ANTENATAL CARE

SERVICES
BY DR.CHINEDU IBEH
Thursday,16TH APRIL 2015
 Sir Robert Hutchison, 20th
century physician, British
Medical Journal (1953), 1: 671.

From inability to let well alone; from putting knowledge

before wisdom, science before art and cleverness before
common sense; from treating patients as cases; and from
making the cure of the disease more grievous than the
endurance of the same, Good Lord, deliver us.
OUTLINE
 INTRODUCTION
 OBJECTIVES
 FREQUENCY OF VISITS
 ANTENATAL SERVICES
 FOCUSED ANC
 GOALS OF FOCUSED ANC
 DANGER SIGNS DURING PREGNANCY
 ROLE OF FATHERS IN ANC
 POST NATAL CARE
 SUMMARY
INTRODUCTION
 Antenatal services entail the holistic assessment of
mother and fetus during pregnancy for the purpose
of obtaining the best possible outcome for both the
mother and the child
 Series of appointments with a Doctor or
sometimes with a Midwife[in resource constraint
regions] is offered.
 Women and their families are equiped with
appropriate information and advice for a healthy
pregnancy, safe child birth and adequate postnatal
recovery.
 An effective ANC depends on competent health
care providers, functioning health system with
OBJECTIVES OF ANC
 To promote, protect and maintain the health of the
mother during pregnancy

 To detect high risk cases and give them special

attention

 To take decision regarding timing and mode of

delivery

 To ensure the baby has a good start in life

 To teach the mothers elements of child care

 To reduce maternal and infant mortality and morbidity

and to provide opportunities for health education of
both parents with respect to their children’s well being.
FREQUENCY OF VISITS[TRADIONAL MODEL]

 4 weekly---------- 28 weeks
 2 weekly --------- 36 weeks
 weekly ------------ delivery

 Frequency could be increased if need arises

 ANC activities should be carefully planned to

ensure the most effective use of time, to
exclude meaningless routines and to include
examinations to detect major problems,
especially those of local importance.
Schedule of Key Antenatal
Visits[FANC]
-Multi-country randomized trial by W.H.O showed
that essential interventions can be provided over 4
visits at specified intervals.
 8-14 week visit
 20-24 week visit
 36-38 week visit
 41-42 week visit
-The trend is towards reducing the number of visits,
while at the same time establishing clearly defined
objectives to be achieved at each visit.
-There appears to be little difference between a four-
visit approach and a fourteen-visit schedule.
ANTENATAL SERVICES
 Screening for high risk pregnancy

 Health Promotional Services

 Preventive Services

 Curative/ Rehabilitative Services

 Natal Care/ Care at Delivery

A. SCREENNING FOR HIGH RISK
PREGNANCY
Factors associated with high risk pregnancy
must be identified as early as possible and
appropriate referrals made.

 Age of mother < 18yrs, > 35 yrs at 1st

Pregnancy
 Height/ Stature - <145cm or< 5ft in height
 Booking Weight<45kg or >90kg
 Parity - lst preg >4[grandmultip]
 Birth interval < 2yrs since the last birth
 Multiple gestation
 Abnormal lie/Presentation.
 SFH inconsistent with dates
 Proteinuria
A. SCREEENING FOR HIGH RISK
PREGNANCY CONTD
 Previous bad obstetric hx eg previous CS/
myomectomy, post natal depression, congenital
anomaly, cervical cerclage, late pregnancy
loss[14-24wks],hx of low birth wt baby< 2.5kg or
macrosomia[>4.5kg], premature births,
miscarriage or abortion, still birth, APH, PPH,
manual placenta removal
 Gynecological history- infertility>2 years,
fibroid/ovarian cyst at booking, IUCD in situ
 Pre – existing medical conditions e.g HBP,
cardiac, renal, diabetes, SCD.
 Conditions developing during pregnancy e.g
Hepatitis, HIV/AIDS, malaria, severe anaemia
 Extreme social deprivation/disruption (Teenager,
B. HEALTH PROMOTIONAL SERVICES
 Health Education: - The content would include
educating the women on the value of rest and
recreation, discouraging smoking and alcohol
ingestion, allaying anxiety, infant feeding,
contraception techniques.

 Nutrition education - aimed at encouraging the

mother to take an adequate diet based as far as
possible on locally available food which are cheap-
eg; Ebiti,Ukwa, okpa.

 Education on sinister signs and symptoms in

pregnancy.

 Education on improved personal hygiene and

environmental sanitation .
C. PREVENTIVE SERVICES

(i)Anti malarials / Malaria prophylaxis

Malaria is one of the major causes of anaemia in
pregnancy. Prevention of malaria:
-Intermittent preventive treatment (IPT)
-Use of insecticide-treated nets (ITNs)
-Other methods (environment free of breeding
sites for mosquito), personal protection
(ii) Haematinics - Folic acid, fersolate,
multivite. Good compliance to haematinics has
been shown to protect pregnant women from risk
of anaemia especially in developing countries
where poor nutrition and helminthiasis are
prevalent.
D. CURATIVE/ REHABILITATIVE
SERVICES

 Early diagnosis and prompt treatment of

medical conditions that may arise in
pregnancy.

 Emotional and social problems should be

promptly diagnosed and managed ( I don’t
want this baby) Teenagers and single mothers
may need emotional support.
E. NATAL CARE SERVICES

Aimed at ensuring that every

delivery is attended by
appropriately trained personnel
under sterile conditions which
should result in a healthy mother
and the birth of a healthy child.
FOCUSED ANTENATAL CARE
Is an approach to ANC that emphasizes:

 Evidence-based, goal-directed actions

 Family-centered care

 Quality, rather than Quantity of visits

 Care by skilled providers

GOALS OF FOCUSED ANTENATAL
CARE
To promote maternal and newborn health and
survival through:

 Early detection and treatment of problems and

complications

 Prevention of complications and disease

 Birth preparedness and complication readiness

 Health promotion
GOAL 1; EARLY DETECTION AND
TREATMENT OF PROBLEMS
 Malaria – history and physical exam, fever and
accompanying signs/symptoms, region where
woman lives, complicated vs. uncomplicated
cases

 Severe anaemia – physical exam, testing

 Pre-eclampsia/eclampsia – measurement of
blood pressure

 HIV – voluntary counseling and testing

GOAL 1- EARLY DETECTION AND
TREATMENT OF PROBLEMS CONTD

 Sexually transmitted infections, including

syphilis – testing, HBV, HCV

 Rhesus incompatibility
GOAL 2 –PREVENTION OF DISEASES
AND COMPLICATIONS

 Intermittent preventive treatment (IPT) and

 Use of insecticide – treated nets (ITNs) to
prevent malaria
 Tetanus toxoid immunization to prevent
maternal and neonatal tetanus
 Iron/folate supplements to prevent anaemia
 Nutrition
 Specific interventions as appropriate
GOAL 3: BIRTH PREPAREDNESS
AND COMPLICATION READINESS
This is the process of planning for safe delivery
and anticipating the actions needed in case of
emergencies

 Develop individual birth plan – exact plan for

normal birth and possible complications:

-Arrangements made in advance by woman and

family (with help of a skilled provider)
GOAL 3: BIRTH PREPAREDNESS
AND COMPLICATION READINESS
CONTD
-Reviewed/ revised at every visit as need arise

-Minimizes disorganization at time of birth or in

an emergency

-Ensures timely and appropriate care

ESSENTIAL ELEMENTS OF
INDIVIDUAL BIRTH PLAN
1.Facility or Place of Birth: Home or health facility
for birth, appropriate facility for emergencies

2.Skilled provider: to attend birth

-Provider/facility contact information

3.Transportation: reliable, accessible, especially

for odd hours
ESSENTIAL ELEMENTS OF
INDIVIDUAL BIRTH PLAN
4.Funds: personal savings, emergency funds,
community loan schemes, e.t.c

5.Decision – making: who will make decisions,

especially in an emergency

6.Family and community support:

Care for woman’s family in her absence and
birth companion during labour
ESSENTIAL ELEMENTS OF
INDIVIDUAL BIRTH PLAN CONTD

7.Blood donor: In case of

emergency

8.Needed items: for clean and

safe birth and for new born
care
GOAL 4- HEALTH EDUCATION
 Inform and educate the woman with health
messages and counseling appropriate to :
-Individual needs, concerns, circumstances
-Gestational age
-Most prevalent health issues

 Support the woman in making decisions and

solving actual or anticipated problems

 Involve partner and family in

supporting/adopting healthy practices
Health Education: Topics to be
addressed
 Prevention of malaria:
-Intermittent preventive treatment (IPT)
-Use of insecticide-treated nets (ITNs)
-Other methods (environment free of breeding
sites for mosquito), personal protection

 Nutrition

 Care for common discomforts

Health Education topics contd

 Use of potentially harmful substances (avoid

herbs, unperceived drugs)

 Hygiene

 Rest and activity

 Importance of delivery by skilled attendant

 Sexual relations and safer sex

 Early and exclusive breastfeeding

Health Education topics contd

 Prevention of tetanus and anaemia

 HIV/AIDs prevention and care

 Prevention of other endemic

diseases/deficiencies

 Child spacing
Danger signs during Pregnancy
-Vaginal bleeding or discharge

-Difficulty in breathing

-Fever

-Severe abdominal pain

-Severe headache/blurred vision

-Swelling of the feet

-Convulsions/loss of consciousness

-Labour pains before 37 weeks

The role of Fathers in Antenatal care

The role of men/fathers include:

 Support and encourage women
throughout pregnancy

 Provide financial support

 Help the woman to make a birth plan

Role of Fathers contd
 Encourage pregnant women to attend the
antenatal clinic and take their SP under provider
supervision

 Ensure mothers sleep under insecticide-treated

nets (ITNs), buying the net & retreating when
necessary

 Ensure that they remain faithful (or use condoms

consistently and correctly) to prevent STIs/HIV

 Accompany their wives/ partners to the health

INTERCONCEPTIONAL CARE OR
POST NATAL CARE: -
 Early detection and Rx of puerperal sepsis
and other puerperal conditions.

 Encouragement and support to initiate and

continue Breast feeding till at least 2 years.

 Counseling on proper diet for adequate

lactation and about the need for rest.

 Family planning education and service

SUMMARY
 Good Antenatal Care ensures;

- that pregnant women remain healthy

throughout pregnancy

- that medical illnesses and pregnancy-related

complications are detected early and treated
promptly

-early detection and referral of high risk cases

 SUMMARY

A skilled
attendant at
childbirth is the
most effective
intervention!

Current Approach to Reduction of

WHO 1999.
Maternal Mortality 34
MERCI! ANY CONTRIBUTION?
Further Reading
 Stuart Campbell, Chritopher Lees. Antenatal Care in
Obstetrics by Ten Teachers. 2000 17th Edition. ELST
with Arnold Publishers, New Delhi.
 K. Park. Preventive Medicine in Obstetrics, Pardiatrics
and Geriatrics in Preventive and Social Medicine. 2011;
21st Edition. M/s Banarsidas Bhanot Publishers,
Jabalpur India
 Adetokunbo Lucas, Herbert Gilles. Family Health in
Short Textbook of Public Health Medicine for the
Tropics. 2003; 4th Edition, Arnold Publishers Malta.
 Ornella Lincetta, Seipati Mothebesoane-Anoh, Patricia
Comez, Stephen Munjanja. Antenatal Care, WHO
publications,
Genevahttp://www.who.int/pmnch/media/publications/ao
Further Reading contd
 Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel BJ,
Farnot U et al. WHO antenatal care randomised trial for the
evaluation of a new model of routine antenatal care. The
Lancet 2001;357:1551-1564.
 Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu
M. Patterns of routine antenatal care for low-risk pregnancy.
Cochrane Database of Systematic Reviews 2001; Issue 4.
Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.
 Pregnancy, childbirth, postpartum and newborn care: a guide
for essential practice. Geneva, World Health Organization,
2006.
 Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM,
Khan-Neelofur D, Piaggio GGP. Alternative versus standard
packages of antenatal care for low-risk pregnancy. Cochrane
Database of Systematic Reviews 2010, Issue 10. Art. No.:
CD000934; DOI: 10.1002/14651858.CD000934.pub2
PELVIMETRY
BY DR CHINEDU IBEH
Thursday,16TH APRIL 2015
OUTLINE
 Introduction
 Methods of Pelvimetry
 When to do pelvimetry
 Pelvic Anatomy
 Pelvic Types
 How pelvimetry is Done
 Obstetric Prognostic Factors
 Radiological Pelvimetry
 Role of Pelvimetry in CPD diagnosis
 Problems Associated with Pelvimetry
 Research Findings
INTRODUCTION

 Pelvimetry is the assessment of the

dimensions and capacity of adult female pelvis
in relation to the birth of a baby.
 Traditional obstetrical services used to rely
heavily on pelvimetry in leading decision of
natural, operative vaginal delivery or
Caesarean Section.
 All pelvic measurements relate to bony points;
as the pelvic ligaments loosen in pregnancy,
the pelvis is often more flexible than the
measurements would suggest which is why
pelvimetry may not be clinically useful.
METHODS OF PELVIMETRY
 Clinical Pelvimetry
a] External/Indirect Pelvimetry;
-measures diameters of false pelvis
-little value, unreliable, no longer
used.
b]Internal/Direct Pelvimetry

 Radiographic Pelvimetry
a] Xray Pelvimetry
c]CT Pelvimetry
When is Pelvimetry done?

 At first prenatal visit screen

 In
late Pregnancy[preferable]-around
36-37wks GA or at onset of labour.
[soft tissues are more distensible
thus making the procedure more
accurate and less uncomfortable
when done around this time]
 PELVIC ANATOMY
 Bony Pelvis
 Pelvic Planes
 Pelvic Diameters
BONY PELVIS
BONY PELVIS CONTD
PELVIC PLANES AND DIAMETERS

 Pelvic inlet is bordered by;

-symphysis pubis anteriorly,
-ilio-pectineal line of the innominate bone laterally,
-ala of sacrum and sacral promontory posteriorly.

 The transverse diameter of the pelvic inlet

measures 13.5 cm while the anterior-posterior
diameter is 11cm

 The fetal head enters the pelvis through this plane

in the transverse position
PELVIC INLET
PELVIC ANATOMY CONTD
 Pelvic Mid-cavity[plane of greatest diameter]
bordered by:
-posterior midpoint of the symphysis pubis
anteriorly,
-pubic bone, obturator fascia and inner aspect of
the ischial bone and spines laterally,
-jxn of the 2nd and 3rd pieces of the sacrum
posteriorly.

 Transverse Diameter = Anterior posterior

Diameter=12cm; it is the largest part of the pelvic
cavity
 Fetal Head rotates to the anterior position in this
plane
PELVIC ANATOMY CONTD
Plane of least diameter is bordered by
-Lower edge of the pubis symphysis
anteriorly
-Ischial Spines and Sacrospinous Ligament
laterally
-Lower Sacrum Posteriorly

 This is the most important plane from the

clinical standpoint because most instances of
arrest of descent[low transverse arrest] occur at
PELVIC ANATOMY CONTD
 Pelvic outlet is formed by two triangles with a
common base at the level of ischial tuberosities.
 Anterior triangle is bordered by
-subpubic angle at the apex
-pubic rami on the sides
-bituberous diameter at the base
 Posterior triangle is bordered by
-Sacrococcygeal joint at its apex
-Sacrotuberous Ligaments on the sides
-Bituberous diameter at the base.
 Anterior posterior diameter=13.5cm while the
Transverse Diameter= 11cm.
 This plane is the site of low pelvic arrest.
PELVIC ANATOMY CONTD
PELVIC DIAMETERS
 Represent the amount of space available at
each level
 The key measurements of assessing the
capacity of the maternal pelvis include;
-Diagonal Conjugate Diameter
-Obstetric conjugate of the inlet
-Bispinous Diameter
-Bituberous Diameter
-Posterior Sagittal Diameters at all levels
-Curve and length of the Sacrum
-Subpubic angle
PELVIC PLANE
DIAMETERS
PELVIC PLANE DIAMETERS CONTD

Diagonal conjugate is the

distance from undersurface of
pubic arch to sacral promontory
12.5cm).
OC=DC-1.5CM
Pelvic Diameters contd
CALDWELL MOLOY CLASSIFICATION
OF PELVIC TYPES
 Traditional obstetrics characterizes four types of
pelvises:
 Gynecoid:[50%] Ideal shape, with round to slightly
oval inlet, most common and most favourable for
normal vaginal delivery.
 Android: [20%]triangular inlet, and prominent
ischial spines, more angulated pubic arch. At risk
of deep transverse arrest.
 Anthropoid:[25%] the widest transverse diameter
is less than the anteroposterior (obstetrical)
diameter. At risk of persistent occipitoposterior
position.
 Platypelloid: [5%]Flat inlet with shortened
How Pelvimetry is Done
 Diagonal Conjugate
 -is measured from the lower border of the pubis
to the sacral promontory using the tip of the
second finger and the point where the index
finger meets the pubis
 -it is normally 12.5cm and cannot be reached
 -if it is felt, the pelvis is contracted
 -Obstetric Conjugate=Diagonal Conjugate-
1.5cm
 -Not done if the head is engaged.
PELVIC INLET MEASUREMENTS- SACRAL PROMONTORY
PROMINENCE ESTIMATION, DIAGONAL
CONJUGATE,OBSTETRIC CONJUGATE, TRUE CONJUGATE
AND TRANVERSE DIAMETERS
PELVIC INLET SUBPUBIC ANGLE
SUBPUBIC
ANGLE
PELVIC OUTLET MEASUREMENTS- COCCYX
PROMINENCE ESTIMATION, SUBPUBIC ANGLE,
BITUBEROUS DIAMETER
OBSTETRIC PROGNOSTIC FACTORS
 Size and Shape of bony pelvix[influenced by hereditary,
Vitamin D deficiency, history of pelvic fracture, stage of pregnancy]

 Size of the fetal head

 Force exerted by uterine contractions
 Moldability of the head
 Presentation and position.
Of these, only size and shape of the bony
pelvis can be fairly measured and it is the
object of pelvimetry to eliminate this one factor
from the category of unknown.
RADIOLOGICAL PELVIMETRY
Indications
 Clinical Evidence or Obstetric History
suggestive of pelvic abnormalities

 History of Pelvic Trauma

RADIOLOGICAL PELVIMETRY
 Types Radiological Pelvimetry;
1. Xray: high radiation exposure, limited value &
no role in guiding management

2. CT: ease of performance & interpretation;

10% less radiation exposure to the fetus

3. MRI[method of choice]: lack of ionizing

radiation, higher resolution and contrast,
higher cost.
CT Pelvimetry
MRI Pelvimetry
Cephalopelvic Disproportion
 CPD is obstructed labour resulting from
disparity between the size of the fetal head and
maternal pelvis eg, small pelvis, nongynecoid
pelvis, large fetus, or more commonly a
combination of these factors.
 True CPD is rare, 1in 250 pregnancies or 0.4%
of the time
 Failure to Progress: Lack of progressive
cervical dilatation or lack of descent:
 Mostly due to asynclitism, malpresention or ineffective
uterine contraction
Role of Pelvimetry Diagnosis of CPD
 Research indicates that pelvimetry is not a useful
diagnostic tool for CPD and that in all
cases[except in obvious abnormal pelvis],
spontaneous labour and birthing should be
facilitated.
 This is because a ‘’trial of labour’’ is the only true
way to diagnose CPD for it is difficult to anticipate
how well the fetal head will mold and woman's
pelvis loosens up and adjust before birth (with the
help of hormones).
 An upright and/or squatting position will open the
pelvis by atleast 33% causing a woman to birth a
considerably larger baby unlike lithotomy positon
Role of Pelvimetry Diagnosis of CPD
 If the Doctor is absolutely certain that there is a
CPD, then a CS is the only option for delivery
 But if diagnosis is doubtful, a ‘’trial of labour’’
should always be offered; if after sufficient time,
symptoms of prolonged labour or fetal distress
begins to develop, a CS needs to be carried
out.
PROBLEMS WITH PELVIMETRY
 It increases the caesarean section rate and is a
poor predictor of the outcome of labour

 Theoretically, X ray pelvimetry poses a danger

to the fetus both in the immediate and in future
life in the production of childhood leaukamia

 There is also danger to the gonads of the baby

with a risk of producing an increase in the
incidence of congenital malformation
RESEARCH FINDINGS

 In a systematic review, Cochrane

collaboration stated that ‘’for women whose
baby is presenting cephalic, review of trials
found too little evidence to show whether
pelvimetry is beneficial’’.

 Cochrane Collaboration [independent, premier evidence based clinical

decision support resource trusted worldwide by health care practioners to
help them make the right decision at the point of care]
RESEARCH FINDINGS CONTD
 In a similar vein, a retrospective review in
2004 by Blackadar, C.S. & Viera, A.J in
conclusion stated thus:
 ‘’Our study indicates that clinical pelvimetry
does not change management of pregnant
patients. Current practice is to allow all
women a trial of labor regardless of
pelvimetry results. This makes the routine
performance and recording of pelvimetry
a waste of time, a potential liability, and an
unnecessary discomfort for patients.”
RESEARCH FINDINGS CONTD
 Also in reviewing research findings on
usefulness of pelvimetry from 1937-1987,
Cunningham etal in Williams Obstetrics (2009)
concluded that;
‘’There is little rationale or current research
related to the utility of pelvimetry in obstetrical
care’’
CONCLUSION
 In cases of definite and certain CPD
[ht<145cm, hx of pelvic fracture, hx of rickets],
Caesarean Section should be done.

 Otherwise in every other case; proper

management is a good trial of labour.
Gracias! Any Contribution?

THANK YOU FOR LISTENING!

ANY CONTRIBUTION?
REFERENCES
 Stuart Campbell, Chritopher Lees.[2000] Labour in
Obstetrics by Ten Teachers. 17th Edition. ELST with
Arnold Publishers, New Delhi.
 Gray Cunningham etal[2009]. Pelvimetry in William
Obstetrics, 23rd Edition. McGraw Hill Professional
Publishing , New York
 Pattinson RC, Farrell E-ME [2009] Pelvimetry for fetal
cephalic presentation at or near term Cochrane
Collaboration
http://www.cochrane.org/search/site/pelvimetry
[accessed 13/04/15]
REFERENCES CONTD

 Rasha Dabbagh[2011] Fetal Head, Maternal

Pelvis and Pelvimetry, Slideshare.
http://www.slideshare.net/RashaDabbagh/fetal-
head-maternal-pelvis-pelvimetry [accessed
13/04/15]
 Blackadar, C.S., Viera, A.J. (2004) A
Retrospective Review of Performance and
Utility of Routine Clinical Pelvimetry, Fam Med
http://www.ncbi.nlm.nih.gov/pubmed/1524
3832 [accessed 13/04/15]