1. Antenatal Care
Asheber Gaym M.D.
January 2009

2. Outline
• Describe the objectives of antenatal care
• Discuss different models of antenatal care
• Describe activities of antenatal care
• Detail essential diagnostic work-up during
antenatal care
• Outline ANC fetal well being assessment
strategies
• Discuss health interventions during ANC
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3. Objectives of Antenatal Care
• Antenatal care refers to the health care provided to a
pregnant woman throughout pregnancy until labor.
• Basically a screening program intended to detect
complications early; provide health education and
implement effective health promotive and preventive
interventions
• Objectives
– Overall- reduce maternal and perinatal morbidity and mortality
– Timely detection and management of complications
– Ensure the birth of a healthy child
– Ensure the health of the mother
– Provide essential health education to the mother including
information on the danger signs of pregnancy
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4. 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 has recently been suggested that the traditional ANC practice
be replaced by new models of focused ANC programs
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5. Models of ANC – Continued
• Focused ANC- also called “new” or “WHO” models
– Followed large randomized multicenter trials between the
traditional and focused ANC programs that identified
evidence based interventions and visit patterns that
benefited mothers and their fetus and were cost effective
as well
– 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 on an individual basis
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6. 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
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 supplement
•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
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7. Visits of Antenatal Care – Objectives
• Initial 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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8. Initial visit- History
• Present pregnancy-
– Accurate dating of gestational age
– Any symptoms – minor or major complaints
– Fetal movement perception
– ANC details – investigations and interventions if the mother is referred from
other facilities
– Presence of any of the danger signs
• Past obstetric history
– Details of any obstetric complications in previous pregnancies
• Family history
– Any familial medical conditions
– Family history of congenital anomalies; multifetal gestations and hypertensive
disorders of pregnancy
• Personal history
– History of medical illnesses
– History of smoking, alcohol intake and habitual drugs use
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9. Initial visit- Physical Exam
• Vital signs and anthropometry (weight and height)
• Detailed physical exam for medical or surgical illnesses
• Abdominal exam –objectives
– Fundal height by symphysis-fundal height measurement by the tape
method
– Fetal heart auscultation after 10th week by doppler or 20th week by
fetal heart stethoscope
– Fetal presentation after the 28th week but malpresentations abnormal
after the 34th week
• Pelvic examination - objectives
– For uterine size measurement if gestation is less than 12th week
– Adnexal abnormalities or masses
– Early evidence of pregnancy on physical exam- cervical softening;
Chadwick’s sign( bluish color of vagina, cervix); Von-Fernwald’s sign(
localized softening of the fundus) and Hegar’s sign
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10. Subsequent visits – Activities
• History
– Follow up on previous complaints
– Any new complaints since last visits
– Development of any of the danger symptoms
– Fetal movements history
• Physical examination
– Brief detailed exam including the vital signs,
anthropometry and general examination
– Adequacy of weight gain since last visit
– Adequacy of fundal growth since last visit
– Presence of fetal heart beat
– Presence of other findings such as generalized edema
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11. Diagnostic work-up 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
Indirect Coomb’s test Initial visit
Serum alpha-fetoprotein test 16-18 weeks
Routine ultrasonography 16-18 weeks
Screening test for gestational diabetes 24-28 weeks
Pap smear Initial visit
Cervical smear gram stain and culture Initial visit
HBsAg; HIV tests Initial visit 11Asheber Gaym, 2009

12. Assurance of fetal well being at ANC- Strategies
• 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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13. Health Interventions during ANC
• Health education – topics
– Prompt reporting of danger signs of pregnancy
– Balanced diet
– Labor and delivery preparation
– Basics of family planning, child rearing and
immunization
• Iron supplementation
• Psychological support
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