ANTENATAL CARE IN TANZANIA

Care given to a pregnant woman. It is a systematic supervision of a woman during pregnancy. It comprises of
Careful history taking and examinations Ear-marking the high-risk group Advice given to the pregnant woman.

Aims of ANC
To screen the high risk cases in pregnancy. To prevent or to detect and treat at the earliest any complications of pregnancy To ensure that the pregnant woman reaches the end of her pregnancy healthy. To educate the mother about the physiology of pregnancy and labour To advice on the place, time and mode of delivery, provisionally and care of the newborn.

Specific objectives
To ensure a good standard of health to all pregnant women To observe any abnormality in the pregnancy and advise the woman the best course of action thereafter. To deal with any common illnesses during pregnancy To make the mother aware of the benefits offered by antenatal , postnatal and family planning clinics.

Normal pregnancy
Delivery of a single baby in good condition at term (between 38-42 weeks ) , with fetal wt of 2.5kg and with no complication

1.FIRST VISIT
Activities include
Registration Wt and ht measurement History taking Physical examination Lab investigation Mgt of minor complaints Prophylactic rx Immunization Health education

Physical examination
1. General examination Pts general appearance
Whether ill-looking or not Short stature Whether she walks in a limp.

Nutritional status
Check signs of wasting- zygomatic bones, wasted intercostal spaces, and hypothenar and thenar muscles.

 Blood pressure
BP 140/90 is considered abnormal

Signs of anaemia
Look for clinical anaemia in the conjuctivae, tongue, mouth, palms, fingernails, soles of the feet and even the vaginal wall.

Look for oedema of the ankles, sheen of tibia,sacral area, anterior abdominal wall and periorbital area.

2. Systemic examination
CVS- check PR, size of the heart, heart sounds and murmurs RS rule out PTB and any lung lesions. MSS- check the pelvis structure and the spine, rule out bony abnormalities. CNS- should be examined if indicated

Obstetric examination
Inspection of the abdomen
Check and record any scars, superficial irregularities or overdistension

Height of the fundus

The fundal height is compared with the GA in weeks as calculated from L.N.M.P

Lie of the fetus

Relationship of the long axis of the fetus to that of the mother. Indicates whether the fetus is upright(longitudinal) or lying crosswise(transverse) or obliquely. It is most important after 32 weeks , by which time it should have settled into a longitudinal lie.

 Presenting part
Part of the fetus that is at the pelvic brim. It will be either cephalic, or breech( buttocks)

Attitude of the fetus parts

Relation of the fetal parts to one another. If the head is bent so that the chin is touching the chest , it is said to be flexed. A well flexed head presents the smallest diameter and delivers easier

Investigations
Initial routine investigations for each pregnancy at first antenatal visit (obtain informed consent for each test): include Full blood picture-for Hb estimation Blood group and atypical antibody screen Syphilis serology (VDRL tests) Rubella titre Hepatitis B surface antigen Hepatitis C antibodies HIV antibodies for PMTCT Random blood glucose (if mod/high risk of diabetes) Midstream Urine for protein Chlamydia screening Stool examination for hookworms and ascaris ova.

 Investigations to be considered depending on the womans clinical circumstances: Early dating ultrasound if dates uncertain Vitamin D screening if at risk for Vitamin D deficiency e.g., women who have reduced sun exposure, veiled women and dark skinned women Pap smear (if not done within two years) Diabetes screening as indicated Haemoglobinopathy Screening if in high-risk group e.g. high risk ethnic background, FHx of haemoglobinopathy

Management of minor ailments in pregnancy.

1. Morning sickness
a) b) c) woman should take small frequent meals She should take lots of fluids She should aviod heavy meals or staying hungry for long time.

2. Heart burn
a) She should use many pillows to raise her head when sleeping b) To take small sips of milk or warm water c) To avoid over eating and not to go to bed immediately after eating. d) Liquid antacids may be helpful.

Routine prophylaxis
Malaria Pregnant women should be given sulfadoxine pyrimethamine (SP) as intermittent preventative treatment (IPT) as follows:
First single dose after 16-20 weeks Second single dose after 30 weeks

Anaemia Give iron tablets like ferrous sulphate 600mg daily in divided doses throughout pregnancy. This should also depend on the Hb level. Hb level < 10.0mg/dl give thrice a day. Give 5mg folic acid daily throughout pregnancy.

Immunization
Tetanus Toxoid To prevent tetanus neonatorum. So it is recommended to give TT to all mothers
WHO TT immunization schedule.

This should be started for all school attending girls so that by the time they get into reproductive age they are fully immunized against tetanus.

WHO TT IMMUNIATION SCHEDULE.

Dose TT---1 When to give At 1st contact or as early as possible during pregnancy At least 4 weeks after TT--1 At least 6 months after TT--2 % of protection Nil Duration of Protection None

TT--2 TT--3 TT---4 TT--5

80% 95%

3 years 5 years 10 years 20 years

At least 1 year after 99% TT--3 At least 1 year after TT--4 99%

 For mothers who have never been vaccinated before, give 3 doses of 0.5 cc IM toxoid at intervals of at least 1 month. The last dose should be given during the last 2 months of pregnancy. For those who have been vaccinated before, a booster dose of 0.5cc IM is given in the last trimester.

ARV DRUGS
It is recommended that pregnant women who are HIV +ve take Nevirapine tablets 200mg during labour and the newborn is given nevirapine syrup 0.2mg/kg body wt within 72 hours after delivery

ANTI-D IMMUNIZATION
Anti-D It is recommended that anti-D (625 IU) be given to all rhesus negative, antibody negative women at 28 and 36 weeks gestation. These women will therefore need to be seen at 28 weeks and 36 weeks. Anti-D is also given to these women after the birth of their baby if the baby is rhesus positive.

A blood test for blood group and antibodies needs to performed prior to administering the 28 week dose of anti-D. It is recommended that anti-D is given to all rhesus negative and antibody negative women if there is risk of fetal-maternal transfusion of blood, such as a miscarriage. Anti-D should be given within 96 hours of the onset of bleeding (the earlier the better)

Anti-D dosage
First trimester 250 IU (minidose vial). Indications are threatened or inevitable miscarriage, termination of pregnancy, chorionic villus sampling and ectopic pregnancy. Note: For a multiple pregnancy give 625 IU.

Anti-D dosage
Second and third trimester, postnatally 625 IU (full dose vial). Indications are at 28 weeks, 36 weeks, postnatally (if baby is rhesus positive) and episodes when a fetal-materal haemorrhage may occur such as amniocentesis, external cephalic version, antepartum haemorrhage or abdominal trauma. Note: For second and third trimester, a Kleihauer test should be performed (1-24 hours after the bleeding or sensitising event) so additional anti-D may be given if required.

SUBSEQUENT VISIT
The pregnant woman should be encouraged to re-visit ANC. After each visit the woman should be told the date of her next visit and the date written on her ANC card which she takes home. It is every 4 weeks until 28 weeks then every 2 weeks until 36 weeks and weekly thereafter till delivery.

 The activities during re-visit periods are as during the first visit but brief. The schedule for seeing pregnant women should be at least 4 according to WHO in developing countries.
1. 2. 3. 4. In the 1st trimester around 16 weeksFirst visit Between 24-28 weeks2nd visit At 32 weeks 3rd visit At 36 weeks---4th visit.

Objectives of re-visit
To assess
Fetal well being Fetal lie, presentation, position and # of fetuses Anemia, pre- eclampsia, amniotic fluid volume and fetal growth

To organise specialist antenatal clinics for pts at high risks To select time for USS, amniocentesis or chorion villus biopsy when indicated.

High- risk group

Are pregnant women whose pregnancies are at higher-risk of having complications that affect the pregnancy outcome maternal or perinatal or both.

Factors which put a woman in high-risk group

1. Past obstetric history

Previous c/section, vacuum extraction, symphysiotomy, laparotomy for ruptured uterus and forceps deliveries Retained placenta PPH Recurrent miscariage Previous stillbirths or neonatal deaths Grand multiparity (4+) History of 10 + years of involuntary infertility

2. Past gynaecological operations

o Repair of VVF o Repair of genital prolapse o Repair of complete perineal tear o Repair of stress incontinence

3. Primigravida
Height 150 cm or less Age 35 years and above or below 16 years Deformities of musculo-skeletal system, eg kyphosis,

4. Maternal diseases
PIH Blood Pressure of 140/90 mmHg and above Pre eclampsia Hb level of 8g/dl or less- Anemia Cardiac diseases, pulmonary diseases (TB), renal diseases, Diabetes mellitus Syphilis and HIV Infection Uterine Fibroid

5. Abnormal pregnancy
Multiple pregnancy Malpresentation of fetus Abnormal lie of the fetus IUFD Polyhydramnios APH IUFGR

6. During labour
Fetal distress Prolonged labour PROM Preterm labour Hyperpyrexia IUFD Breech presentation Pre- eclampsia, eclampsia