ANTENATAL CARE (ANC)

ANC is the care given to a pregnant women

with the aim of improving the maternal and
perinatal outcome.
Ultimate goal of ANC is the delivery of a
healthy baby without impairing the health of
the mother
ANC is provided by organized health care
services

ANC The traditional Approach

Began in the early 1900s
Care is given based on risk assessment and
frequent visits.
Based on initial Risk Assessment women are
labeled as either Low Risk ( at no risk ) or High Risk
However this approach was shown to be ineffective in
predicting and preventing pregnancy complications
E.g APH, Hypertensive disorders , obstructed labor,
infections can develop later in pregnancy or during
labor and delivery in both high and low risk women.

ANC-The traditional Approach

women required to have several visits

First visit preferably following the first missed
period followed by:
every four-week until the 28 WKs of GA ( 6 visits)
every fortnight from the 28 - 36 weeks of GA
weekly, or more frequently if indicated, 36
weeks onwards

Focused ANC
A new approach Recommended by WHO
(2002)
Being implemented in Ethiopia
Emphasizes the quality of care rather
than the quantity.

ANC-NUMBER AND FREQUENCY OF VISITS

Women who came late in pregnancy ( at any
GA after the 16th week)for the first time will
get all the services required for first visit as
well as services appropriate for her gestational
age.
Women are also advised for visiting the health
institution anytime if they have complaints or
problems.

Focused ANC
Women are put on either the basic (routine)
or specialized care programs on the first visit
A classifying check list is used for this purpose
A woman with any of the conditions (risks) in
the list deserve specialized care while those
with none of these conditions are eligible for
the basic/ routine follow up.
Pregnant women with identified risks will be
enrolled in specialized care , number and
frequency of visits depend on their specific
problem.

SAMUEL BEZABIH (MD) MEGABIT 2005

GUH

THE CLASSIFYING CHECK LIST

Obstetric History
Previous stillbirth or neonatal loss?
History of 3 or more consecutive spontaneous
abortions?
Birth weight of last baby < 2500g or >400gm.
Last pregnancy: hospital admission for PE/ HTN
/eclampsia?
RT surgery?(Myomectomy, fistula repair, cone
biopsy, CS, repaired rapture, CX. Circlage, septum
removal..)

THE CLASSIFYING CHECK LIST

CURRENT PREGNANCY
Multiple pregnancy
Age less than 16 years? or more than 40
years?
Isoimmunization Rh (-) in current or in
previous pregnancy
Vaginal bleeding
Pelvic mass
Diastolic BP 90mm Hg or more at booking

THE CLASSIFYING CHECK LIST

GENERAL MEDICAL CONDITION
Diabetes mellitus
Renal disease
Cardiac disease
Chronic Hypertension
Known 'substance' abuse (including heavy
alcohol drinking, Smoking)
Any other severe medical disease or condition
TB, HIV, Ca, DVT..

Focused ANC For normal pregnancies WHO

recommends only four antenatal visits
(Routine ANC).
1st visit before 16 weeks
2nd visit- 24- 28 wks of gestation
3rd visit- 30-32
4th visit 36-38

Objectives of Focused ANC

The major goal of focused antenatal care
is to help women maintain normal
pregnancies through:
1. Health promotion and disease prevention*
2. Early detection and treatment of
complications and existing diseases**
3. Birth preparedness and complication
readiness planning.

1. Health Promotion and Disease Prevention

Counseling is offered on such issues as :

Recognition of danger signs, what to do, and
where to get help
Voluntary counseling and testing for HIV
The benefit of skilled attendance at birth
Breastfeeding
Good nutrition and the importance of rest
Risks of using tobacco, alcohol, local stimulants,
and traditional remedies
Hygiene and infection prevention
Birth spacing

Cont
Interventions (care provision)
Immunization against tetanus
Iron and folate supplementation.
Malaria protection- insecticide-treated bed
net
PMTCT of HIV
Protection against iodine deficiency
Prevention of intestinal parasites.
Establishing access to family planning

2.Early Detection And Treatment Of Complications

And Existing Diseases*

The woman is examined and evaluated for

pre-existing or new health conditions that:
May affect the outcome of pregnancy,
Require immediate treatment
Or require a more intensive level of monitoring
and follow-up care over the course of pregnancy.

*Eg. Anemia, STI,UTI, intestinal parasites,

cardiac disease, malnutrition, TB v. Etc

3.Birth Preparedness and Complication

Readiness

Approximately 15% of women will develop a lifethreatening complication.(E.g, Vaginal bleeding)

So, every woman and her family should have a
plan for the following:
A skilled attendant at birth
The place of birth and how to get there including how
to access emergency transportation if needed.
Items needed for the birth
Money saved to pay for transportation, the skilled
provider and for any needed medications and supplies
that may not been provided for free
Support during and after the birth (e.G., Family,
friends)
Potential blood donors in case of emergency

1. ANC

st
1

visit

Should be before the end of the 4th month (16 week)

To establish diagnosis of pregnancy, estimation of GA.
To ascertain risk factors, and asses medical status of
the mother.
To determine eligibility for routine / basic component
or the need for specialized care and referral
To provide health promotional services (such as
education on nutrition supplements, danger signs of
pregnancy, labor, STI &, breast feeding)
To initiates preventive measures (such as
immunizations, iron supplementation, malaria
prophylaxis and control of mother to child transmission
of HIV)
Develop individualized birth plan.

ANC-The first visit

History
1. History of Present Pregnancy
Name, age, address, religion, education, gravidity,
parity, abortion.
Current pregnancy: planned/unplanned,
wanted/unwanted, supported/unsupported.
Assessment of gestational age
Last Normal Menstrual Period (LNMP), regularity of
menses, and use of contraception , EDD (LMP + 280 days).
Quickening
Symptoms & signs of pregnancy (if early gestation)

vaginal discharge / bleeding

Any complaints / concerns

ANC 1st ,HX.

2.Past Ob. history
Multiple gestation, Preterm / Post term birth,
Congenital anomalies
Still birth/Early neonatal death (ENND) ,Abortions
and ectopic pregnancy
Med. and surgical problems
APH / PPH
Hypertension / Eclampsia, SGA/LGA, IUGR,
operative deliveries
History of female genital cutting
Sepsis, STDs, other infections
SAMUEL BEZABIH (MD) MEGABIT 2005
GUH

ANC 1st ,HX.

3.Social, Family History

Family history of DM, HPN, multiple gestation,

Congenital abnormality
Personal and family history
Social status & support
Habits of smoking, alcohol abuse or drug use
SAMUEL BEZABIH (MD) MEGABIT 2005
GUH

ANC -First Visit

4.Medical history
Specific diseases and conditions: DM, renal
disease, cardiac disease, chronic hypertension, TB
, past history of HIV related illnesses and
HAART, varicose veins, DVT, allergies other
specific conditions depending on prevalence in
service area (for example, hepatitis, malaria)
Operations other than caesarean section
Blood transfusions. Rhesus (D) antibodies
Current use of medicines specify, any
medications

ANC First visit

General Physical Examination

General appearance,
vital signs
Height and weight
Clinical signs of anemia, icterus and edema
Systemic examination
Signs of physical abuse

ANC First visit

Obstetric Examination
Inspection:

Abdominal distention & Symmetry,

Streia, Dilated veins,
Fetal movement, any old scars

Palpation (Leopolds maneuver)

Uterine size:-Symphysis Fundal Height (SFH) with tape measure
or finger approximation.
Fetal lie, presentation, attitude and engagement

Auscultation: Fetal heart rate

Pelvic assessment
speculum examination as indicated look for: vulvar ulcer, vaginal discharge, scratch marks, pelvic
mass, cervical lesion and estimate uterine size in first
trimester,
genital malformation, severe FGM.

ANC first visit

Laboratory Tests
Urinalysis ( dipstick for proteinuria, bacteruria)
Blood group + Rh
Hemoglobin/Hematocrit
Syphilis test ( RPR, VDRL)
HIV test ( if the woman doesnt say 'NO)
The following are also done if available/affordable
HBSAg, urine culture-sensitivity , U/S ,pap
smear

ANC -First Visit:interventions

Iron and folate supplements to all women:
One tablet of 60mg elemental iron and 400 micgm
folate/day.
To enhance the absorption of iron, instruct mothers to
take iron when eating meat or vitamin-rich foods (fruits
and vegetables).
Avoid tea, coffee, and milk at the same time when
taking iron;
it interferes with the bodys absorption of iron.

Iron can also be taken between meals. .

Give first injection of Tetanus toxoid:.

Provide ITN In Malaria Endemic Areas.

ANC -First Visit: interventions-contd.

If rapid test for syphilis is positive:
Treatment of the couple and counseling on safer
sex,

Treat other STIs

Treat UTI or asymptomatic bacteruria
For HIV positive pregnant women Perform
additional laboratory investigations and
provide care and treatment according to the
Guideline for PMTCT of HIV in Ethiopia.
Refer clients that need specialized care,
according to diagnosis

ANC -First Visit

Issues to be discussed
Danger signs of pregnancy
recognition, where to get help

Advice on birth plan including transport facilities

to health care institutes.
Advice to avoid alcohol, tobacco and illicit drugs
Benefit of HIV testing, PMTCT and safe sex
HIV testing is routine test in ANC unless the woman
says no ( opt out approach)

Advice on exclusive breast-feeding and

postpartum contraceptive use.

nd
ANC-2

Visit (24-28 Weeks)

HISTORY
Revising the history:
Identifying risk factors
Complaints & concerns

Vaginal bleeding and vaginal discharge

Dysuria, frequency, urgency during micturition
Severe/persistent headache or blurred vision
Severe abdominal pain
symptoms of severe anemia,.
Opportunistic infections in HIV positive women

Fetal movement ( Quickening)

Social support/physical abuse

ANC- second Visit

Medical history
Review relevant issues of medical history as
recorded at first visit.
Note inter current diseases, injuries, or other
conditions and additional histories for HIV
positive women since first visit.
check compliance Iron intake
Note other medical consultations,
hospitalization or sick-leave in present
pregnancy.

ANC- second Visit

PHYSICAL EXAMINATION
General appearance
Vital signs
Body weight gain
Systemic examination
Uterine height in centimeters
Fetal lie & presentation
Auscultate for fetal heart beat
Vaginal examination if it was not done at
first visit.

ANC- second Visit

Interventions ,Advice, questions and
answers
The same as in the first visit

ANC 3rd Visit (30-32 wk)

To screen for hypertension, multiple

gestation, anemia, preterm labor, DM,

Rh sensitization.
To ascertain fetal growth & well being
To further develop individualized birth plan.
To further continue provision of medical care
and health promotional services

ANC 3rd Visit (30-32 wk)

History, Physical examination, advices and
discussions similar to the previous visits
Investigations: Hgb/Hct, Urinalysis , OGTT, indirect coombs test
for Rh negative women

Ultrasound and fetal well being surveillance if

indicated

ANC 4th Visit (36-38week)

To screen for pregnancy related disorders like
hypertension, APH, multiple gestation
To ascertain fetal growth, well being, fetal lie,
presentation
If breech, ECV may be considered

To strengthen health promotional service &

discuss client concern
Finalize the individualized birth plan.

ANC 4th Visit (36-38wks)

The same activities as the previous visit are

performed
Individualized birth plan is revised,
prepare women and their families for childbirth such
as selecting a birth location, identifying a skilled
attendant, identifying social, support, planning for
costs, planning for transportation and preparing
supplies her care and the care of her newborn.

Danger signs are discussed ,the mother and her

family are educated on signs of labor
Benefits of breast feeding and avalablity of
contraceptives for postpartum use are
reemphasized
Appointment is Scheduled for postpartum visit.

th
ANC-4

visit

All the usual physical examinations are

performed

Danger Signs During Pregnancy

1. Vaginal bleeding
2. Sudden gush of fluid or leaking of fluid from
vagina
3. Severe headache not relieved by simple
analgesics
4. Dizziness and blurring of vision
5. Sustained vomiting
6. Swelling (hands, face etc)
7. Loss of fetal movements
8. Convulsions
9. Premature onset of contractions (before 37
weeks)
10.Severe or unusual abdominal pain
11.Chills or fever
SAMUEL BEZABIH (MD) MEGABIT 2005
GUH

Tetanus Toxoid(TT) Immunization

Schedule.
TT1 At first contact, or as early as possible
during pregnancy and do not protective
TT2 Four weeks after TT1 ---protective For 1 month.
TT3 Six months after TT2,--protective for 6 month.
TT4 One year after TT3,---protective for 1
year????

TT5 One years after TT4,---life long protection.