Antenatal Care (Anc)

Introduction

Antenatal Care (ANC) is the clinical assessment of mother and fetus, with the overall goal to obtain the best possible outcomes for both.
ANC is an excellent example of preventive health care, as it deals mainly with normal individuals with an emphasis on the practice of health promotion.
Availability, accessibility and utilization of ANC remain poor in many
developing nations including Nigeria.

Aims of antenatal care

  • Assessment and management of
    maternal risk and symptoms
  • Assessment and management of fetal risks
  • Prenatal diagnosis and management of fetal abnormality
  • Diagnosis and management of perinatal complications.
  • Decisions regarding timing and mode of delivery.
  • Parental education regarding pregnancy and childbirth
  • Parental education regarding child rearing

Providers of antenatal care

  • Community care, supervised predominantly by the midwife
  • Shared care between the woman’s general practitioner, midwife and obstetrician, with visits interspersed between all health professionals concerned

Basic care component

  • 75% of pregnant women usually qualify for this

Hospital-only care:

  • In cases where there is increased risk to the mother, fetus, or both-

specialized – care component

  • A critical 25% of women will usually fall under this category

Schedule of visits during pregnancy

Previously, antenatal visits were:

  • Monthly until 28 weeks gestation, then fortnightly until 36 weeks, and weekly thereafter until delivery, resulting in up to 14 hospital visits during pregnancy
  • Best available evidence indicates that there is no difference in outcome between a four-visit schedule and a twelve-visit schedule
  • Current trends favour fewer visits,
    while establishing clearly defined
    objectives to be achieved at each visit.
  • This pattern of ANC is called Focused Antenatal Care
  1. Pre-conception visit
  2. 1st ANC visit
    • Best before, and not later than the 12 week
  3. 2nd ANC visit
    • Scheduled around the 26, weeks
  4. 3rdANC visit
    • Scheduled around the 32 week
  5. 4thANC visit
    • Between the 36a, and 38a, week
  6. Postnatal visit
    • Scheduled within 1 week postnatally

This model is suited for the basic care component;
The specialized care component is better managed with the 12-visit schedule

Malaria Prophylaxis

  • Intermittent preventive treatment in pregnancy using Sulphadoxine pyrimethamine (IPTP-SP).
  • Administered as directly observed therapy (DOT) of three tablets of Sulphadoxine pyrimethamine (each tablet containing 500mg/25mgSP).
  • Three doses of IPTp-SP is recommended
  • Starting as early as possible in 2nd Trimester (after quickening or 16-18 weeks)
  • IPTP-SP is recommended at each scheduled ANC visit until time of delivery provided that the doses are given one month apart.
  • IPTP-SP should be avoided in first trimester.
  • SP should not be administered to women receiving co-trimoxazole.
  • SP can be safely used in a woman on daily dose of 0.4mg of Folic acid.
  • Folic acid at a daily dose equal or above 5mg should not be given together with SP as this counteracts its efficacy as antimalaria.

Activities during each visit

Pre-conception visit

  • Assess the general health and well-being of the patient
  • Take appropriate action based on the outcome assessment
  • General advice regarding nutrition and lifestyle

1st ANC visit

Should be in the 1’trimester, preferably before the 12th week.
Should last between 30 40 minutes.
Key objective is to obtain the patient’s medical and obstetric history:

  • Assess the woman’s eligibility to follow the basic component of the new WHO model using the classifying form which contains 18 sets of questions.

Activities during the visit should include:

1. Physical examination

  • General examination including height and weight
  • Blood pressure
  • Chest and heart auscultation
  • Symphyio-fundal height (SFH) measurement and abdominal palpation.
  • Vaginal examination-specifically for Pap smear if the woman has not done one in the past 2 years; also for women with past history suggestive of cervical incompetence-assessment and referral
  • Any medical or obstetric conditions that require specialized care

2. Investigations

  • Urinalysis for bacteriuria, proteinuria and glycosuria
  • Haemoglobin, genotype
  • Blood group
  • HIV screening
  • VDRL
  • Hepatitis B and C screening
  • Haemoglobin concentration/packed cell volume

3. Interventions

  • Iron and folate
  • Tetanus toxoid-1″ injection.
  • Treat for syphilis if VDRL is positive.
  • Refer if other investigation results so require.
  • Allow time for advice, questions and answers, and scheduling of next appointment.
  • Maintain complete clinic records of all transactions of the visit

2nd ANC visit

Should be close to, or at 26thweek.
Expected to take about 20 minutes.
Activities during the visit should include:

  • Review of history for any changes.
  • Assessment of adherence to routine ANC medicines.
  • Assess for referral
  • Update the risk status and refer if the need arises.

1. Physical examination

  • General examination: pallor, edema
  • Blood pressure
  • SFH measurement

Investigations

  • Urinalysis for bacteriuria, proteinuria for nulliparous women and those with a history of hypertension or pre-eclampsia/eclampsia
  • Haemoglobin concentration/packed cell volume only if there is evidence of anaemia

Interventions

  • Iron
  • Folic acid
  • Malaria prophylaxis
  • Intermittent treatment with
    sulfadoxine/pyrimethamine

    • One full treatment dose in the 2 and 3rdtrimesters.¬† Last dose not later than 1 month before the Expected Date of Delivery

Or

    • Proguanil 100-200 mg orally daily
  • Maintain complete clinic records as well as ANC card records

3rd ANC:

Should be around the 32 week.
Activities during the visit:

  • Expected to take about 20 minutes.
    medicines.
  • Review history for any changes
  • Assess adherence to routine ANC
  • Extra attention to advice on what to do if labour occurs, what to do if membranes rupture
  • Birth spacing and counselling on contraception.
  • Assess for referral

1. Physical examination

  • General examination: pallor, edema, dyspnea
  • Breast examination
  • Blood pressure
  • Abdomen: SFH palpation to exclude twin gestation, and fetal growth retardation

2. Investigations

  • Haemoglobin concentration or packed cell volume, compulsory for all in this visit
  • Urinalysis: bacteriuria, proteinuria; for nullipara and those with hypertension, pre-eclampsia/ eclampsia

3. Interventions

  • Iron
  • Folic acid
  • Tetanus toxoid (2 injections)
  • Antimalarial drugs
  • Maintain complete records: clinic as well as ANC card records

4th ANC visit

  • The final visit before labour or delivery
  • Should take place about or between the 36 – 38weeks

Activities during the visit include:

  • Review history for any changes
  • Assessment of adherence to routine ANC medicines

1. Physical examination

  • General examination
  • Blood pressure
  • Abdomen: SFH, fetal lie and presentation; presence of multiple gestations
  • Advise on the concept of prolonged
    pregnancy and the need to present if still not in labour by the 41 week

2. Investigations

  • Urine: proteinuria; only in nullipara, hypertension, pre-eclampsia/ eclampsia
  • Assess for referral

3. Interventions

  • Iron
  • Folic acid
  • Malaria prophylaxis
  • Advice, questions and answers; scheduling next appointment
  • Maintain complete records: clinic as well as ANC card records
  • Malaria treatment for breakthrough episodes
    • Quinine is safe and can be used in all trimesters.
    • Artemisinin-based combinations are safe in the 2 and 3rdtrimesters. Artemether-lumefantrine is considered safe
  • Postnatal visit Should hold within 1 week postpartum
  • Offer contraception
  • Complete tetanus prophylaxis with tetanus toxoid
  • Continue interventions: iron, folic acid and malaria prophylaxis