physiology
of pregnancy and labour by demonstrations ,
charts and diagrams so that fear is removed
and psychology is improved
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10. GOALS (CONT’D)
5.To predict problems on the basis of the medical ,
socio-economic , obstetrics history and physical
examination
6 .Discussion with the couple about the place, time
and expected mode of delivery and care of the
newborn
7. Motivation of the couple about need for family
planning
8. Counseling the mother about breast –feeding ,
post-natal care and immunization
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11. Comprehensive maternity care
The type of maternity care given in this hospital is
the comprehensive maternity care.
Comprehensive maternity care comprises of
1. Preconception care
2. Antenatal care
3. Intrapartum care
4. Postnatal care
Antenatal care comprises of: Careful history
taking, examination, investigations', prophylaxis
and treatments
Counseling given to the pregnant woman at
different stages of the pregnancy 11

12. Models of Antenatal Care Provision
• Traditional ANC model(s)
Began two hundred years ago and instituted
programs and interventions that were traditionally
thought to benefit the mother and her fetus
Activities were not scientifically tested as to their
effectiveness or benefit
Followed a visit pattern of 4 weeks until 28th
week; then every 2 weeks until 36th week and a
weekly visit with many interventions at each visit
Led to upto 14 visits and cost incurred for many
investigations that were not necessarily warranted
It was suggested that the traditional ANC practice
be replaced by new models of focused ANC
programs 12

13. Models of ANC – Continued
• Focused ANC- FANC : INTRODUCED IN 2002
FANC is providing goal oriented care that is timely
, friendly , simple, ,beneficial and safe to pregnant
women in order to achieve a good outcome for
the mother and baby and prevent any
complications that may occur in pregnancy,
labour, ,delivery and postpartum
Suggested four routine visits only at different
gestations with a few evidence based diagnostic
and intervention modalities performed at each
visit
– Visits were at <16,28,32 and 36 weeks
– Additional visits were individualized depending on
patients need 13

14. Focused ANC Program Activities
Visit First Visit Second visit Third visit Fourth visit
Gestational
age
<16 weeks 28 weeks 32 weeks 38 weeks
Activities •Classification to
either the basic or
specialized
component
•Clinical exam
•Hgb test
•Gestational age
determination
•Blood pressure
•Weight/Height
•Syphilis/STIs
•Urinalysis
•ABO/RH
•TT administration
•Iron /FA
supplementation
•Document on ANC
card
•Clinical exam for
anemia
•Gestational age;
FH; FHB exam
•Blood pressure
•Weight- only if
underweight at
initial visit
•Urinalysis- for
nullipara or
previous
preeclampsia
•Iron / FA
supplementation
•Complete on ANC
card
•Hgb test
•TT second dose
•Instructions for
birth planned
•Recommendation
s for
lactation/contrace
ption
•Document on
ANC card
•Examine for
breech
presentation
•Document on
ANC card
Asheber Gaym, 2009

15. WHAT'S NEW?
2016 WHO ANC MODEL

16. A minimum of eight contacts Is now been
recommended
This recommendation was informed by evidence
suggesting
• increased perinatal deaths in 4-visit ANC model
• improved safety during pregnancy through
increased frequency of maternal and fetal
assessment to detect complications
• improved health system communication and
support around pregnancy for women and families
• that more contact between pregnant women and
doctor is more likely to lead to a positive pregnancy
experience

17. 2016 WHO ANC model

18. Antenatal Care
• Booking visit –
– Detailed evaluation through history, physical exam
and laboratory work-up as required
– Based on the results further work up and a program of
care is planned on individual basis
– Maternal or fetal factors that may require special care
for the specific mother are identified and noted
• Subsequent visits-
– Are conducted based on the plans made at initial visit
– Newly developing situations during follow up are also
noted and management plans modified accordingly
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19. HISTORY TAKING
Bio-data of the patient . This comprises of –
 Name
 Age
 Address
 Her occupation
 Marital status , duration of marriage
 Religion
 Partners name , and occupation etc
Presenting complaints and history of presenting
complaints
Gynaecological history- LMP(in some places they use
LNMP ie last normal menstrual period) ,menarche
,menstrual period pattern ,menstrual cycle 19

20. HISTORY(CONT’D)
History of index pregnancy
Obstetrics history – gravida , parity, details of previous
pregnancies ,determination of GA and EDD .EDD is
determined using NAEGELE’S FORMULA
Contraceptive history
Drug history ,history of immunization
Past medical and surgical history
Family and social history
NB: Even if there is no complaint, enquiry is to be made
about the sleep, appetite, bowel habit and urination
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21. GENERAL SYSTEMIC REVIEW
CNS
GIT
GENITALIA
URINARY SYSTEM
MUSCULOSKELETAL SYSTEM
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22. PHYSICAL EXAMINATION
General examination
Abdominal examination
Systemic examination
Physical examination is important because –
It exposes the patients current state
It helps to detect previously undiagnosed physical
problems that may affect the pregnancy
To establish baseline levels that will guide the
treatment of the expectant mother and the fetus
throughout pregnancy
22

23. Important to note before physical
examination
Before examination , explain to the patient the
need and the nature of the proposed
examination
Obtain a verbal consent
The examiner (either male or female)should be
accompanied by another female.
Respect her privacy and examine in a private
room.
Expose only relevant parts of her anatomy for
examination
Ensure the patient is comfortable and warm
Ask her to empty the bladder. 23

24. IMPORTANT TO NOTE (CONT’D)
Patient should lie in the dorsal position with
thighs slightly flexed .
Stand to her right.
She is slightly rolled to the left side to prevent
compression of the inferior vena cava by the
enlarged uterus(inferior venacaval syndrome
or supine hypotensive syndrome).
Ask for any tender area before palpating the
abdomen
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25. General Examination
• GENERAL APPEARANCE
• FACIAL FEATURE/EXPRESSION
• NUTRITIONAL STATUS
• HEIGHT
• WEIGHT
• BMI
• SKIN
• ICTERUS
• LEGS
• NECK
• BREAST

26. ABDOMINAL EXAMINATION
The abdomen is examined in three parts
1. Inspection
2. Palpation
3. Auscultation
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27. INSPECTION
Size of uterus
If the length and breadth are both increased
Multiple gestation , polyhydramnios
If the length is increased only
Large baby
Shape of the uterus
Length should be large than broad. This
indicates longitudinal lie. But if the uterus is
low and broad it indicates transverse lie .
Pendulous abdomen in a primigravida is a sign
of inlet contraction
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28. INSPECTION (CONT’D)
If there is lateral implantation of the placenta
then the uterine enlargement will be
asymmetrical – piskacek’sign.
look for fetal movements (more prominently seen
in 3rd trimester / less in oligohydramnios)
Look for scars
Herniations
Cutaneous signs such as linea nigra ,striae
gravidarum , is umbilicus flat or everted
,superficial viens
Skin conditions ; scabies ,fungal infection
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29. PALPATION
Aim
Palpation of fetal parts
Height of the uterus(symphysis – fundal height)
Foetal lie
Presentation
Position
Attitude
Level of engagement
Active foetal movements
To assess fetal position,lie,presentation, attitude
and engagement, LEOPOLD’S MANOUEVRE is
followed
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30. PALPATION(CONT’D)
Fetal position, lie, presentation, engagement
and attitude of fetal head are assessed by
LEOPOLD’ MANOUEVRE – this is done by four
obstetrics grips
1. Fundal grip
2. Lateral grip or umbilical grip – to assess fetal
lie
3. Pawliks grip – to assess presenting part
4. Deep pelvic grip – to assess engagement and
attitude of fetal head
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31. PALPATION(CONT’D)
 Estimate foetal weight
The Following methods can be used :
• 1- Fetal Growth Velocity : Normal growth-26.9
gm/ day
• More during 32-36 weeks
• Declines by 24 gm/day after 36 weeks
• ** individual fetal growth varies
• 2- Johnsons Formula:
• Fundal height (cm)- 12 (if Vertex above Ischial
Spine ) × 155 = weight
• Fundal height (cm)- 11 (if vertex below Ischial
Spine) × 155 = weight
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32. PALPATION(CONT’D)
AUSCULTATION :
 FHS is maximum below the umbilicus in
cephalic presentation and
FHS is maximum around the umbilicus in
breech
Auscultation can be done using :
1. Pinnard's Foetal Stethoscope and sonicaid
2. Regular stethoscope : useful in monitoring
heart beat after 18 to 20 weeks (same as
pinnards fetoscope) .
3. Ultrasound fetoscope: 32

33. Vaginal Examination
• A vaginal examination (speculum or digital
examination) can be used to
To detect anatomical abnormalities
To detect FGM if present and the type
to see any rupture of membranes,
 to determine onset of labour by checking
cervix
cephalopelvic disproportion.
• Can be done bimanually by hands and by
speculum.

34. Vaginal examination:
PRE-REQUISITS:
• EXPLANATION
• EMPTY BLADDER
• DORSAL POSITION
• FULL ASEPSIS
• Equipment are
present
Contraindications :
 Placenta praevia.
 Abruptio placentae

35. Pelvic assessment
This is done to assess for the adequacy of the
pelvis
Check ischial spines if prominent or not
Diagonal conjugate distance from lower
border of the symphysis pubis to the sacral
promontory (pelvic inlet)
Shape of the sacrum
Side walls of the pelvis

36. OTHER SYSTEMIC EXAMINATIONS
This will be determined from the patients
presenting complaint and the finding on
general physical examination
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37. INVESTIGATIONS DURING ANTENATAL CARE
Diagnostic procedure Gestational age
Hemoglobin/hematocrit determination Initial visit; repeat at 28-32 weeks
ABO and RH typing Initial visit
VDRL Initial visit; repeat at 28 weeks if negative
Urinalysis At each visit to detect proteinuria
Urine culture and sensitivity Initial visit to detect asymptomatic bacteriuria
Serum alpha-fetoprotein test 16-18 weeks
Routine ultrasonography 10-13 ,18-20,28,36 weeks
Screening test for gestational diabetes 24-28 weeks
Pap smear Initial visit especially if not done in the past 2
years
Cervical smear gram stain and culture Initial visit
HBsAg; HIV tests Initial visit
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38. INVESTIGATIONS(CONT’D)
OTHER INVESTIATIOS INCLUDE
FBS
OGTT
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39. Ultrasound scan
At BOOKING:
for dating
Localize fetus in the uterus
Detect multiple gestation
Screening for Downs syndrome
At18 -20 weeks for fetal anomaly
• At 28 weeks for placenta localization
if earlier suspected to be low lying
• At 36 weeks for estimated birth
weight, AFI, presentation
November 10, 2019 39

40. Assurance of fetal well being at ANC
• Progressive increase in maternal weight
• Progressive fundal height growth as per expectations
• Adequate maternal perception of fetal movement ( at
least 10 in 12 hours)
• Fetal well being tests – from 28 weeks onwards
(specific timing of follow up initiation depends on the
individual risk profile concerned)
– Non stress test
– Contraction stress test
– Fetal biophysical profile score
– Doppler ultrasound velocimetry
• Ultrasonographic fetal scan for anomalies
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41. Routine medical interventions
Folic acid supplementation(0.4mg) daily
Iron supplementation (30-60mg) daily of
elemental iron
Intermittent preventive treatment for malaria
with fansidar twice during pregnancy
Tetanus toxoid injection
The following are not recommended :
,supplementation with multiple
micronutrients , Vit 6 (pyridoxine),VIT E, VIT C
, VIT D
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42. EDUCATION AND COUNSELLING OF
THE PREGNANT WOMAN
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43. Diet
• The daily requirements are:
* Calories: 2500 Kcal.
* Proteins: 60 gm.
* Carbohydrates: 200- 400 gm.
* Lipids: should be restricted.
* Vitamins:
o Vitamin A: 5000 IU.
o Vitamin B1 (Thiamine): 1mg.
o Vitamin B2 (Riboflavin): 1.5 mg.
o Nicotinic acid: 15mg.
o Ascorbic acid (vit. C): 50mg.
o Vitamin D: 400 IU.
* Minerals:
o Iron: 15 mg.
o Calcium: 1000 mg.

44. • So the suggested daily diet should include:
* One litre of milk or its derivatives,
* 1-2 eggs,
* fresh vegetables and fruits.
* 2 pieces of red meat replaced once weekly
by sea fish and once weekly by calf ’s liver.
* Cereals and bread are recommended also.
• Coffee and tea: should be restricted.
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45. COUNSELLING ON DAY TO DAY
ACTIVITIES
Smoking: should be avoided as it may cause
intrauterine growth retardation or premature labour.
Rest and sleep: 2 hours in the midday and 8 hours at
night.
Exercises: violent exercises as diving and water sports
should be avoided. House work short of fatigue and
walking are encouraged.
ON CLOTHINGS
Lighter and looser clothes of non synthetic materials
are better due to increased BMR and sweating
Clothes which hang from the shoulders are more
comfortable than that requiring waste bands
Breast support is required.
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46. Counseling cont’d
Bathing: Shower bathing is preferable than
tube or sea bathing for fear of ascending
infection. Vaginal douching should be avoided
Shoes: High - heeled shoes should be
discouraged as they increase lumbar lordosis,
back strain and risk of falling
 Bowels: Constipation is avoided by increasing
vegetables, fluids and mild exercise. Liquid
paraffin should not be used for long period as
it interferes with absorption of fat- soluble
vitamins (A and D
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47. Counseling cont’d
Coitus: Whenever abortion or preterm labour is a
threat, coitus should be avoided. Otherwise, it is
allowed with less frequency and violence. Some
obstetricians advise abstinence in the last 4
weeksof pregnancy for fear of ascending infection
 Travelling: long and tiring journeys should be
avoided particularly if the woman is prone to
abortion or preterm labour. Flying is not
contraindicated but not the long ones and near
term
Medications: not to be taken without
obstetrician advice due to risk of teratogenicity
Exposure to irradiation: is to be avoided whether
diagnostic or therapeutic 47

48. WARNING SYMPTOMS
 vaginal bleeding,
 gush of fluid per vagina,
 severe or persistent abdominal pain,
 persistent headache,
 blurring of vision,
severe oedema of lower limbs or swelling of
the face,
 persistent vomiting.
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49. Mitigating factors against ANC
Inadequate accessibility to health care facilities
Poor female education
Economic factors
Lack of adequate facilities in our health
institutions
Inadequate public awareness
Cultural practices e.g. early marriage ,use of local
untrained birth attendants
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50. THANK YOU
FOR
LISTENING
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51. REFERENCES
1. ABC of antenatal care ,fourth edition ,Geoffrey
Chamberlain.
2. Obstetrics examination ,clinical skills resource centre
university of Liverpool uk
3. WHO recommendations on antenatal care for a positive
pregnancy experience 7 November 2016
4. D.C. Dutta’s texbook of obstetrics, 8th edition-2015-
Google eBook
5. Oxford handbook of clinical examination and practical
skills, 1st edition (vishal)
6. Textbook of Obstetrics and Gynaecology for Medical
Students .second edition , Akin Abgoola
7. Google images
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