ANTENATAL CARE

BY
MRS MWANANUKU
 Introduction
Antenatal care refers to the care which is given to the
pregnant woman from the time that conception is
confirmed until the beginning of labour (Fraser and
Cooper 2003). Antenatal care should be made as
attractive and educational as possible, so that many
women and their partners can attend the antenatal
clinic from early pregnancy, and also that they should
understand the information given to them and follow
all the instructions. This is only achieved by the way
the women and their partners are treated during the
antenatal visit.
 Introduction cont’...
The midwife should emphasise that help will
always be available to each pregnant woman
and her family, at any time they are in need of
help so as to allay anxiety. In addition, the
nurse/midwife will provide a woman - centred
approach to the care of the woman and her
family by sharing information with the woman
to facilitate her to make informed choices
about her care.
 General objective
• At the end of this lecture, students should be
able to demonstrate knowledge of antenatal
care activities.
 Specific objectives
1. Define antenatal care.
2. State the aims of antenatal care.
3. Outline the components of antenatal care.
 Definition of terms
• Antenatal care refers to the care which is
given to the pregnant woman from the time
that conception is confirmed until the
beginning of labour (Fraser and Cooper 2003).
 Aims of antenatal care.
1. To ensure a normal pregnancy whenever possible by
maintaining and where necessary by improving the
general health of pregnant women.
2. To ensure early detection, referral and management of
complications during pregnancy.
3. To ensure a normal labour whenever possible by
preparing the woman for labour psychologically and
physically.
4. To provide careful screening of all women especially
those who are to deliver either at the clinic or in their
own homes.
 Aims of antenatal care cont’...
5. To prepare the woman for a normal
peurperium and the care for a normal
newborn baby.
6. To create awareness to the woman and her
family on the possible abnormalities that can
occur to the mother and the baby.
7. To promote health education and family
planning, and in so doing, to uplift the quality
of life of all the people.
 Aims of antenatal care cont’...
8. To create nurse – patient relationship.
9. To exchange information with the woman and
her family, enabling them to make informed
choices about pregnancy and birth.
10. To facilitate the woman to make informed
choices about methods of infant feeding and
to give appropriate and sensitive advice about
her decision.
 RECOMMENDED ANTENATAL VISITS
• A woman is supposed come for booking as
soon as she realises she is pregnant or
pregnancy is confirmed.
• Antenatal visits should be done on monthly
basis till delivery. So if one could start as early
as in the second month, then recommended
number of visits would be 8 and it is known as
‘‘refocused antenatal care’’.
• Note – antenatal visits are done monthly.
 Components of antenatal care
• Antenatal Booking
• History taking
• Physical Examination
• Laboratory investigations
• Care provision
• I.E.C
• Documentation of Antenatal care
 Booking
• This is the first visit a pregnant woman makes to
the clinic. It should take place as soon as one
realises she is pregnant.

Registration
At the first visit, the woman is given an ANC card
with a number and her name is entered in the
register or she is given a smart care card and
details are entered in the smart care system.
 Reception of the woman
• When the woman comes for antenatal clinic,
greet her with a smile and offer her a sit to make
her feel free, this will help in building a
relationship.
• Introduce yourself and ask what her name is so
that you can communicate with her using her
name.
Reception of the woman cont’...
Ask the woman how she is feeling and respond
immediately to any of the danger signs like vaginal
bleeding, severe headache, visual changes,
shortness of breath, severe abdominal pains,
fever, oedema, palpitations or draining.
 Reception of the woman cont’...

• If any of these danger signs are present, then

the history taking should be postponed and be
done later. If not present then proceed as
follows;
 Observations.
Blood pressure, temperature, pulse and
respiration should be checked.
measure the height check the weight and for
the shoe size.
Document your findings.
 History taking
• History taking is a very important aspect of
antenatal care and serves as a screening
procedure, which can identify factors that can
be detrimental to the normal course of
pregnancy.
 History taking cont’...

• Comprehensive history is taken on the first

visit which will help the health care provider
meet the ANC objectives

• History taking should be done in privacy with

respect to every woman.
 Social history
• This is obtained for identification, follow-up
and as a basis for IEC
• It helps the nurse or midwife to know the
client better and for easy follow up care. This
includes;
Client particulars
1. Full name for easy identification.
 Social history cont’...
2. Full address, that is, both residential and postal
addresses for easy follow up care.
3. Telephone number for easy follow up care.
4. Age and date of birth to rule out risk factors like under
age.
5. Religion so that religious beliefs are considered in the
care.
 Social history cont’...
6. Ask the woman if she is married for social
support.
7. Occupation for financial support and also to
rule out other factors, like exposure to radiation
that may affect both the mother and the baby.
8. Ask about the attitude to and acceptance of
pregnancy for psychological support to the
woman.
 Social history cont’...

9. Ask the woman about her social habits.

10. Ask about her hobbies as some of them do
not promote rest, like athletics.
11. Ask the woman about the social support
person (e.g. husband, mother, mother- in-law)
 Social history cont’...

Particulars of next of kin

12. Name, age and address for easy contact in

case of an emergency.

13. Educational standard to assess the levels of

understanding and social support
 Social history cont’...

Ask about the occupation of the next of kin for

social support.
Environmental history
Ask about the type of accommodation in
terms of number of windows to ensure good
ventilation.
 Social history cont’...
• Ask the woman about her social habits, that is
if she smokes as this will predispose her to
respiratory tract infections. Nicotine a
substance found in cigarettes can cause
placental insufficiency, resulting to
prematurity, low birth weight and congenital
malformation.
 Social history cont’...
• Ask if she takes alcohol as this may predispose
her to malnourishment, and accidental falling
due to alcohol intoxication. Alcohol can also
pose a risk of foetal alcohol syndrome which
can bring about prematurity, low birth weight
and congenital abnormalities like heart
defects.
 Social history cont’...
• Ask about the type of accommodation in
terms of number of windows to ensure good
ventilation and number of rooms in relation to
the number of occupants to rule out
overcrowding which may predispose her to
respiratory tract infections.
 Social history cont’...
• Cooking facilities to rule out carbon monoxide
intoxication if using charcoal.
• Source of water supply to prevent diarrhoeal
diseases.
• Type of toilet and refuse disposal to rule out
diarrhoeal diseases like cholera etc.
 Family medical history.

• Ask the woman if there are any family

members who have suffered from; diabetes
mellitus, hypertension, asthma, epilepsy
cardiac disease, sickle cell anaemia, mental
illness, these run in families and can
complicate pregnancy if acquired them.
 Family medical history cont’...
• Any contact with TB patients may pose a risk of
contracting it.
• However, twin pregnancy is not a medical
condition, but has a tendency of running in
families especially on the maternal side.
• Any current medication that she is currently
taking.
Past personal medical history cont’...
• Ask for any diseases which the woman has
either suffered from or is currently suffering
from. They may complicate pregnancy, or may
be complicated by pregnancy or may recur in
pregnancy.
• These include:- sickle cell anaemia, epilepsy,
psychosis, diabetes mellitus, cardiac diseases,
renal diseases recurrent attacks of malaria,
tuberculosis, STIs.
 Past personal medical history cont’...
• Pregnancy is a diabetogenic state. The
increased levels of oestrogen, progesterone
and Human placental lactogen produce a
resistance to insulin in the maternal tissues.
Therefore blood sugar levels may be high and
a woman can suffer from diabetis mellitus.
 Personal surgical history
• Ask the woman if she has had injuries or
operations involving the pelvic bones, spine or
lower limbs. These could alter the pelvic
diameters and angle of inclination that may
lead to cephalo-pelvic disproportion.
Remember to ask about history of blood
transfusion to exclude iso-immunisation if the
woman is rhesus negative.
 Past obstetric history cont’...
Ask the woman about the past obstetric history,
that is;
• Parity and gravid to rule out grand multiparity
which is a risk factor.
• Year when the baby was born to assess child
spacing.
• Health during pregnancy to rule out neonatal
problems.
 Past obstetric history cont’...
• Duration of pregnancy to rule out prematurity
or post maturity.
• Outcome of each pregnancy to rule out
complications like abortions or ectopic
pregnancy.
• Mode of delivery and duration of labour to
rule out complications like prolonged labour
or caesarean section.
 Past obstetric history cont’...
• Weight of the baby at birth to rule out
prematurity or overweight.
• Find out if the baby is alive or dead and at
what age, if alive find out about the health
status. This will help rule out bad obstetric
history.
• Type of feeding to give appropriate health
education on feeding options.
 Past obstetric history cont’...
• Health during puerperium to rule out
complications of puerperium, like, puerperal
sepsis, puerperal psychosis or post partum
haemorrhage.
• Method of contraception, when, how long and
the reason for stopping for appropriate health
education.
•
Present obstetrical history cont’...
• Ask the woman about health and other
concerns during pregnancy such as:
Fatigue, drowsiness, headaches, sore tongue,
loss of appetite, nausea and vomiting and
oedema. Find out at what age she had her
menarche
Find out about her menstrual flow and how
long she takes
Find out if she has dysmenorrheal during her
periods.
Present obstetrical history cont’...
Menstrual history cont’…
Find out when she last had her normal
menstrual period and calculate the expected
date of delivery as follows:-
Add 7 days to the date
Add 9 months to the month e.g
If her LNMP was 10.09.2018
Add 7 to 10 and you will have 17
Present obstetrical history cont’...
• Menstrual history cont’…
Then add 9 to the month and you will have 18
So for as long as the months are more than 12, subtract
12 which represents number of months in a year and
you will get 06. Add 1 to the year 2018 and you will
have 2019. Your EDD will be 17.06.2019
Then to calculate the by-dates you need to add all the
days she has been pregnant and divide by 7 to make
them into weeks.
 LNMP & EDD
Taking the same LMP as an example you will have the
following ; LNMP 10.09.2018
Month number of days weeks days
Sept 20 2 2
Oct 31 4 3
Nov 30 4 2
Dec 31 4 3
Jan 31 4 3
Feb 01 0 1
September 10 1 3
Present obstetrical history cont’...
• When you add all the days you will have 14
days.
• Divide by 7 to turn them into weeks you will
have 2 weeks.
• Add these 2 weeks to the number of weeks
which is 20 weeks you will have 20 weeks.
• So the gestational age today the 1st of
February is 20 weeks.
 Family planning history
Find out if she has been on family planning
and what type.
If she was, find out why she stopped and if
she had some problems with the method she
was using.
 Physical examination
• This is done from head to toe and it should be
done systematically and with competence.
On the head assess for the following:-
• The state of the hair- nutritional status, any
scars
The eyes
• Check for cyanosis, jaundice, pallor and any
abnormal discharge.
 Physical examination cont’...
Ears – check if they are symmetrical, abnormal
discharge, growths, auricular and
periauricular.
Nose- polyps, abnormal discharge.
Mouth- pallor, dental carries.
Neck- enlarged goiter, palpate for goiter,
enlargement submandibular lymph nodes.
 Physical examination cont’...
 Upper extremities- check if they are symmetrical,
assess the venous return, check for oedema in
between the knuckles.
 Armpits- inspect the hygienic state, palpate for
enlarged lymph nodes
 Breasts - inspect the breasts for any signs of
pregnancy, palpate them and pay much attention on
the upper outer quardrants
• N.B DO NOT SQUEEZE THE NIPPLES
 Abdominal palpation
• This is carried out to establish and confirm that fetal
growth is consistent with gestational age during the
progression of pregnancy.
• The specific aims of abdominal examination are to:-
 Observe the signs of pregnancy
 Assess fetal size and growth
 Auscultate the fetal heart
 Locate fetal parts
 Detect any deviation from normal
 Abdominal palpation cont’…
• Preparation
Abdominal examination will be most effective
if the woman is consistently in the same
position at each antenatal check
A full bladder will make the examination
uncomfortable; this can also make the
measurements of fundal height less accurate
Expose only the area of the abdomen that
needs to be palpated and provide privacy.
 Abdominal palpation cont’…
Inspection.
The size and shape of the uterus which should
correspond with the gestational age.
Note that- a full bladder, distended colon or
obesity may give false impression of fetal size.
Skin changes- stretch marks from previous
pregnancy appear silvery and recent ones
appear pink.
 Abdominal palpation cont’…
• A linea nigra may be seen; this is a normal
dark line of pigmentation running
longitudinally in the centre of the abdomen
below and sometimes above the umbilicus
• Scars may indicate previous obstetric or
abdominal surgery
 Abdominal palpation cont’…
• Palpation-
Ensure the hands are clean and warm before
you start palpating the woman as cold hands
tend to induce contractions of the abdominal
and uterine muscles and the woman may feel
uncomfortable.
Hands and arms should be relaxed and the
pads and not tips of the fingers should be
used.
Move the hands smoothly over the abdomen in
 Abdominal palpation cont’…
• In order to determine the height of fundus,
place the hand just below the xiphisternum
• Pressing gently, move the hand down the
abdomen until you feel the curved upper
border of the fundus, noting the number of
fingerbreadths that be accommodated
between the two.
• Alternatively, the distance between the
fundus and the symphysis pubis can be
determined with a tape measure.
 Abdominal palpation cont’…
Approximate height of fundus at various weeks
of pregnancy;
• 12 weeks : just above the symphysis
• 16 weeks: half-way between the upper border
of the symphysis and the lower border of the
umbilicus. Quickening or fetal movements can
now be felt by the mother. The Uterine
soufflé, the sound of the maternal blood
coursing through the large uterine vessels can
be heard on auscultation.
 Abdominal palpation cont’…
• 20 weeks: the lower border of the umbilicus.
The fetal parts and fetal movements can be
felt on palpation.
• 22 weeks: the centre of the umbilicus
• 24 weeks: the upper border of the umbilicus
• 30 weeks: half-way between the upper border
of the umbilicus and the lower border of the
xiphisternum.
• 36 weeks: the lower border of the
xiphisternum.
 Abdominal palpation cont’…
• 38 weeks to the onset of labour: This time the
uterine ligaments the pelvic viscera become
more vascular and soften. The cervix ripen
and there is partial effacement of the cervical
canal causing the presenting part to descend
may even pass through the pelvic brim into
pelvic cavity. This will then cause the height of
fundus to drop about 2 finger’s breadth and to
remain at the level of about 32-34weeks.
 Abdominal palpation cont’…
• This is known as Lightening. It usually takes
place in the primegravida but may occur in the
multigravida with tight abdominal muscles.
 Abdominal palpation cont’…
Pelvic palpation
• It determines the part of the fetus that is
presenting at pelvic brim.
• If it’s the head presenting, it feels round and
hard and can be balloted between the hands
or the thumb and a finger of one hard.
• Palpate for the shape, size, consistency and
mobility.
 Abdominal palpation cont’…
• Pelvic palpation cont’...
press deeply with fingertips into the lower
abdomen and move towards the pelvic inlet:
for a vertex presentation, the sinciput is felt
on the same side with fetal small parts with
one hand, for the face presentation, the
occiput is felt on the same side with fetal back
with one hand and a brow presentation is
indicated if both hands feel the sinciput and
the occiput at the same level.
 Abdominal palpation cont’…
Pelvic palpation cont’...
• The fetal breech will feel irregular, larger or
bulkier than a head, it cannot be well outlined
or readily moved or balloted.
• Determine if the head has descended into the
maternal pelvis.
• This is calculated in fifths of the fetal head
above the pelvic brim. From 36 weeks,
lightening takes place due to increase in pelvic
vascularity causing softening of the cervix.
 Abdominal palpation cont’…
Pelvic palpation cont’...
• Engagement of the fetal head is also
determined to rule out cephalo pelvic
disproportion. This usually occurs in prime
gravidae, while in multiparous women
engagement occurs when they go in labour.
• Note the woman’s facial expression as sign of
tenderness.
 Abdominal palpation cont’…
Lateral palpation
• This is used to locate the fetal back in order to
determine the position.
• The hands are placed on either side of the uterus at
the level of the umbilicus.
• Gentle pressure is applied with alternate hands in
order to detect which side of the uterus offers
greater resistance.
• By feeling along the length of each side with fingers
more detailed information is obtained.
 Abdominal palpation cont’…
Lateral palpation
• This technique can be done by sliding the
hands down the abdomen while feeling the
sides of the uterus alternatively
• Walking the fingertips of both hands over the
abdomen from one side to the other is an
excellent method of locating the back
 Abdominal palpation cont’…
Fundal palpation
• This determines the presence of the breech or
the head.
• This information helps to diagnose the lie and
presentation of the uterus.
• Apply pressure gently using the palmar
surfaces of the fingers to determine the soft
consistency and indefinite outline that
denotes the breech
 Abdominal palpation cont’…
Fundal palpation cont’…
• Sometimes the buttocks feel rather firm but
they are not as hard, smooth or well defined
as the head.
• The breech can not be moved independently
of the body as can the head- it can not be
balloted.
 Abdominal palpation cont’…
Ausculation
• Listening to the fetal heart is an important part of the
process.
• It is a double sound but more rapid than the adult
heart.
• A Pinard’s fetal stethoscope will enable the
nurse/midwife hear the fetal heart directly and
determine that it is fetal and not maternal
• A fetal scope is placed on the mother’s abdomen, at
right angles to it over the fetal head.
 Abdominal palpation cont’…
Ausculation
• The ear must be in close, firm contact with the
stethoscope but the hand should not touch it
while listening because strenuous sound are
produced.
• The stethoscope should be moved about until
the point of maximum intensity is located
where the fetal heart is heard most clearly.
 Abdominal palpation cont’…
• Count the beats per minute which should be
in the range of 120-160.
• Take the woman’s pulse at the same time as
listening to the fetal heart to enable you
distinguish between the two.
 Abdominal palpation cont’…
Lower limbs- check the symmetrical, observe
for pedal, ankle oedema, check for venous
return, assess for vericose veins or Horman's
sign.
Back – check for sacral oedema, spinal injury.
Vulva – for cleanliness, any abnormal
discharge, sores, genital warts, oedema,
vericose veins.
Anal area- sores, anal prolapse or
haemorrhage.
 Investigations and tests.
• Urinalysis to exclude proteins, glucose and
ketones.
• Blood for Haemoglobin levels to rule out
anaemia.
• Blood group.
• Rapid Plasma Reagin.
• HIV.
 Medication
• The following are the drugs given to the
pregnant woman;
Intermittent Presumptive Treatment :
• Six doses of Fansidar (SP) to be given at
3,4,5,6,7 and 8 months to prevent malaria in
pregnancy and/or treat asymptomatic malaria.
The SP is to be taken by the woman under
Direct observation by the nurse/midwife.
 Medication cont’...
• Tetanus toxoid injection to be given up to 5th
dose to prevent adult/neonatal tetanus.
• Mebendazole 500 mg per oral stat is given for
deworming. This is given as a single dose with
a minimum gestational age of 16 weeks.
• Daily doses of ferrous sulphate 200mg and
Folic acid 5 mg to prevent and correct iron
deficiency anaemia and folic acid deficiency
anaemia.
 Medication cont’...
• HB of less than 6g/dl is severe anaemia and
the mother is supposed to be reffered for
possible BT. HB of 6-10.9g/dl, give ferrous and
folic acid as treatment (T), while HB of 11 and
above we give feso4 and folic for as
prophylaxis (P).
• HIV- once found positive, link the mother for
ARVs its now ‘test and treat’.
• RPR - +ve, treat both the mother and her
partner.
 Medication cont’...
TT SCHEDULE
• 1st dose at first contact
• 2nd dose at 4weeks after TT1
• 3rd dose at least 6months after TT2
• 4th dose at least 1 year after TT3
• 5th dose at least 1year after TT4
 Education Information and
Communication.
Give IEC on;
• Nutrition in pregnancy
• Hygiene in pregnancy
• Danger signs in pregnancy
• Minor disorders in pregnancy
• Birth preparedness and complication
readiness,
• Malaria in pregnancy
 Education Information and
Communication ( IEC) cont’...
• EMTCT
• Importance of ANC
• Signs of true labour
• Family planning
• Birth registration
• Child immunisation and many more.
 Documentation.
Recording of findings
• Record or enter all the information gathered
and the care provided on the Antenatal Card
and in the Safe Motherhood Register
• Enter information in smart care system and
issue smart card to clients.
 CONCLUSION
• Quality ANC helps to reduce maternal and
infant mortality rates through early detection
of risk factors, referral and appropriate
management. It gives an opportunity to and
her family to receive information concerning
for normal course of pregnancy, labour,
puerperium and care of the new born.
 References
• Fraser. M/ Cooper. A/ Nolte. A (2006), Myles
Textbook for midwives, African Edition, Elsevier ltd,
Philadelphia, USA.
• Sellers. P, Volume 1(2008), Midwifery, 10th Edition,
Juta and Co. ltd, Pietermaritzburg, South Africa.
• Verralls. S (1993), Anatomy and Physiology Applied
to Obstetrics, 3rd Edition, Longman Singapore
Publishers ltd, New York. Bennett V and Brown. L
(1989), Myles Textbook for midwives, 11th Edition,
Longman group UK ltd, New York.
• Ministry of Health (2003), Pregnancy, Childbirth,