Ante-natal care is organized to achieve several main objectives viz:
• Identification of the high risk pregnancy
• Prevention and treatment of pregnancy complications
• Satisfying the un-met needs of the pregnant woman: nutritional, social, emotional or physical
• Provision of patient education
• Planning for labour and delivery.
CONDUCT OF ANTENATAL CARE
Antenatal care should start as early as possible. The first visit should be in the first trimester. During this visit a detailed history is taken. It should include age, marital status, occupation, education, ethnic origin, area of residence, drinking, smoking and any substance abuse habits, past obstetric and gynaecological history. Record of each pregnancy in chronological order should include date, place, maturity, labour, delivery, weight, sex and fate of the infant and any puerperal morbidity.
The patient's past medical and surgical history is recorded as is any family history of diabetes, hypertension, TB, hereditary diseases, multiple pregnancy. The history of the current pregnancy is enquired into: LMP, EDD, maturity at present, any problems encountered so far e.g. bleeding. LMP is first day of LMP, gestation is calculated in weeks from LMP, EDD is calculated by adding 7 days of LMP and 9 to the month e.g. LMP 1/1/93, EDD 8/10/93.
Physical exam is then done to include:
• BP, weight, urinalysis
• General physical exam
• Abdominal exam: Fundal height, lie, presentation, foetal heart sounds, presence of multiple gestation, liver spleen and other masses.
• Vaginal exam - indicated as follows:
- early pregnancy; to confirm and date pregnancy
- in late pregnancy at 36 weeks; to assess pelvic adequacy
- in labour; to confirm diagnosis and monitor progress
- other times; to evaluate symptoms/complaints.
TABLE OF COMMON COMPLAINTS IN PREGNANCY
COMPLAINT |
WHAT TO DO |
WHAT TO AVOID |
ABDOMINAL PAIN, BACKACHE |
Exclude UTI and local lesion. If none re-assure |
Avoid unnecessary medication |
MORNING SICKNESS (Nausea & Vomiting) |
Re-assure up to 3 months. If severe with dehydration admit for hydration. Exclude UTI and malaria and typhoid |
Avoid anti-emetics |
INDIGESTION (Flatulence, heartburn & Constipation) |
High roughage diet. If severe give mild laxative and antacid e.g. senokot 2 at bed time x 5 days. Mg trisilicate 10 mls TDS x 5 days |
Avoid strong laxatives or enema |
PTYALISM (Excessive salvation) |
Re-assurance |
Avoid anti-cholinergic drugs |
FOOD FADS PICA (Craving for unusual foods and substances) |
Advise on balanced diet. Eat according to desire. Give haematinic supplements as for prophylaxis |
Discourage harmful and contaminated materials eg. soil |
GENERALISED PRURITUS |
Re-assurance: Mild anti-pruritic, phenobarbitone 30 mg TDS x 5 days Exclude skin and systemic diseases |
Avoid steroids |
PRURITUS VULVAE |
See under vaginal discharge |
Avoid douching |
MUSCLE CRAMPS |
Calcium tablets 2 TDS x 5 days |
Avoid NSAIDs |
FATIGUE |
Re-assurance, bed rest 3-7 days Advise on balanced diet |
Avoid Drugs |
BREAST TENDERNESS |
Reassure. Advise on breast support |
Avoid NSAIDs and breast massaging |
BLEEDING GUMS |
Oral hygiene, massage gums, vitamins ABC Refer to dentist if necessary |
Do not excise hypertrophied gums (epulis) |
Investigations
Should include a minimum of:
• Blood group - ABO + Rhesus
• VDRL
• Hb
• HIV screening as per protocol
Other tests as appropriate for individual patient.
The second visit is scheduled 2 weeks later to discuss the laboratory results and assess the degree of the patient's risk (e.g. normal or high risk).
Revisits are scheduled according to the patient's needs but at least monthly up to 28 weeks. Fortnightly between 28 and 36 weeks and weekly thereafter. Patients should be told how to recognize and report promptly any deviation from normal so that prompt treatment may be initiated.
At each return visit care should include:
• Interval history of symptomatology and/or problems. Date of first foetal movements
• Weight: amount and pattern of weight change
• Blood pressure, check for oedema
• Urinalysis for glucose, proteins, ketones
• Obstetric examination, vaginal examination/speculum as indicated
• Repeat laboratory tests, if necessary, e.g.
- Hb at 28-36 weeks
- serology for syphilis at 36 weeks
- if Rh -ve, Indirect Coombs' Test every 4 weeks
• Special laboratory tests as indicated for individual patients to assess maternal/fetal well being:
- examination of amniotic fluid
- ultrasound
-foetal heart/movements monitoring and evaluation
• Decision on place and expected mode of delivery should be made and communicated to the patient not later than 36 weeks of gestation
• Counselling should be provided for FP in general and for postpartum voluntary surgical contraception (VSC). Duly signed informed consent forms should be available at admission
• Patients should be advised to report to the health facility promptly if they have PV bleeding, draining of liquor, blurred vision, or labour pains.
