The main objectives of antenatal care are:

• Identification of high-risk pregnancy
• Prevention and treatment of any complications
• Emergency preparedness
• Birth planning
• Satisfying any unmet nutritional, social, emotional and physical needs of the pregnant woman
• Provision of patient education, including successful care and nutrition of the newborn
• Encouragement of (male) partner involvement in antenatal care

Goal-Oriented Antenatal Care Protocol

• Goals for ANC vary depending on the timing of the visit/duration of pregnancy
• In normal (uncomplicated) pregnancies, aim for 4 routine visits as follows:

• If a woman comes for first ANC later than the 1^st trimester, combine and attend to the preceding goals
• At all visits: address identified problems, check BP, and measure the symphysiofundal height (SFH)
• Encourage the woman to brnig her partner or a family member to at least one visit

First antenatal visit (between weeks 10-16)

Goals

• Risk assessment
• Health education
• Plan for delivery

History taking

• Record name, age, marital status, occupation, education, ethnic origin, residence
• Enquire if patient has any problems and obtain details
• Medical history:

- include family history of diabetes, hypertension, TB, hereditary diseases, multiple pregnancy

• Surgical history
• Obstetric and gynaelogical history:

- record for each pregnancy: date, place, maturity, labour, delivery, weight, sex and fate of the infant, and any puerperal morbidity

• Current pregnancy:

- record history of current pregnancy: date of (first day of) last menstrual period (LMP), date of conception

- confirm period of gestation/present maturity (= no of weeks from LMP)

- calculate estimated delivery date (EDD) by adding 7 days to the LMP and 9 months to the month of LMP. eg. LMP = 1/1/02, EDD = 8/10/02 Where the months total is >12, subtract 12 from this, eg. LMP = 5/5/02, add 9 months = 5+9 = 14, subtract 12 months = 14-12 = 2, therefore EDD = 12/2/03

- any problems encountered, eg. bleeding

• Contraceptive use
• Check for STIs
• Social history:

- smoking, (alcohol) drinking, drug use habits

Examination

• General physical examination, BP, weight, breasts

• Obstetric examination: symphysiofundal height (SFH), lie, presentation, foetal heart sounds, presence of multiple gestation

• Vaginal (vulval) examination (only carry out if indicated; use a speculum) as follows:

- in early pregnancy: to confirm and date the pregnancy
- in late pregnancy: to assess pelvic adequacy
- in labour: to confirm diagnosis and monitor
- other times: to evaluate symptoms/complaints

• Abdominal examination: to look for Caesarian scar, rule out multiple pregnancy

Laboratory investigations

Blood: for ABO, rhesus grouping, RPR (syphilis), Hb

Urine: for albumin, glucose

Other tests - as appropriate for the individual patient to assess maternal well-being, eg. ultrasound, amniotic fluid, foetal heart/movements

Management of common complaints (see table over)

Health promotion

• Address any problems
• Involve husband in ANC
• Draw up delivery plan
• Discuss future family planning (FP) (see p424)
• Discuss symptoms of miscarriage, pregnancy-induced hypertension (PIH)
• Educate & counsel on PMTCT of HIV
• Proper nutrition:

- eat more and greater variety of foods, have an extra meal each day
- advise against any taboos regarding nutritionally important foods

• Adequate hygiene
• Breastfeeding and breastcare
• Sexual activity during pregnancy
• Avoidance of smoking

Routine medication

see p295

Management of Common Complaints in Pregnancy

Second antenatal visit (between weeks 24-28)

Goals

• Take action if abnormal lab results
• Ensure tetanus toxoid (TT) vaccination
• Exclude multiple pregnancy
• Assess for signs of PIH
• Check foetal growth
• Exclude anaemia
• Assess the degree of the patient’s risk (normal or high) - see p296

History taking

• Interval history of symptoms and/or problems, eg. vaginal bleeding (antepartum haemorrhage [APH])
• Date of first foetal movements

Examination

• As for 1^st antenatal visit plus
• Weight: amount and pattern of weight change

Laboratory investigations

As for 1^st antenatal visit

Health promotion

• As for 1^st antenatal visit plus

• Advise/discuss with patients how to recognize and promptly report any problems so that prompt treatment may be given eg. vaginal bleeding (APH), draining of liquor, blurred vision and labour pains

• Discuss lab results and the need to treat the partner

• Discuss voluntary counselling & testing (VCT) in relation to HIV

Routine medication - see p295

Third antenatal visit (between weeks 28-36)

Goals

• Check foetal growth
• Exclude anaemia
• Assess for signs of PIH
• Review delivery plan

History taking, laboratory investigations

• As for 2^nd antenatal visit

Examination

• As for 2^nd antenatal visit plus
• Pallor - check palms and conjunctiva (for anaemia)

Health promotion

• As for 2^nd antenatal visit plus
• Discuss labour/early rupture of membranes (EROM)
• Review delivery plan

Routine medication - see p295

Fourth antenatal visit (after week 36)

Goals

• As for 3^rd antenatal visit plus
• Exclude abnormal presentation/lie

History taking, examination, laboratory investigations, health promotion

• As for 3^rd antenatal visit plus
• Lab test: serology for syphilis

Routine medication - see p295