Antenatal Care in Reproductive Health

 Antenatal Care in Reproductive Health

Antenatal care; antenatal care is a planned program of medical management of pregnant  women directed towards making pregnancy, labour a safe and satisfying experience.

The health of pregnant women would be improved if effective antenatal care (ANC) was  available to all. Antenatal care therefore, constitutes one of the cornerstones to safer motherhood.  It is suggested that more flexibility concerning the place of consultation and timing of visits  could lead to better attendance and consumer satisfaction. The ministry of health therefore  recommends integration of services, e.g. family planning, EMTCT focused antenatal care,  immunization etc. 

Aims/purposes of antenatal care 

1. To promote and maintain the physical, mental and social health during pregnancy. 
2. To detect and treat conditions pre-existing or arising during pregnancy whether medical,  surgical or obstetric. 
3. To prepare the mother for the safe birth of the child for emergencies, complications. 
4.  To achieve delivery of a full term healthy baby or babies with minimal morbidity to  mother. 
5. To help the mother to experience normal puerperium and in conjunction with the partner to  take good care of the Childs‘ physical, psychological and social needs. 
6. To recognize deviation from normal and provide management or treatment as required by  ensuring privacy at all times. 
7. To prepare the mother for successful breastfeeding and give advice about adequate  preparation for lactation. 
8. To offer nutritional advice to the mother. 
9. To offer advice on parenthood either in a planned program or an individual basis taking  into consideration the clients‘ concerns. 
10. To build up a trusting relationship between the family, the mother and health workers  which will encourage them/her to share their anxieties, fears about pregnancy and care  being given through adequate communication and counseling. 
11. During this time, the pregnant woman is provided with previous preventive and advisory  services. The health worker makes consultation with her regarding the most appropriate  place of delivery of the baby and the things she needs to prepare emphasizing the concept  of a clean safe delivery e.g. having maama kits. 

Goals of Focused/Oriented Antenatal Care 

Important:  

• – Goals are different depending on the timing of the visit. 4 visits are aimed for an  uncomplicated pregnancy. 
• – If a woman books later than in the first trimester, preceding goals should be combined and  attended to. At all visits, address any identified problems, check BP and measure the  symphysio-fundal height (SFH) 

To promote maternal and newborn health survival through: 

• ∙ Early detection and treatment of problems and complications. 
• ∙ Prevention of complications and disease.
• ∙ Birth preparedness & complication readiness. 

Scheduling and timing of goal/focused antenatal care visits 

• ∙ First visit: by 0-16 weeks or when a woman first thinks she is pregnant. 
• ∙ Second visit: at 16-28 weeks or at least once in the second trimester. 
• ∙ Third visit: at 28-32 weeks 
• ∙ Fourth visits: if complication occurs, follow-up or referral is needed, woman wants to  see a provider, or provide changes frequently based on findings (history, exam, testing) or  local policy. 
• ∙ Refer  

Risk factors during pregnancy 

The following conditions are considered to have adverse effect on the course and outcome of  pregnancy and therefore are considered risk factors: 

1. Conditions likely to recur and cause bleeding: 

• – Previous hemorrhage, APH, PPH, retained placenta 
• – Too many pregnancies of five (5) or more 
• – Aneamia 
• – Multiple pregnancy 
• – Uterine scar. 

1. Conditions that affect intrauterine fetal growth and may cause abortion or premature – Preeclampsia 

• – Aneamia 
• – Malnutrition 
• – HIV 
• – Malaria, smoking, maternal underweight due to malnutrition 
• – Birth less than 2 years apart 
• – Diabetes 
• – Multiple pregnancy 
• – Excessive alcohol 
• – Sickle cell disease 
• – Abortion in the last 3 months 

1. Conditions that pose risk of infections to mother and baby and may cause abortion – HIV infection 

• – STIs e.g. syphilis 
• – Early rupture of membranes 
• – Diabetic mellitus 
• – Malaria 

1. Conditions where delivery may have to be assisted by cesarean section or vacuum extraction.

• – Short stature below 150cms 
• – Young primigravida below 18 years 
• – Elderly primigravida above 35 years 
• – Previous uterine scar 
• – Cardiac disease 
• – Diabetes mellitus 
• – Injury or deformity of the pelvis and lower part of the spine. 5. Severe pre-eclampsia and eclampsia 

Other conditions which are likely to: 

1. a) Recur  

• – Abortion 
• – Stillbirth 
• – Premature delivery 
• – Eclampsia 

1. b) Worsen with pregnancy 

• – Renal disease 
• – Mental illness 
• – Epilepsy 
• – Pulmonary tuberculosis 
• – Heart disease 
• – AIDs 
• – Diabetes mellitus 

1. c) Cause social discomfort 

• – Lack of support from partner/family 
• – GBV 
• – Low socio-economic status 
• – Unwanted pregnancy 

1. Conditions likely to cause abnormalities or disease to the baby – Age of mothers above 35 years 

• – STDs such as syphilis, HIV infection etc. 
• – Some drugs used to treat other conditions in the mother e.g. Tetracycline 

1. Methotrexate 
2. Efavirenz 
3. Ciprofloxacin 

• – Alcohol consumption and smoking including passive smoking. – Some genetic diseases e.g. hemophilia, Sickle cell disease 

1. Common problems that may complicate pregnancy and its management 

• – Aneamia 
• – Malaria
• – STDs 
• ▪ HIV 
• ▪ Gonorrhea 
• ▪ Syphilis 
• ▪ Vaginal/vulvar warts 
• – Urinary tract infection 

Roles of health workers in reducing the dangers of risk factors facing pregnant women

1.  Health education targeted at the community and pregnant women , giving them  sufficient time to express their concerns and discuss them 
2. Identification of pregnant women at risk of recurrent conditions or developing  complications such as pre-eclampsia and eclampsia, cephalo-pelvic disproportion etc.  and refer them appropriately 
3. Discuss the birth plan and emergency preparedness with the mother and another person  of her choice. 
4. Prepare management of pregnancy 
5. Appropriate referral of women with risk factors. 

Services offered during antenatal care 

• ✔ Health education 
• ✔ Counseling  
• ✔ Screening and risk assessment through 

1. – History taking 
2. – General and abdominal examination 
3. – Investigations 
4. – Vaginal pelvic examination where applicable 
5. – STIs testing including HIV 

• ✔ Provision of hematinic 
• ✔ Deworming 
• ✔ Immunization against tetanus (TT) 
• ✔ Intermittent presumptive treatment of malaria (IPT) 
• ✔ Early recognition, management and referral of high risk mothers and those who  develop complications 
• ✔ Delivery and postpartum care plan for every woman. 
• ✔ Treatment of medical conditions e.g. malaria, hypertension, diabetes, STIs,  Pulmonary tuberculosis 
• ✔ PMTCT, EMTCT 

In order to offer the services at ANC, the clinic should have at least the following: 

1. Waiting room: space where mother assemble for antenatal education: – Reception table

• – Benches for clients to sit on 

1. An examination room with privacy 
2. A stable and firm examination couch 
3. Weighing scale, a height measure in centimeters, a tape measure, a clinical thermometer,  urine testing kits, BP machine, a stethoscope and a fetoscope. 
4. A small laboratory capable of screening for common problems such as aneamia,  hookworm infestations, syphilis, pre-eclampsia and diabetes. 
5. Essential drugs spelt out for health centre including vaccines such as TT, SP, hematinic,  elimination of mother to child transmission of HIV/AIDs (EMTCT) drugs. 

The following are also recommended 

1. Mothers should be advised to attend ANC as early as possible preferably to have the first attendance during the first sixteen (16) weeks of pregnancy 
2. ANC should be integrated in other family health services and offered on a daily basis 
3.  Outreach ANC services outside the established health facilities should be held on specified  and regular days of the week which should be known by the general public in the area.

Health Education 

Aims  

• To provide clients with information that will help a pregnant woman to ensure that she remains  healthy throughout pregnancy and delivery. 
• The information should be given at appropriate periods including during follow up visits.

Some  key messages include the following: 

1. – Services offered to pregnant women during ANC and benefits of ANC. – How to keep health during pregnancy 
2. – STIs and other effects on pregnancy and newborn 
3. – Malaria and its complications during pregnancy 
4. – Minor disorders of pregnancy and how to cope with them 
5. – Diet during pregnancy and lactation 
6. – Danger signs during pregnancy and labour 
7. – Pregnant women who must be attended to and delivered in hospital 
8. – Benefit of family planning and different options 
9. – Women who are likely to get problems if they become pregnant 
10. – What to prepare for delivery 
11. – Signs of labour 
12. – Benefits of delivery under a skilled provider in a health unit 
13. – Family planning methods of postpartum mothers 
14. – Postnatal care 
15. – Benefits of breastfeeding

Steps in planning maternal health client education session 

• ✔ Identify target group 
• ✔ Identify needs of target groups e.g. 

1. – Present knowledge and practices in R.H 
2. – The priority message related to problem 

• ✔ Best media approach and language 
• ✔ Identify resources such as: 

1. – Leaders in the community 
2. – Influential supporters of RHS for example, old acceptors of RHS 
3. – Materials/visual aids relevant to the topic 
4. – Venue/ that is conducive for effective RHS client education session 

Preparation 

1. ✔ Prepare venue, which is conducive for the session delivery 
2. ✔ Notify target group through their leaders in the community 
3. ✔ Prepare yourself 
4. ✔ Identify satisfied clients 
5. ✔ Prepare influential supporters of RHS 
6. ✔ Prepare materials/visual aids 
7. ✔ Prepare contents and channels for delivering it, e.g. a song or a talk 

Steps in conducting education session talks; 

1. Introduction of self and colleagues 
2. Acknowledge leaders and group present 
3. State purpose of the session in a stimulating way by use of a slogan, poster or small story 
4.  Deliver content allowing groups to participate and use visual aids where appropriate 
5.  Allow for questions and answers 
6. Evaluate the sessions, using simple methods e.g. observing group participation, asking a  few questions while referring to the contents, getting to know and understand their  feelings, learning and how they will use this knowledge 
7. Summarize key points 
8. Give follow on information e.g. where one can obtain individual attention 
9.  Allow them to select a topic among R.H topics 
10. Announce where the next session will be held 
11. Thank the group for participating 

Antenatal Risk Assessment 

This is an evaluation carried out on pregnant women during the antenatal period to screen them from  the probability of these women who are likely to develop poor pregnancy outcome during childbirth, detection and management of any illness or pregnancy complications as they arise.

First Antenatal Visits/Booking Visit 

The purpose of this visit is to obtain the baseline information against which subsequent findings  in a woman will be assessed. 

This baseline information is obtained through:- 

1. ✔ History taking 
2. ✔ Physical taking – General, systemic and abdominal examination 
3. ✔ Investigations 

1. History taking 

This is done in a proper and orderly manner to assess the health status of the mother and  fetus. 

History must include:- 

• ✔ Name and place of residence, noting accessibility to medical and maternity care 
• ✔ Age: noting the high risk age of below 18 and above 35 years 
• ✔ Parity: noting the young and elderly primigravida, those above Para 4 and closely  spaced pregnancies (>2 years in between) 
• ✔ Social history, inquire whether married, source of social and financial support,  education status, genital mutilation, where applicable, alcohol, smoking, health of  partner.  
• ✔ Medical history e.g. hypertension, renal disease, epilepsy, diabetes mellitus, sickle  cell disease, asthma, TB and HIV, surgical history, operation, blood transfusion,  skeletal deformity, fractures of pelvis, spine and femur. 
• ✔ Obstetric and gynecological history, inquire about previous pregnancy and their  outcomes such as previous cesarean section, previous retained placenta, PPH, still  birth, prolonged labour and early maternal death, ectopic pregnancies, D & C , APH,  pre-eclampsia etc. 
• ✔ Family e.g. history of hypertension, diabetes in her family, twins, sickle cell disease.
• ✔ Menstrual history:- 

1. – Information on the woman‘s‘ menstrual history is obtained and recorded  e.g. age at menarche, length and regularity of the cycle, duration and  amount of menstrual flow. 
2. – Contraceptive history e.g. use of modern contraceptive methods and dates  of discontinuation should be noted. 

• ✔ History of present pregnancy:- Information regarding the first day of LNMP is obtained and the expected  date of delivery (EDD) calculated. This will guide the provider during  examination to compare the weeks of amenorrhea with the height of fundus. If pregnancy is over 20 weeks, dates of quickening should be noted. Any problems encountered since she became pregnant should be probed into and noted e.g.  bleeding, vomiting, hospitalization, HIV sero-status and diseases like fever,  cough, and diarrhea. 

1. Physical examination 

General  

A physical examination from head to toe should be performed and note nutritional state and  illness which may not be related to pregnancy:- 

• ✔ Measure the weight, noting those that are underweight or over- weight (below 45  Kg and above 80 Kg) 
• ✔ Measure height and note those below 159Cms and check for skeletal deformities  or limping. 
• ✔ Take blood pressure- note those with BP 140/90 mmHg and above 
• ✔ Check for anemia and jaundice by examination of the conjunctiva, tongue, palm  of the hand and capillary refilling in the nail beds 
• ✔ Check for oedema of feet, hands, face and sacral area 
• ✔ Carry out a systematic examination of the respiratory and cardiovascular systems  to exclude abnormalities. 
• ✔ Examine breasts for possible masses and signs of breast malignancy, educate  women to care the nipples and teach herself breast examination 
• ✔ Assessment of physical abuse: 

1. – Drug abuse 
2. – Bruising 

• ✔ Assessment of any complaints 

1. Abdominal examination 

The abdomen should be adequately exposed to show important landmarks. 

1. ✔ Inspect the abdomen and note: 

• – size, shape of abdomen and presence of scar that may indicate a previous  uterine operation 
• – presence of fetal movements 

       2. ✔ Palpation of abdomen noting: 

• – presence of enlarged liver, spleen and tenderness of renal angles 
• – Height of fundus and compare it with the weeks of gestation. excessive  enlargement of abdomen, maybe an indication of multiple pregnancy or  presence of polyhydramnios 
• – The lie, presentation, position, any tenderness and the amount of liquor. 

        3. ✔ Auscultation. listen to fetal heart noting the rate, volume and rhythm

Inspection of the vulva 

This should be done to detect lesions of the vulva, vagina and abnormal discharge. Note any  scars at the perineum or vulva. If an abnormal discharge is detected and there are facilities for  gram stain, take of specimen for analysis. If there are no laboratory services, use the STI  ―syndromic approach to provide treatment to the mother. 

Laboratory Investigations during Antenatal Care 

Baseline investigations: 

• – Hb (normal 10.5-15gm) 
• – Blood group (ABO and Rhesus factor) 
• – Urinalysis (protein and sugar) 
• – VDRL, RPR for syphilis 

Special Investigations (Refer When Necessary) 

1. – Rhesus antibodies for RH-ve mothers 
2. – Random blood sugar where there is a history or presence of glycosma 
3. – Mid-stream urine for culture and sensitivity 
4. – High vaginal swab (HVS) 
5. – Elisa test for HIV 
6. – Sickling test 

Others 

• – Provide TT to complete the recommended schedule for immunization against tetanus. this  is routinely done to protect the mother and neonate from tetanus 
• – Explain to the mother the importance of tetanus immunization 

Recording, Assessing Findings and Planning For Management 

• ✔ After examination, all finding should be recorded on ANC clients‘ card and register 
• ✔ Review findings on history, examination and investigations 
• ✔ Share plans for next steps 
• ✔ If the woman has to be referred, a referral note should be filled, handed to the client and  she should be explained on where to go for further management 

The health worker should refer a client/patient to health facility that is able to handle the types of  obstetric condition identified to avoid wastages of time and transport costs encountered by the  patient/family. The health worker with assistance of relatives should organize quick means of  transport. A relative/health worker escorts the mother where applicable. 

Conducting Follow up Visits for Pregnant Women 

Purpose 

1. Monitor progress of pregnancy and the well-being of the mother and foetus
2. Identify and manage arising conditions such as STIs or HIV risk, pre-eclampsia, anemia,  syphilis 
3. Provide information on planning to delivery, preparing for the newborn, postpartum care  and family planning 
4. Get opportunity to deal with the woman‘s‘ concerns 

Frequency of Follow-Up Visits 

Routine 

1. More frequently if the mother has recurrent risk factor 
2. Every 4 weeks until 30 weeks 
3. Then every 2 weeks until 36 weeks 
4. And then every week until delivery 

More frequently if the client has risk factors (past or present such as: 

• – Vaginal bleeding during pregnancy late 
• – Unsure of dates and booked 
• – Past history pre-eclampsia, premature labour, small or large gestation 
• – Not gaining weight or fundal height not growing 
• – Gaining weight exclusively