Antenatal care

Dr Gemeda Dadhi
Asst professor of gynecology and
obstetrics
 Outline
• Introduction
• Definition
• Traditional ANC
• Focused ANC
• New WHO 2016 Model
• FANC vs New Model comparison
• Summary
• References
 Objective
• To discuss different models of ANC
• To discuss up to date recommendations of ANC and
how to deliver quality ANC service
 Introduction
• Believed to be started around 1901 by social
reformers.
• Antenatal care clinics started in US, Australia,
Scotland between 1910–1915
• Basically ANC is a screening program and best
example for preventive medicine.
• Its main aim is to get healthy baby with possible
minimal maternal risk.
 Definition
• WHO:
– A care provided by skilled health-care
professionals to pregnant women and adolescent
girls in order to ensure the best health conditions
for both mother and baby during pregnancy.
 Objectives of ANC
• To establish diagnosis of pregnancy and GA
• To screen high risk cases
• To deal with minor ailments of pregnancy
• To prevent or to detect & treat at the earliest any
complications.
• To ensure continued medical surveillance &
prophylaxis
• To educate the mother
 ANC Coverage
• Globally, only 64% of pregnant women attended the
WHO-recommended minimum four contacts for
ANC(2007-2014)
•Developed countries- 98%
• Ethiopia - 62% from a skilled provider (EDHS 2016)
• 90 % urban, 58 % rural
• 32 percent made four or more antenatal visits
• 63 % urban, 27 % rural
• Median gestational age at initial visit in Ethiopia is
20 weeks.
ANC Coverage cont…
 Models of Antenatal Care Provision
• Traditional ANC- since 1901
• Focused antenatal care FANC – since 2002
• New model – the 2016 WHO ANC model
 Traditional ANC
• Activities were not scientifically tested as to their
effectiveness or benefit.
• Followed a visit pattern of 4 weeks until 28th week;
then every 2 weeks until 36th week and a weekly visit
with many interventions at each visit
• Led frequent visits of 12 – 14
• Each visit lasts not more than 5 minutes
• Cost for many unnecessary investigations.
 Focused antenatal care FANC
• It is a goal-oriented antenatal care approach, which
was recommended by researchers in 2001 and
adopted by the World Health Organization (WHO) in
2002.
• Emphasizes the quality of care rather than the
quantity.
• For normal pregnancies WHO recommends only four
antenatal visits.
 FANC cont..
• Visits at <16,24-28,30-32 and 36 -40 weeks
• Additional visits individualized on an
individual basis
• A few evidence based diagnostics and
intervention
• Two categories of pregnant women
• Basic care ( 75 % of pregnant mothers)
• Special care ( number of visits depends on
identified risk)
Focused ANC classifying checklist to classify
the pregnant women
 Components of the checklist(19)
1. Personal
2. OBSTETRIC HISTORY(6)
3. Current pregnancy(7)
4. General medical (6)
Components of the check list
 The first visit ( before 16weeks)
• Lasts 30-40 minutes
• Complete history and physical examination
• Risk stratification
• Gestational age determination
• Basic Laboratory investigations ƒ ƒ
• To provide routine Iron supplementation
• Malaria prevention ƒ
• Teach and advise on danger signs ƒ
 Laboratory tests(MOH)
– syphilis (rapid test - RPR if available or VDRL)
– U/A
– C) Blood-group typing (ABO and rhesus). ƒ
– D) Hemoglobin (Hb) or hematocrit. ƒ
– E) Stool exam
– F) Perform HIV test if the woman does not say
“NO”.
– H) urine culture and sensitivity, ultrasound, Pap
smear, HBsAg if available.
Implement the following interventions
– Iron and folate supplements to all women:
– Tetanus toxoid: give first injection. ƒ
– In malaria endemic areas provide ITN.
– If rapid test for syphilis is positive: treat, provide
counseling on safer sex, and arrange for her
partner’s treatment and counseling.
Assess weight
 2 visit (24-28)
nd

• Lasts 20 minutes
• Objectives of the second visit is to ƒ
– Revise history ƒ
– Pertinent examination(weight, BP, uterine height)
– laboratory investigation(U/A)
– Assess fetal well being ƒ ƒ
Uterine height chart
 The third visit
• Lasts 20 minutes
• Objectives of the third visit is to ƒ
– Revise history
– Pertinent physical examination
– Laboratory (U/A, Hgb)ƒ
– assess for multiple pregnancy,
– assess fetal well being ƒ
– advice on family planning, breastfeeding ƒ
 The fourth visit
• Objectives of the fourth visit is to: ƒ
– Revise history
– Pertinent examination
– Laboratory as indicated
– Birth preparedness (logistics, personnel..)
– Family planning , breast feeding
Late enrolment and missed visits
– Late enrolled women should have in their first visit
all activities recommended for the previous
visit(s), as well as those which correspond to the
present visit.
– A visit after a missed appointment should include
all the activities of the missed visit(s), as well as
those that correspond to the present visit.
 New model – the 2016 WHO ANC model
• Replaces the previous four-visit focused ANC (FANC) model.
• It recommends a minimum of eight contacts
(<12,20,26,30,34,36,38,40)
• Additional contacts( 1 at 2nd Tmx, 3 at 3rd TMx)
• The word “contact” has been used instead of “visit”, as it
implies an active connection between a pregnant woman
and a health-care provider that is not implicit with the
word “visit”.
• The aim of 2016 WHO ANC model is to provide pregnant
women with respectful, individualized, person-centered care
at every contact for positive pregnancy experience.
A positive pregnancy experience is
defined as:
– Maintaining physical and sociocultural normality
– Maintaining a healthy pregnancy for mother and
baby (including preventing and treating risks,
illness and death)
– Having an effective transition to positive labour
and birth, and
– Achieving positive motherhood (including
maternal self-esteem, competence and autonomy)
 Recommendations and Interventions

• It contains 39 recommendations related to

five types of interventions:
A) Nutritional interventions(10)
B) Maternal and fetal assessment(13)
C) preventive measures(7)
D) Interventions for common physiological
symptoms(6)
E) Health system interventions to improve
utilization and quality of ANC
 Types of recommendation
• Recommended
• Recommended under specific circumstances
• Not recommended
1)Nutritional Intervention
.
 Nutrition…
• B) Iron and folic acid supplements
– Daily oral iron(30-60 mg elemental) and folic acid
(0.4 mg)
– Intermittent oral iron (120 mg elemental) and folic
acid (2.8 mg) supplementation if side effects are
intolerable & anemia prevalence in pregnant
women is less than 20%.
– Anemic from the outset ?
• Therapeutic 120 mg of elemental iron until hgb is
corrected then daily prophylactic supplementation.
.

2) Maternal and fetal assessment 

.
 Maternal assessment
• A) Anaemia
– CBC, or
– Hgb with hemoglobinometer color scale
• B) Asymptomatic bacteriura
• When to screen?
– 1st visit, 3rd visit & 5th visit
• Why do we screen for ASB?
– Increased risk of pyelonephritis (1.8% to 28%)
– Preterm delivery
– PROM
– Recurrent UTI
 Maternal…
• How do we screen ASB?
– Midstream urine culture
– On-site midstream urine Gram staining
– Microscopic U/A ( pus cells)
– Multiple dipstick tests (nitrite, leucocyte esterase,
protein, blood)
• For how long do we treat ASB?
– seven day course of antibiotics
– Rescreen after 14 days of treatment completion.
 Maternal…
• C) Intimate partner violence (IPV)
– On each contact
– Incidence in Ethiopia – 54%, USA- 4-8%
– Should be strongly considered
– Minimum requirements are:
• Trained personnel on how to ask about IPV, and on how to
provide the minimum response or beyond;
• private setting;
• confidentiality ensured;
• system for referral in place; and
• Time to allow for appropriate disclosure.
.
 Maternal…
• G) Syphilis
– When to screen?
• At 1st contact
• repeat at 3rd trimester for high risk groups
– Screening non treponemal antibody test
– If reactive confirm with treponemal tests
 Maternal…
• Vertical transmission syphilis can occur at any
stage of the disease.
• Risk of perinatal transmission is higher in early
stage disease
– Primary or secondary syphilis - 50 %,
– Early latent - 40 percent,
– Late latent - 10 percent,
– Tertiary - 10 percent.
 Maternal…
– Treatment depends on stage of disease
• 1⁰, 2⁰ and early latent – stat dose of 2.4 million IU IM of
B. penicillin
• Late latent and 3⁰ - B. penicillin 2.4 million IU IM three
doses on weekly interval
• Neurosyphilis - aqousous c. penicillin 3-4 million IU IV
Q4rly for 10-14 days
• How do you proceed if the duration is unknown?
– Treat as late latent
.
.

3) Preventive measures
.
.
.

4) Interventions for common physiological

symptoms
.
.

5) Health systems interventions to improve

the utilization and quality of antenatal care
.
.
 Group ANC
• women were invited to join a group of 8 to 12 other
women with a similar(not more than 2 weeks)
estimated date of delivery.
• Begin at 12-16 weeks of G/A
• Eight contacts
• Each contact lasts for 2 hours
• Self assessment sheets
• Facilitated by two group leaders
• Physical examinations and investigations individualized
Comparison of FANC to New Model
• Moderate-certainty evidence indicates that FANC
probably increases perinatal mortality compared with
“standard” ANC with more visits (3 trials, 51 323 women;
RR: 1.15, 95% CI: 1.01–1.32)
• 2012, the WHO undertook a secondary analysis of
perinatal mortality data from the WHO FANC trial. This
secondary analysis, which included 18365 low-risk and
6160 high-risk women, found an increase in the overall
risk of perinatal mortality between 32 and 36 weeks of
gestation with FANC compared with “standard” ANC in
both low- and high risk population.
Comparison
 Other screenings which are not mentioned
on the guideline
• 1) Gonococcal
– Screening for gonorrhea in women is indicated in
high risk group.
– Gonococcal infection is also a marker for
concomitant chlamydial infection in up to 40
percent of infected women.
 2) CHLAMYDIAL INFECTIONS
• Screening at the first prenatal visit for women
at increased risk for chlamydial infection and
again during the third trimester if the high-risk
behavior continues.
• There is vertical transmission to 30 to 50
percent of neonates delivered vaginally from
infected women.
3) Group B Streptococcus (GBS)
 Common concerns of pregnancy
• 1) Sexual activity-generally no restriction
– Tell about
• Positioning
• Contraindications
• Dangers of Cunnilingus
• Travel
– Air
– Driving- max 6 hours, rest Q 2hrly for 10 minutes
• Exercise – “talk test”
 Absolute Contraindications to Aerobic
Exercise During Pregnancy
• Hemodynamically significant heart disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for preterm labor
• Persistent second- or third-trimester bleeding
• Placenta previa after 26 weeks of gestation
• Preterm labor during the current pregnancy
• Ruptured membranes
• Preeclampsia/pregnancy induced hypertension
 Relative Contraindications to Aerobic
Exercise During Pregnancy
• Severe anemia
• Extreme morbid obesity
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current pregnancy
• Poorly controlled hypertension
• Poorly controlled seizure disorder
• Poorly controlled hyperthyroidism
• Heavy smoker
 Immunization
• TT vaccine
– Schedule
– Protection
• Hepatitis B vaccine
 Immunization ….
• Contraindicated in pregnancy
– Measles
– Mumps
– Rubella
– Varicella
– Smallpox
– HPV
 Immunization…
• Indications which not altered by pregnancy
– Rabies
– Hepatitis B
– Pneumococcus
– Meningococcus
– Tdap -- Recommended in every pregnancy,
preferably between 27 and 36 weeks to maximize
passive antibody transfer.
 Specific Immune Globulins
• Postexposure prophylaxis(not contraindicated
in pregnancy)
– Hepatitis B
– Rabies
– Tetanus
 Summary
• ANC is an important tool in reducing maternal
and fetal morbidity and mortality by
prevention and early detection of problems.
• Minimum of eight ANC contacts are
recommended.
• First contact should be in the first trimester.
• ANC for positive pregnancy experience not
just mere survival.
 References
• WHO recommendations on antenatal care for a positive pregnancy
experience.I.World Health Organization.2016
• Management protocol on selected obstetrics topics (FMOH) January, 2010
• Williams obstetrics 24th edition , chapter 64-page 1239-1258 ,infectious diseases
• Steffen G. Gabbe normal and problem pregnancies,6 th edition ,prenatal care
• Ethiopian Demographic and Health Survey 2016
• WHO antenatal care randomized trial: manualfor the implementation of the new
model.Geneva: World Health Organization;
2002(http://www.who.int/reproductivehealth/publications/maternal_perinatal_he
alth/RHR_01_30/en/, accessed 9 march 2016).
• Dowswell T, Carroli G, Duley L, Gates S,Gülmezoglu AM, Khan-Neelofur D, Piaggio G.
Alternative versus standard packages of antenatal care for low-risk pregnancy.
Cochrane Database Syst Rev. 2015;(7):CD000934
• file:///C:/UpToDate%2021.2/contents/mobipreview.htm?43/48/44807#H2236266