PRENATAL/ ANTENATAL CARE

➡️ Prenatal/Antenatal Care

Learning Objectives

Definition of terms

Prenatal/Antenatal care

Describe concept of FANC

Describe essential element and characteristics of FANC

Identify detailed process involved in FANC

Describe FANC visits and their activities

Picking up abnormalities during visits

👉 Prenatal/ Antenatal care

Is the care given to the pregnant women by a skilled attendant in order to assist women and her unborn baby to maintain and improve their health throughout the pregnancy period to delivery period.

Prenatal period covers the time of pregnancy from the first day of the last normal menstrual period to the birth of the baby.

ANC should also provide support and guidance to the woman and her partner or family, to help them in their transition to parenthood.

It includes;

(1) Giving Health education

(2) Counseling

(3) Screening

(4) Treatment of pre-existing and newly discovered diseases to monitor and to promote the well-being of the mother and fetus

•Focused Antenatal Care (FANC)

Background to Focused ANC

In Tanzania, in spite of high antenatal attendance of pregnant women in various health facilities, maternal mortality rate remains as high as 578 per 100,000 live births while infant mortality rate is at 68 per 1,000 births.

•While 94% of all pregnant women received antenatal care from health professionals, only 47% of all births in 2004-05 occurred in a health facility. (DHS 2004/5).

•In view of this, the MoHSW felt the need to strengthen the quality of RCH services by developing the National Package of Essential Reproductive and Child Health Interventions (NPERCHI).

Focused antenatal care (FANC) is one of the interventions (adopted by WHO in 2002).

It is also one of the Safe Motherhood pillars.

Background cont…

Safe Motherhood means ensuring that all women and their new borns receive the care they need to be as healthy as possible throughout pregnancy, childbirth and postpartum period.

Safe Motherhood can be achieved by providing high-quality maternal health services to all women during pregnancy, childbirth and postpartum period.

Cont...

🔻SAFE MOTHERHOOD PILLARS

1. Family Planning

2. Focused antenatal care

3. Clean and Safe Delivery

4. Prevention of mother to child transmission of HIV

5. Neonatal care

6. Targeted postpartum Care

7. Postabortion care

8.Essential obstetric care

The focused antenatal care pillar depends on the health system including health care providers and clients themselves.

All must work together in the same direction to improve the mother’s and the baby’s health

Focused Antenatal Care is:

Goal oriented care that is client centered, timely, friendly, simple, beneficial and safe to pregnant women.

•It emphasizes quality over quantity of antenatal visits.

•The optimum number of ANC visits for limited resource settings depends not only on effectiveness, but also on costs and other barriers to ANC access and supply

Aim of FANC

The aim of focused antenatal care is to provide timely and appropriate care to women during pregnancy to reduce the maternal morbidity and mortality as well as achieving a good outcome for the baby.

This process is part of the national RCH big program of improving quality of the services in Tanzania.

Goals of Focused Antenatal Care

Maintain & improve the wellbeing of the mother and baby physically, mentally, and socially.

– Early detection and treatment of existing diseases

– Prevention of disease

– Promotion and maintenance of physical, mental and social health of mother and a baby

– Early detection and management of the complications during pregnancy, labour, delivery, and postpartum

– Supporting clients to develop an individual birth plan (IBP) and readiness plan for possible complications

Source: World Health Organization

FANC Goal: Healthy Mothers and Babies!

Essential Elements of FANC

*Identification & management of obstetric complications; e.g. pre-eclampsia

*Tetanus toxoid immunization

*Intermittent prevention treatment for malaria (IPTp)

*Identification and management of infections including HIV, syphilis & STIs

*Promotion of skilled attendance at birth

*Counseling for healthy behaviors including nutrition, breastfeeding & family planning

Source: World Health Organization

Characteristics of Effective ANC

-Well organized & prepared health facility

-Provision of care from a skilled and motivated health care provider

-Preparations for birth and potential complications

-Individualized – based on the mother’s need

-Promote linkage among providers & facilities to ensure continuity of care

-Woman-friendly care & inclusive of her partner or family to become active participants in the care.

-Culturally appropriate

Focused ANC Visits

The minimum recommended number of ANC visits is four:

1st visit: before 16 weeks of gestation

2nd visit: from 20 to 24 weeks of gestation

3rd visit: from 28 to 32 weeks of gestation

4th visit: from 36 to 40 weeks of gestation

It is recommended that: -

Women with normal pregnancy should receive at least 4 thorough, comprehensive, individualized antenatal visits, spread out during the entire pregnancy.

Pregnant women with complications need more visits depending on individual condition.

Early referral to appropriate level of care whenever a complication is detected should take place.

STEPS OF FANC;-

Quick check

History taking

Physical examination

Laboratory investigation

Immunization

Health education

Steps: #1 Quick Check

Observation as a woman enters ANC clinic/room

– General appearance – facial expression, pallor, sweating, shivering, difficult breathing etc.

– Gait (how the woman is walking)

Asking general screening questions to identify danger signs and symptoms such as severe headache, PV bleeding, PV leaking, dizziness, fever, etc.

Steps #2 History Taking

History taking will help the service provider gather information about a woman.

It is important to ensure comfort and keeping privacy, and keeping the information confidential.

History taking includes;

Personal information

Obstetrical history - details about previous pregnancies

LNMP - calculate EDD and gestational age

Use of medications, including contraceptives, and drug allergies

Nutrition – dietary habits and locally available foods

Use of alcohol/tobacco/other substances such as herbal medicine and use of non-food substances (PICA)

Tiredness, breathlessness and use of IFA, any side effects

Immunization status

Intermittent Preventive Treatment (IPTp) and use of ITN

History related to STIs including HIV and AIDS

Past and present medical and surgical history

Social and financial support

Other concerns and respond appropriately.

-Personal information

Name of a woman, name and relationship of a person accompanying her (if any) after midwife introducing him/her self to them.

Age

Address

Level of education

Occupation

Gather similar information for the spouse/husband

-Obstetric history

Information about past pregnancies is important in considering the possible out come of the current pregnancy

It can include;

Stillbirth or neonatal death

Anemia

Rhesus isoimmunization

PIH

Parity more than four.

History of retained placenta

Cont..

-Two or more termination of pregnancy

Three or more spontaneous miscarriages

Previous preterm labor

Previous C/S

-APH- or PPH

Precipitate labor

Multiple pregnancy

Cervical cerclage in past or present pregnancy

Common Terms used;

Gravid – pregnant

Gravida – a pregnant woman; subsequent number indicates the number of times she has been pregnant

nulligravida – a woman who has never been pregnant

G 1 (primigravida)– means this is the woman’s first pregnancy

G 2 – means this is the woman’s second pregnancy

Gravidity – number of pregnancies regardless of pregnancy outcome

Para – having given birth; number indicates the number of times woman has given birth

– Includes live or stillborn babies (excludes miscarriages)

Nullipara – a woman who has never given birth

Primipara – a woman who has delivered one baby

Multipara – a woman who has delivered > 2 pregnancies to stage of fetal viability; more than one baby; Para 2, 3, 4…

Multigravida- a woman who has been pregnant > 2 times

Grand multigravida – a woman who has been pregnant >5 times; irrespective of outcomes

Grand multipara – a woman who has given birth >5 times

Convention for Communicating Gravidity & Parity

Standard usage: G_ P_L

5-Digit system: GTPAL

G_ P term_ preterm_ abortions_ living_

Cases

A mother reports this is her first pregnancy.

What term describes her?

What is her G and P?

Cases

A mother has a history of 5 pregnancies which include 2 miscarriages and 3 live births.

What terms describe her?

How would you describe her gravity and parity? (G, P and L)

Cases

A mother reports this is her 4th pregnancy with a history of 1 premature birth and 2 term births and 2 of her babies died.

What term describes her?

What is her G and P?

Cases

A mother reports she has been pregnant 7 times before and had 2 miscarriages, 5 live full-term births and has 4 living children.

What term describes her?

What is her G and P?

Cont..

Term: a pregnancy from 37 completed weeks to the end of the 42nd week of pregnancy

Postdate or post term: a pregnancy that goes beyond 42 weeks gestation

Preterm: a pregnancy that has reached 20weeks of gestation but has not completed 37 weeks

Viability: capacity to live outside the uterus; about 24 weeks since LMP; fetal weight >500 grams.

History of present pregnancy

Ask the patient if she has any current problem, such as:

Nausea & vomiting.

Abdominal pain.

Headache.

Urinary complaints.

Vaginal bleeding.

Oedema.

Backache.

Heartburn.

Constipation

-Menstrual history:

If the woman has a history of heavy, long, or very frequent periods, look for anemia.

-Ask for menstrual regularity the date of the last normal menstrual to determine the expected date of delivery and weeks of gestation (pregnancy).

🔻Calculation of EDD

-Know the first date of the Last Normal Menstrual Period (LNMP)

-Add 7 days to the date

-Subtract 3 months from the months (if the month is above March)

-Add 9 months to the month if the month is below April

-Add 1 to the year if it is above April.

- Calculation of Gestational Age

- Know the first date of the LNMP

- Add up all the days from the LNMP to the date of visit.

- Divide by 7 to get gestational age in weeks.

Note: Use a gestational age calculator if available

*Surgical history:

If a woman has had surgery in the past ,it is important to determine if surgery might cause complications during this pregnancy. Eg;

previous cesarean section.

Previous myomectomy

Previous repaired fistula

Previous third degree tear

Previous history of female genital mutilation

*Medical history:

Certain medical conditioning may complicate pregnancy. This include:

Diabetes mellitus

Sickle cell disease

Heart disease

Thyroid disease

Anemia /blood transfusion.

Tuberculosis

HIV/AIDS

Epilepsy

Cont..

History of thrombosis

Hypertensive disorder

Also woman should be asked if currently she is taking any medication, and advised not to take any medication unless prescribed by pharmacist/midwife/doctor and after sharing her pregnancy status.

Step #3 Physical examination:

Summary of physical examination:

General appearance,

Blood Pressure

Pulse and Respiratory rates

Weight, height

e) Head to toe assessment

Conjunctiva

Lymph nodes

Breast examination

Cont:physical exam:

abdominal examination

Fundal height

Foetal lie

Foetal presentation

Foetal heart sound

Genital inspection( if necessary)

-Female Genital Mutilation  Sores, swelling, discharge  PV Bleeding

Cont:physical exam:

Decision Making:

Interprets information from client’s history, physical examination and laboratory investigations and deciding on the care to be given

Height :needs to be checked only once per pregnancy.

Weight: pregnant woman should gain at least 2kg per month after 20weeks of the gestation.

A woman who fail to gain weight after 20weeks

indicates that the fetal well-being is at risk.

Cont:physical exam:

A sudden and excessive weight gain indicates development of occult oedema (fluid retention).

Blood pressure:

Measure the blood pressure ,if is equal or above 140/90mmhg is a risk factor.

Look for anemia:

Paleness in the conjuctiva,nail beds gums and palms indicate anaemia.

Cont:physical exam:

Breasts and lymph nodes examination:

Palpation:

Have the patient lie supine .

place her hand behind her head on that side. Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers.

Cont:physical exam:

If open sores or discharge are visible, wear gloves.

Press breast tissue against the chest wall in small circular motions.

Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers.

Cont:physical exam:

Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast including the axillary "tail." Palpate around the areola and the depression under the nipple.

Press the nipple gently between thumb and index finger and make note of any discharge.

Cont:physical exam:

Lower the patient's arm and palpate for axillary lymph nodes.

Have the patient replace the gown and repeat on the other side. Reassure the patient, discuss the results of the exam.

Cont:physical exam:

Examination of the fundal:

Compare the fundal height with the gestation age as calculated from the last normal menstrual period (LNMP) difference of more than 2 weeks is abnormal.

Cont:physical exam:

Abdominal Examination

Inspection: Surface of abdomen (scars, movement with respiration, shape of the abdomen)

Palpation:

Measure fundal height (from 12 weeks gestation - from symphysis pubis to top of fundus) whereby 1cm represents one week.

22 + weeks use tape measure.

Cont:physical exam:

Fetal parts and movements (from 20 weeks of gestation)

Fetal lie and presentation (is of concern from 36 weeks of gestation)

Fetal heart sound (from 24 weeks of gestation).

Palpation of the abdomen

Palpate to determine fetal parts, lie, presentation and descent of the presenting part

Fundal Palpation

Palpate to determine which fetal part is at top of uterus:

Place both hands on sides of fundus at top of abdomen

Use finger pads to assess consistency/ mobility of fetal parts

Lateral Palpation

To feel for fetal back:

Move hands smoothly down sides of uterus

Smooth and firm versus bulge and moveable.

It is important for easy hearing of fetal heart beats.

Pelvic Palpation (Supra Pubic)

To feel presenting part:

Place hands on sides of uterus, palms below umbilicus, fingers toward symphysis pubis

Grasp fetal part.

Fetal heart sound

By 24 weeks fetal heart sounds are heard with fetoscope

Normal fetal heart rate is from 120 to160 beats per minute (during pregnancy only, not in labor).

Note: Abnormal or absent fetal heart sound require urgent/ further attention

Physical Examination cont…

Genital Inspection

Ensure privacy, good light and infection prevention practices

Inspect the perineum for sores, discharge, evidence of FGM and bleeding.

Cont:physical examination:

Oedema:

Look for oedema; mild or moderate oedema is normal during pregnancy. but marked oedema may indicate problems.

STEP# 4 Investigations during

pregnancy:

Hemoglobin estimation.

Blood group and RH factor.

Urinalysis for detection of urinary tract infections,albuminuria and glucosuria.

Stool for ova

VDRL/RPR for detection of syphilis.

Voluntary counseling and Testing (VCT) for HIV.

RH Negative: Isoimmunization in Pregnancy

Step#5 HEALTH EDUCATION

A. Danger signs:

Complications related to pregnancy and childbirth:

At each ANC visit pregnant women will be educated on early detection of danger signs and complications related to pregnancy and childbirth, so that they seek early medical care.

Danger signs:

Severe anemia (lethargy, fatigue, breathless, shortness of breathe)

Bleeding during pregnancy including spotting

Oedema of legs, hands, and or face

Painful urination

Foul smelling vaginal discharge.

Malaria (fever chills ,severe vomiting)

cont..

Rupture of membrane

Severe headache

i)Dizziness, blurred vision or double vision j)Decreased or absence of fetal movement

k)Persistence abdominal pain and/or severe backache

Cont:danger signs:

*Note:

every pregnant ,delivering ,or postpartum woman is considered to be at risk of serious life threatening complications.

B. Individual birth plan

/preparedness:

Each pregnant woman attending ANC services must be counseled on individual birth plan/preparedness as well as be assisted to develop an individual birth plan (IBP).

Cont: birth plan..

The plan includes:

Identify a birth place where there is skilled birth attendant.

Identifying someone to take care of her family in her absence.

Collect essential items necessary for clean birth, if not available at the delivery site.

Cont: birth plan…

Identify a blood donor.

Identifying transport/funds in case of an emergency or labour.

Identify a decision making family member to accompany the mother to hospital.

Health education cont…..

C. Nutrition – dietary habits and locally available foods(avoiding PICA)

D. Sleep and resting

E. Sexual counseling

Hygiene

Daily activities

Weight gain

Bladder and bowel

Post natal follow-ups

STEP #6 Immunization:

The nurse instructs the woman to receive immunization against -tetanus to prevent the risk for her and her fetus.

Also, it is important that every pregnant mother should receive a tetanus vaccination card with her first tetanus dose and keep it to record subsequent doses

NOTE; Preventive Treatment

During visits we give SP for preventive treatment of malaria during pregnancy (starting from the 12 weeks then after every visit till the maximum of five doses even if the fifth dose is during the maternity period)

Also Mebendazole (for preventive treatment of worms especially hook worms)

Follate is given as early as the pregnancy is detected to be taken daily till post-delivery to prevent anaemia, it is advised to be taken 3 month before conceiving as the research proved that they reduce neurotube defect

Antenatal visits:

-I dearly a woman should receive at least 4 thorough ,comprehensive ,personalized antenatal visits spread out during the entire pregnancy.

-Some women may need more visits depending on their conditions:

First visit:

Takes place as soon as the woman detects that she is pregnant ,preferably not later than the fourth month of pregnancy (16 weeks).

-Here the health provider will screen ,detect and treat conditions such as ,syphilis and malaria

Also good opportunity to begin individual birth plan.

FIRST VISIT

Activities are:

History taking, include confirm pregnancy, EDD and GA

Head to toe assessment

Classify women for basic ANC (four visits) or more specialized care.

Screen, treat and give preventive measures.

Develop a birth and emergency plan.

Advise and counsel.

(28-32 weeks)

Second and third visits:

-The second visit should follow in the 6 or seventh month (20-24 weeks)

-The third visits should be in the eight month

These weeks are meant for detecting and managing conditions such as multiple gestation , pre-eclampsia, anemia and to further and develop the individualized birth plan.

Routine intermittent preventive treatment (IPT) for malaria using sulphadoxine Pyrimethamine (SP).

Cont…

Activities:

Assess maternal and fetal well-being.

Exclude PIH and anaemia.

Give preventive measures.

Review and modify birth and emergency plan

Advise and counsel

Fourth visit:

The fourth visit should take place in the nine month (36 weeks), activities are;-

-Assess maternal and fetal well-being.

-Exclude PIH, anaemia and multiple pregnancy,

-Confirm lie of the foetus (exclude malpresentation) detect the existence of any abnormalities and finalize the indidualised birth plan.

*remember to complete filling in the ANC card at every visit.

Cont:fourth visit:

-During each visit ensure the following are done:

-Goal oriented ANC checklist ,patient readily to leave your clinic?

-Has a supply or prescription for iron and foliate?

-Tetanus Toxoid (TT) up to date ?

Cont:fourth visit:

-Taken her SP?

-Has a treated mosquito net ?

-Has a return appointment for the next ANC visit and or SP dose?

-Knows her EDD?

-Knows the danger sign in pregnancy?

-Knows danger sign in labour?

Cont:fourth visit:

-Has individualized birth plans.

-Has a method of postpartum family planning in mind?

-She is read to go?

Record and interpret findings

-After taking proper history, done a thorough physical examination and relevant investigations. The health care provider should record all findings on the antenatal card.

-Interpret the findings so as to identify the risk factors.

-Give care and management accordingly.

-Give appointment for the next visit accordingly.