Routine antenatal care for women of child bearing age in primary health care

1. ANTENATAL CARE
FAMILY MEDICINE DEPARTMENT
AKTH KANO
DR OGECHUKWU MBANU
1

3. OUTLINE
DEFINITION
INTRODUCTION
OBJECTIVE
GOALS
COMPREHENSIVE MATERNITY CARE
MODELS OF ANTENATAL CARE
THE PROCESS INVOLVED IN ANTENATAL CARE
WARNING SYMPTOMS
MITIGATING FACTORS AGAINST ANC
REFERENCES
3

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
According to WHO as of 2015 the maternal mortality
in Nigeria is 814 per 100000 lifebirths ,and skilled
attendance at birth (% of births) is 45% 5

6. INRODUCTION CONT’D
As of 2015 developing regions account for
about 99% of maternal mortality ,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
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
6

7. OBJECTIVE
The overall objective of antenatal care
is to ensure a normal pregnancy with
delivery of a healthy baby from a
healthy mother
7

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
9

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
10

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
• There was increased perinatal deaths in 4-visit ANC
model
• It improved safety during pregnancy through
increased frequency of maternal and fetal
assessment to detect complications
• It 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. The process involved in 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
18

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
20

21. GENERAL SYSTEMIC REVIEW
CNS
GIT
GENITALIA
URINARY SYSTEM
MUSCULOSKELETAL SYSTEM
21

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
24

26. General Examination
• GENERAL APPEARANCE
• FACIAL FEATURE/EXPRESSION
• NUTRITIONAL STATUS
• HEIGHT
• WEIGHT
• BMI
• SKIN
• ICTERUS
• LEGS
• NECK
• BREAST

27. Neck
- Diffuse swelling
- common- 50 %
cases of pregnancy
Abnormal swelling

28. BREAST
Normal in pregnancy
Abnormal in pregnancy

29. ABDOMINAL EXAMINATION
The abdomen is examined in three parts
1. Inspection
2. Palpation
3. Auscultation
29

30. 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
30

31. 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
31

32. LINEA NIGRA
• Dark vertical line appearing on the abdomen
from the pubis to above the umbilicus during
pregnancy due to increase melanocyte
stimulating hormone made by the placenta

33. STRIAE GRAVIDARUM
• Specific scarring of the skin due to sudden
weight gain during pregnancy. Caused by
tearing of the dermis and results in atrophy

34. 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 or the classical method
34

35. PALPATION(CONT’D)
Height of the uterus( symphysio –fundal height)
This is the distance from the symphysis pubis to
the uterine fundus (top of the uterus)
TECHNIQUE
Place the ulnar border of the left hand on the
highest part of the uterus(fundus)
Mark this point with a pen after obtaining
permission
The distance between the upper border of the
symphysis pubis up to the marked point is
measured by tape
This usually corresponds to gestational age
35

36. FUNDAL REGION
SYMPHYSEAL REGION
TAPE

37. PALPATION(CONT’D)
 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
37

38. 1) Fundal grip:
• Both hands placed over the fundus and the contents
of the fundus determined.
• A hard smooth, round pole indicates a fetal head.
• Broad, soft and irregular mass suggestive of breech.
• In transverse lie no parts are palpated.

39. Lateral Grip

40. 2) Lateral Grip or umbilical grip:
• Move both hands in a downward direction
from the fundus along the sides of the uterus
to determine the "lie" of the fetus.
• "Lie" is the relationship btw the longitudinal
axis of the fetus and the longitudinal axis of
the mother.
• The "lie" is usually longitudinal, hence baby is
lying length-wise in the same direction as
mother's longitudinal axis.

41. Pawliks grip:

42. 3) Pawliks grip: (second pelvic grip )
• The thumb and four fingers of the right
hand are placed over the lower pole of
uterus keeping the ulnar border of palm
on the upper border of the suprapubic
area to determine the presenting part.
• Presenting part of fetus is the lowest
part of the fetus at the inlet of the
pelvis.

43. • Note made as to which hand first touches the fetal
head (This point called cephalic prominence).
• Cephalic prominence helps determine the attitude
(i.e. flexion, deflexed or extended) of fetal head.

44. 4) Deep pelvic grip: ( first pelvic grip )
• Determines two points about the fetus
1) The attitude of the fetal head
2) Engagement of the fetal head
1) The attitude of the fetal head :
The examiner turns around to face patients feet.
• Each hand placed on either side of the fetal
trunk lower down.
• The hands moved downwards towards the
fetal head.

46. • If cephalic prominence is the sinciput and is
on the opposite side of fetal back, fetal head is
well flexed (Normal Position).
• If cephalic prominence is the occiput and is on
the same side as fetal back, fetal head is
extended (abnormal position).
• If examiners hands reach the fetal head
equally on both sides ie both sinciput and
occiput then the fetal head is deflexed
(Military position, indicating mal-position)

48. POSITION
• •The position of the foetus is described by the
relationship of the presenting part to the
maternal pelvis
• •The denominator for the presenting part for
a Cephalic presentation = occiput and for a
Breech presentation = sacrum
48

49. Direct occipito-anterior (DOA)
Occiput directly faces the front.Fetal spine is in
alignment with mothers spine.
49

50. The description for a cephalic presentation with
the occiput lying directly lateral to the left . This is
–LEFT
OCCIPITO-LATERAL
50

51. Left occiput-Anterior (LOA)
Fetal spine is in the same plane as the mother’s
spine, This is a longitudinal lie
51

52. Right occipito-lateral (ROL)
The Occiput points to the mother’sRight.The fetal
spine is in alignment with the mother’s spine
52

53. Direct occipito-posterior (DOP)
Fetal spine is in alignment
with the mother’s spine
53

54. Left occipito-posterior (LOP)
Occiput here is slightly to the Mother's left -It is nearly
a Direct Occipito posterior-It may be difficult to
palpate the fetal back
54

55. Right occipito-posterior(ROP)
Fetal spine is in alignment with mother’s
spine.
55

56. • Other "lies" are :
• Transverse Lie: fetus lies across the
longitudinal axis of mother and
• oblique lie: fetus lies at an oblique angle to
the mother's longitudinal axis.
• Can also determine which side the foetal back
is situated by feeling the firm regular surface
of the foetal back on one side and the
irregular, lumpy surface as the foetal limbs on
the other side. This can help us determine the
position of the fetus

57. 57

58. 58

59. 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
59

60. 2)Engagement of the fetal head:
- Engagement of the fetal head is defined as having
occurred once the widest transverse diameter of the
fetal head (bi-parietal diameter) has passed through
the pelvic inlet into the true pelvis.
- Procedure: Continue moving both hands down
around the fetal head, determine how far around the
head you can get.
- Examiner should be able to palpate part of fetal head
still in the lower abdomen (also called the 'false'
pelvis but cannot palpate the part of fetal head in the
true pelvis).

61. Abdominal palpation to determine engagement of the
head
A- Divergence of fingers- Engaged Head
B- Convergence of fingers- Not Engaged

62. - If you divide the fetal head into five-fifths, you
estimate how many fifths of the fetal head can
be felt.
- If 5,4 or 3 fifths can still be palpated, most of
the head is still up, hence the widest part of
the head has not engaged into the pelvis.
- If only 2,1 or 0 fifths of fetal head felt, the
widest part of the head has engaged into the
pelvis.

64. 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: 64

65. 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.

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

67. 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

68. OTHER SYSTEMIC EXAMINATIONS
This will be determined from the patients
presenting complaint and the finding on
general physical examination
68

69. 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
69

70. INVESTIGATIONS(CONT’D)
OTHER INVESTIATIOS INCLUDE
FBS
OGTT
70

71. 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 71

72. 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
72

73. 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
73

74. EDUCATION AND COUNSELLING OF
THE PREGNANT WOMAN
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75. 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.

76. • 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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77. 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.
77

78. Counseling cont’d
Bathing: Shower bathing is preferable than
tube 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
78

79. 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.
Abstinence in the last 4 weeksof pregnancy to
prevent ascending infections
 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 doctors
advice due to risk of teratogenicity
Exposure to irradiation: is to be avoided whether
diagnostic or therapeutic 79

80. 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.
80

81. 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
Poor staffing of medical facilities in terms of both
number and qualification.
81

82. THANK YOU
FOR
LISTENING
82

83. 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. WHO guideline on antenatal care (2016) overview
8. Antenatal care presentation,Asheber Gaym M.D. ,January 2009
9. Obstetrics history and examination presentation. Rajeev Baham
10. Examination of an obstetrics case presentation ,Dr Vamshikrishna
Dussa,16th March 2016
11. www .freelivedoctor.com
12. Google images
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