Antenatal Care in Reproductive Health

1. Aims and Purposes of Antenatal Care

Comprehensive antenatal care fulfills multiple critical purposes for the mother, the fetus, and the family. The aims include:

• Promote Health: To promote and maintain the physical, mental, and social health of the mother during pregnancy.
• Detect and Treat Conditions: To detect and treat conditions pre-existing or arising during pregnancy, whether they are medical, surgical, or obstetric.
• Prepare for Safe Birth & Emergencies: To prepare the mother for the safe birth of the child and mentally/physically prepare her for potential emergencies and complications.
• Achieve Healthy Delivery: To achieve the delivery of a full-term healthy baby (or babies) with minimal morbidity to the mother.
• Ensure Normal Puerperium: To help the mother experience a normal puerperium and, in conjunction with her partner, take good care of the child’s physical, psychological, and social needs.
• Recognize Deviations: To recognize any deviation from normal and provide management or treatment as required, always ensuring privacy.
• Prepare for Lactation: To prepare the mother for successful breastfeeding and give specific advice about adequate preparation for lactation.
• Nutritional Advice: To offer customized nutritional advice to the mother.
• Parenthood Advice: To offer advice on parenthood either in a planned program or on an individual basis, taking the client’s concerns into consideration.
• Build Trusting Relationships: To build up a trusting relationship between the family, the mother, and health workers. This encourages her to share her anxieties and fears about pregnancy through adequate communication and counseling.
• Provide Preventive & Advisory Services: To provide preventive services and consult regarding the most appropriate place of delivery, emphasizing the concept of a clean safe delivery (e.g., preparing Maama kits).

2. Goals of Focused Antenatal Care

Focused Antenatal Care (FANC) emphasizes the quality of targeted actions over the mere quantity of visits. The goals differ depending on the timing of the visit.

• To promote maternal and newborn health survival through:
  • Early detection and treatment of problems and complications.
  • Prevention of complications and disease.
  • Birth preparedness and complication readiness.

Scheduling and Timing of Focused Visits

• First Visit: By 0–16 weeks or as soon as a woman first thinks she is pregnant.
• Second Visit: At 16–28 weeks (must be at least once in the second trimester).
• Third Visit: At 28–32 weeks.
• Fourth Visit: Between 36 weeks and delivery.
• Additional Visits / Referral: Required if a complication occurs, intensive follow-up is needed, the woman wants to see a provider, or if findings (history, exam, testing) dictate frequent changes.

3. Risk Factors During Pregnancy

The following conditions are considered to have an adverse effect on the course and outcome of pregnancy and are strictly categorized as risk factors:

A. Conditions Likely to Recur and Cause Bleeding

• Previous hemorrhage (Antepartum Hemorrhage - APH, Postpartum Hemorrhage - PPH, retained placenta).
• Too many pregnancies (Grand multiparity of 5 or more).
• Anemia.
• Multiple pregnancy.
• Previous uterine scar (e.g., from a previous Caesarean section).

B. Conditions That Affect Intrauterine Fetal Growth (May Cause Abortion or Prematurity)

• Pre-eclampsia.
• Anemia and Malnutrition.
• HIV infection.
• Malaria, smoking, and maternal underweight due to malnutrition.
• Births spaced less than 2 years apart.
• Diabetes.
• Multiple pregnancy.
• Excessive alcohol consumption.
• Sickle cell disease.
• History of abortion in the last 3 months.

C. Conditions That Pose Risk of Infections to Mother and Baby

• HIV infection.
• STIs (e.g., Syphilis, Gonorrhea).
• Early/Premature rupture of membranes (PROM).
• Diabetes mellitus.
• Malaria.

D. Conditions Where Delivery May Have to be Assisted (C-Section or Vacuum Extraction)

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

E. Other Critical Conditions

• Conditions likely to Recur: Abortion, Stillbirth, Premature delivery, Eclampsia.
• Conditions likely to Worsen with Pregnancy: Renal disease, Mental illness, Epilepsy, Pulmonary tuberculosis, Heart disease, AIDS, Diabetes mellitus.
• Conditions causing Social Discomfort: Lack of support from partner/family, Gender-Based Violence (GBV), Low socio-economic status, Unwanted pregnancy.
• Conditions likely to cause Abnormalities or Disease to the Baby:
  • Maternal age above 35 years.
  • STDs such as Syphilis, HIV infection, etc.
  • Teratogenic drugs used to treat maternal conditions (e.g., Tetracycline, Methotrexate, Efavirenz, Ciprofloxacin).
  • Alcohol consumption and smoking (including passive smoking).
  • Genetic diseases (e.g., Hemophilia, Sickle cell disease).

Common Problems That May Complicate Pregnancy

• Anemia.
• Malaria.
• STDs (including HIV, Gonorrhea, Syphilis, Vaginal/vulvar warts).
• Urinary Tract Infections (UTIs).

4. Roles of Health Workers & Services Offered During ANC

Roles in Reducing Dangers of Risk Factors

• Health Education: Targeted at the community and pregnant women, giving them sufficient time to express their concerns and discuss them openly.
• Identification: Detecting pregnant women at risk of recurrent conditions or developing complications (such as pre-eclampsia, eclampsia, cephalo-pelvic disproportion) and referring them appropriately.
• Birth Planning: Discuss the birth plan and emergency preparedness with the mother and another person of her choice.
• Management Preparation: Prepare thorough management of the pregnancy.
• Appropriate Referral: Prompt referral of women presenting with identified risk factors.

Services Offered During Antenatal Care

A comprehensive ANC visit must rigorously include the following 12 services:

1. Health education.
2. Professional Counseling.
3. Screening and risk assessment through: History taking, General and abdominal examination, Investigations, Vaginal pelvic examination (where applicable), and STI testing (including HIV).
4. Provision of hematinics (iron and folic acid).
5. Deworming.
6. Immunization against tetanus (TT).
7. Intermittent Presumptive Treatment (IPT) of malaria.
8. Early recognition, management, and referral of high-risk mothers and those developing complications.
9. A delivery and postpartum care plan drafted for every woman.
10. Treatment of medical conditions (e.g., malaria, hypertension, diabetes, STIs, Pulmonary tuberculosis).
11. PMTCT / EMTCT services for HIV-positive mothers.

Facility Requirements for ANC Clinics

In order to effectively offer these services, the clinic must physically have at least the following:

• Waiting Room: A space where mothers assemble for antenatal education, including a reception table and comfortable benches for clients.
• Examination Room: Must provide strict privacy and contain a stable, firm examination couch.
• Essential Equipment: Weighing scale, height measure (in cm), tape measure, clinical thermometer, urine testing kits, BP machine, stethoscope, and a fetoscope.
• Small Laboratory: Capable of screening for common problems such as anemia, hookworm infestations, syphilis, pre-eclampsia, and diabetes.
• Essential Drugs: Spelt out for the health centre, including vaccines (TT), SP (Fansidar), hematinics, and EMTCT drugs for HIV/AIDS.

It is highly recommended that mothers attend ANC as early as possible (preferably within the first 16 weeks). ANC should be integrated into other family health services, offered daily, and supported by outreach ANC services on specified days known to the public.

5. Health Education in ANC

Aims: To provide clients with vital information that will help a pregnant woman ensure that she remains completely healthy throughout pregnancy and delivery.

Key Messages for Health Education

• Services offered to pregnant women during ANC and the benefits of attending.
• How to keep healthy during pregnancy (nutrition, hygiene, rest).
• STIs and their dangerous effects on pregnancy and the newborn.
• Malaria prevention and its severe complications during pregnancy.
• Minor disorders of pregnancy and effective ways to cope with them.
• Proper diet during pregnancy and lactation.
• Danger signs during pregnancy and labour.
• Identifying pregnant women who must be attended to and delivered in a hospital.
• The immense benefits of family planning and the different options available.
• Identifying women who are likely to get problems if they become pregnant again too soon.
• Exactly what to prepare for delivery (Maama Kits, baby clothes).
• The signs of true labour.
• Benefits of delivery under a skilled provider in a sanitary health unit.
• Family planning methods specifically suited for postpartum mothers.
• The importance of Postnatal Care.
• The lifelong benefits of exclusive breastfeeding.

Steps in Planning and Conducting Health Education

1. Planning the Session

• Identify the target group.
• Identify the specific needs of the target group (e.g., present knowledge/practices in Reproductive Health, priority messages related to local problems).
• Choose the best media approach and language.
• Identify resources: Community leaders, influential supporters (e.g., old acceptors of RH services), relevant visual aids, and a conducive venue.

2. Preparation Phase

• Prepare the venue to ensure it is conducive for delivery.
• Notify the target group through community leaders.
• Prepare yourself thoroughly.
• Identify satisfied clients to act as testimonials.
• Prepare influential supporters.
• Prepare materials and visual aids.
• Prepare the exact contents and the channels for delivering it (e.g., a song, a skit, or a direct talk).

3. Steps in Conducting the Session

1. Introduction of self and colleagues.
2. Acknowledge leaders and the group present.
3. State the purpose of the session in a stimulating way (e.g., use a slogan, poster, or short story).
4. Deliver the content, allowing the group to actively participate and using visual aids where appropriate.
5. Allow time for questions and answers.
6. Evaluate the session using simple methods (observe participation, ask questions to test understanding, gauge their feelings, and ask how they will use the knowledge).
7. Summarize the key points.
8. Give follow-on information (e.g., exactly where one can obtain individual attention).
9. Allow the group to select a topic among Reproductive Health topics for the next visit.
10. Announce where and when the next session will be held.
11. Thank the group for participating.

6. Antenatal Risk Assessment (The Booking Visit)

This is an intensive evaluation carried out on pregnant women during the antenatal period to screen them for probabilities of developing poor pregnancy outcomes, detect illnesses, and manage complications as they arise.

First Antenatal Visit / Booking Visit: The main purpose is to obtain baseline information against which all subsequent findings in the woman will be assessed. This is achieved through three main pillars: History Taking, Physical Examination, and Investigations.

A. History Taking

This must be done in a proper, orderly, and respectful manner to accurately assess the health status of the mother and fetus.

• Demographics: Name and place of residence (specifically noting the accessibility to medical and maternity care).
• Age & Parity: Note high-risk ages (below 18 and above 35 years). Note parity, specifically flagging young/elderly primigravidas, grand multiparas (above Para 4), and closely spaced pregnancies (less than 2 years between).
• Social History: Inquire if married, source of financial/social support, educational status, history of genital mutilation (where applicable), alcohol/smoking habits, and the overall health of the partner.
• Medical History: Inquire deeply about hypertension, renal disease, epilepsy, diabetes mellitus, sickle cell disease, asthma, TB, and HIV. Check surgical history (operations, blood transfusions, skeletal deformities, fractures of pelvis/spine/femur).
• Obstetric/Gynecological History: Outcomes of previous pregnancies (e.g., previous C-sections, retained placenta, PPH, stillbirth, prolonged labour, early maternal death, ectopic pregnancies, D&C, APH, pre-eclampsia).
• Family History: Ask about hypertension, diabetes, twins, or sickle cell disease in her family.
• Menstrual & Contraceptive History: Age at menarche, length/regularity of cycle, duration/amount of flow. Record use of modern contraceptives and exact dates of discontinuation.
• History of Present Pregnancy: Obtain the first day of the LNMP to calculate the EDD (Expected Date of Delivery). This guides the provider to compare amenorrhea weeks with fundal height. If over 20 weeks, note the date of quickening. Probe deeply into problems encountered (bleeding, vomiting, hospitalization, HIV status, fever, cough, diarrhea).

B. Physical Examination (General and Abdominal)

A physical examination from head to toe must be performed, carefully noting the nutritional state and any illness unrelated to pregnancy.

General Examination

• Measure Weight: Note those underweight (below 45 Kg) and overweight (above 80 Kg).
• Measure Height: Note those below 150/159 cm and visually check for skeletal deformities or limping.
• Take Blood Pressure: Note those with BP of 140/90 mmHg and above.
• Check for Anemia and Jaundice: Examine the conjunctiva, tongue, palms, and capillary refill in nail beds.
• Check for Oedema: Inspect feet, hands, face, and the sacral area.
• Perform a systematic examination of the respiratory and cardiovascular systems to entirely exclude abnormalities.
• Examine Breasts: Look for masses or signs of malignancy. Educate the woman on nipple care and teach self-breast examination.
• Assessment of Physical Abuse: Look for signs of drug abuse or unexplained bruising.
• Assessment of any general physical complaints.

Abdominal Examination

• Inspect: The abdomen must be adequately exposed. Note size, shape, presence of fetal movements, and importantly, any scar that may indicate a previous uterine operation.
• Palpate: Note the presence of an enlarged liver, spleen, or tenderness in the renal angles. Measure the Height of Fundus and compare it precisely with gestational weeks. (Excessive enlargement indicates multiple pregnancy or polyhydramnios). Determine the lie, presentation, position, tenderness, and estimate liquor volume.
• Auscultate: Listen to the fetal heart, meticulously noting the rate, volume, and rhythm.

Inspection of the Vulva

• Done to detect lesions, scars (on perineum/vulva), or abnormal discharge. If abnormal discharge is detected and lab facilities exist, take a specimen. If no lab exists, immediately use the STI syndromic approach to provide treatment.

C. Laboratory Investigations

• Baseline Investigations (Routine):
  • Hb (Hemoglobin) - Normal is 10.5–15gm/dl.
  • Blood Group (ABO and Rhesus factor).
  • Urinalysis (Checking for protein to rule out pre-eclampsia, and sugar for diabetes).
  • VDRL / RPR (Testing for Syphilis).
• Special Investigations (Refer when necessary):
  • Rhesus antibodies for RH-negative mothers.
  • Random Blood Sugar (if there is a history or presence of glycosuria).
  • Mid-stream urine for culture and sensitivity.
  • High Vaginal Swab (HVS).
  • Elisa test for HIV.
  • Sickling test.
• Other Interventions:
  • Provide Tetanus Toxoid (TT) to complete the schedule. This routinely protects both mother and neonate from fatal tetanus.
  • Thoroughly explain to the mother the critical importance of tetanus immunization.

7. Recording, Assessing Findings, and Planning For Management

• After the examination, ALL findings must be meticulously recorded on the ANC client's card and the clinic register.
• Review all findings from the history, physical examination, and lab investigations.
• Share plans and next steps clearly with the client.
• If the woman must be referred, a detailed referral note must be filled out, handed to the client, and she must be explicitly explained where to go for further management.

Conducting Follow-Up Visits

Purposes of Follow-up:

• Monitor the strict progress of the pregnancy and the well-being of the mother and fetus.
• Identify and rapidly manage arising conditions (STIs, HIV risks, pre-eclampsia, anemia, syphilis).
• Provide ongoing information on birth planning, newborn preparation, postpartum care, and family planning.
• Provide an opportunity to deal with the woman’s growing concerns.

Frequency of Follow-Up Visits:

• Routine Schedule:
  • Every 4 weeks until 30 weeks.
  • Every 2 weeks until 36 weeks.
  • Every week until delivery.
• High-Risk Schedule: Visits must occur much more frequently if the mother has past or present risk factors, such as:
  • Late vaginal bleeding during the current pregnancy.
  • Unsure of dates and booked late.
  • Past history of pre-eclampsia, premature labour, or abnormally small/large gestations.
  • Not gaining weight, or the fundal height is completely stagnant (not growing).
  • Gaining weight excessively (sign of severe oedema/pre-eclampsia).