Importance of Antenatal Care: Accessible and effective antenatal care (ANC) is crucial for improving maternal health. ANC is a fundamental element for promoting safer motherhood globally. Offering flexible options for consultation locations and appointment times could significantly increase attendance and improve satisfaction for expectant mothers. Health ministries advocate for integrated service delivery, incorporating elements like family planning, prevention of mother-to-child transmission (EMTCT) interventions within antenatal care, and immunization programs.

Aims/Purposes of Antenatal Care

1. Health Promotion: To enhance and maintain the physical, mental, and social well-being of women during pregnancy.

2. Early Detection & Treatment: To identify and manage any pre-existing conditions or health issues that may arise during pregnancy, whether they are medical, surgical, or obstetric in nature.

3. Birth Preparedness: To equip mothers for a safe childbirth experience, including preparation for potential emergencies and complications.

4. Healthy Baby, Healthy Mother: To facilitate the delivery of a healthy, full-term infant (or infants) while minimizing health risks for the mother.

5. Postpartum & Newborn Care: To support mothers through the normal postpartum period and, in collaboration with their partners, enable them to provide optimal physical, psychological, and social care for their child.

6. Deviation Management & Privacy: To identify any deviations from normal pregnancy progression and provide necessary management or treatment, while consistently ensuring patient privacy.

7. Breastfeeding Preparation: To prepare mothers for successful breastfeeding and offer guidance on adequate lactation preparation.

8. Nutritional Guidance: To provide mothers with essential nutritional advice for a healthy pregnancy.

9. Parenthood Counseling: To offer parenthood advice, whether through structured programs or individual consultations, tailored to the client’s specific concerns.

10. Building Trust & Communication: To foster a strong, trusting relationship between the family, the pregnant woman, and healthcare providers. This encourages open communication and allows them to share anxieties and concerns related to the pregnancy and care received through effective communication and counseling.

11. Preventive & Advisory Services: To provide pregnant women with ongoing preventive and advisory services. Healthcare providers should discuss suitable birth locations and essential preparations for a clean and safe delivery, such as the use of birth kits.

Goals of Focused/Oriented Antenatal Care

Important Considerations: Goals are visit-specific and adapted based on the timing of each antenatal appointment. For uncomplicated pregnancies, a schedule of 4 visits is generally recommended. Women initiating care later in pregnancy will require a combination and prioritization of goals from earlier visits. During every visit, any identified health concerns should be addressed, and blood pressure (BP) and symphysio-fundal height (SFH) should be routinely checked.

Overarching Goals for Maternal and Newborn Health: To improve maternal and newborn survival through:

• Early Problem Detection: Prompt identification and treatment of pregnancy-related problems and complications.

• Complication Prevention: Strategies to prevent the occurrence of complications and diseases during pregnancy.

• Birth Preparedness & Emergency Readiness: Ensuring mothers are prepared for childbirth and ready to handle potential complications.

Scheduling and Timing of Goal/Focused Antenatal Care Visits

• First Visit: By 16 weeks of gestation at the latest, ideally as soon as a woman suspects pregnancy (0-16 weeks).

• Second Visit: Between 16-28 weeks gestation, or at least once during the second trimester.

• Third Visit: Between 28-32 weeks gestation.

• Fourth Visit: Additional visits are scheduled as needed based on individual circumstances. This includes:

  • Occurrence of complications.

  • Need for follow-up care or referral.

  • Patient request to see a healthcare provider.

  • Changes in care plan based on assessment findings (history, examination, tests) or local guidelines.

• Referral: Prompt referral to specialized care when necessary.

Risk Factors During Pregnancy

The following conditions are recognized as potentially harmful to the pregnancy and its outcome, and are therefore considered risk factors:

1. Conditions Predisposing to Bleeding:

   • History of hemorrhage (Antepartum Hemorrhage – APH, Postpartum Hemorrhage – PPH, retained placenta).

   • High parity (five or more previous pregnancies).

   • Anemia.

   • Multiple gestation (twins, triplets, etc.).

   • Uterine scar (from previous Cesarean section or uterine surgery).

2. Conditions Affecting Fetal Growth/Viability: Conditions that can hinder intrauterine fetal growth and potentially lead to miscarriage or premature birth:

   • Preeclampsia.

   • Anemia.

   • Malnutrition.

   • HIV infection.

   • Malaria, smoking, maternal underweight due to inadequate nutrition.

   • Inter-pregnancy interval less than 2 years.

   • Diabetes.

   • Multiple gestation.

   • Excessive alcohol consumption.

   • Sickle cell disease.

   • Miscarriage within the last 3 months.

3. Conditions Increasing Infection Risk: Conditions that elevate the risk of infections for both mother and baby, potentially causing miscarriage:

   • HIV infection.

   • Sexually Transmitted Infections (STIs) e.g., syphilis.

   • Premature rupture of membranes.

   • Diabetes mellitus.

   • Malaria.

4. Conditions Potentially Requiring Assisted Delivery: Conditions where Cesarean section or vacuum extraction may be necessary for delivery:

   • Short stature (height below 150cm).

   • Young primigravida (first pregnancy under 18 years old).

   • Elderly primigravida (first pregnancy over 35 years old).

   • Previous uterine scar.

   • Cardiac disease.

   • Diabetes mellitus.

   • Pelvic injury or deformity of the pelvis and lower spine.

   • Severe pre-eclampsia and eclampsia.

5. Other Conditions: Conditions that are likely to:

   a) Recur:
   * Miscarriage (Abortion).
   * Stillbirth.
   * Premature delivery.
   * Eclampsia.

   b) Worsen with Pregnancy:
   * Renal disease.
   * Mental illness.
   * Epilepsy.
   * Pulmonary tuberculosis.
   * Heart disease.
   * AIDS.
   * Diabetes mellitus.

   c) Cause Social Discomfort:
   * Lack of partner/family support.
   * Gender-Based Violence (GBV).
   * Low socio-economic status.
   * Unwanted pregnancy.

6. Conditions Affecting Fetal Health: Conditions that can cause abnormalities or disease in the baby:

   • Advanced maternal age (over 35 years).

   • STIs such as syphilis, HIV infection, etc.

   • Certain medications used by the mother for other conditions, e.g., Tetracycline, Methotrexate, Efavirenz, Ciprofloxacin.

   • Alcohol consumption and smoking, including passive smoking.

   • Some genetic disorders, e.g., hemophilia, Sickle cell disease.

7. Common Pregnancy Complications: Frequent problems that can complicate pregnancy and require management:

   • Anemia.

   • Malaria.

   • STIs:

     • HIV.

     • Gonorrhea.

     • Syphilis.

     • Vaginal/vulvar warts.

   • Urinary Tract Infection (UTI).

Roles of Health Workers in Mitigating Pregnancy Risk Factors

1. Community Health Education: Providing targeted health education to communities and pregnant women, allowing ample time for them to voice concerns and engage in discussions.

2. Risk Identification & Referral: Identifying pregnant women at risk of recurrent conditions or developing complications like pre-eclampsia, eclampsia, cephalo-pelvic disproportion, etc., and ensuring appropriate referral.

3. Birth Planning & Emergency Preparedness: Discussing birth plans and emergency preparedness strategies with the mother and a chosen support person.

4. Pregnancy Management Planning: Developing individualized pregnancy management plans.

5. Appropriate Referral: Ensuring timely and suitable referral for women with identified risk factors.

Services Offered During Antenatal Care

✔ Health Education
✔ Counseling
✔ Screening and Risk Assessment through:
1. History taking.
2. General and abdominal examination.
3. Investigations (laboratory tests).
4. Vaginal pelvic examination (when indicated).
5. STI testing, including HIV.
✔ Provision of Hematinics (iron and folic acid supplements).
✔ Deworming medication.
✔ Tetanus Immunization (TT).
✔ Intermittent Presumptive Treatment of Malaria (IPT).
✔ Early Detection, Management, and Referral of high-risk mothers and those developing complications.
✔ Delivery and Postpartum Care Planning for every woman.
✔ Treatment of Medical Conditions such as malaria, hypertension, diabetes, STIs, Pulmonary tuberculosis.
✔ Prevention of Mother-to-Child Transmission (PMTCT) & Elimination of Mother-to-Child Transmission (EMTCT) services.

Essential Clinic Requirements for Antenatal Care Services

To effectively deliver ANC services, a clinic should ideally have:

1. Waiting Area: A designated space for mothers to gather for antenatal education, including:

   • Reception desk/table.

   • Seating (benches) for clients.

2. Private Examination Room: A room ensuring privacy during examinations.

3. Examination Couch: A stable and firm examination couch.

4. Basic Equipment: Weighing scale, height measuring device (in centimeters), tape measure, clinical thermometer, urine testing kits, blood pressure machine, stethoscope, and fetoscope.

5. Basic Laboratory: A small laboratory capable of screening for common problems such as anemia, hookworm infestations, syphilis, pre-eclampsia, and diabetes.

6. Essential Medications: Essential drugs as per health center guidelines, including vaccines like TT, Sulfadoxine-Pyrimethamine (SP) for IPT, hematinics, and drugs for Elimination of Mother-to-Child Transmission of HIV/AIDS (EMTCT).

Additional Recommendations for Antenatal Care

1. Early ANC Attendance: Women should be encouraged to start ANC as early as possible, ideally within the first 16 weeks of pregnancy.

2. Integrated Services: ANC should be integrated with other family health services and offered daily.

3. Outreach ANC: ANC services should be extended beyond established health facilities through regular outreach programs at specified times and locations known to the community.

Health Education in Antenatal Care

Aims of Health Education: To empower pregnant women with knowledge that promotes their health throughout pregnancy and delivery.

Information should be provided at appropriate times, including during follow-up visits.

Key Health Education Messages:

1. ANC Services & Benefits: Information about the services offered during ANC and the advantages of attending ANC.

2. Maintaining Health During Pregnancy: Guidance on how to stay healthy throughout pregnancy.

3. STIs & Pregnancy Impacts: Information about STIs and their potential effects on pregnancy and newborns.

4. Malaria in Pregnancy: Information about malaria and its complications during pregnancy.

5. Minor Pregnancy Discomforts: Guidance on managing common minor discomforts of pregnancy.

6. Diet During Pregnancy & Lactation: Nutritional advice for pregnancy and breastfeeding.

7. Danger Signs: Recognition of danger signs during pregnancy and labor requiring immediate attention.

8. Hospital Delivery Indications: Identifying pregnant women who should deliver in a hospital setting.

9. Family Planning Benefits & Options: Information on the benefits of family planning and available methods.

10. Pre-Pregnancy Risk Factors: Identifying women who may face increased risks if they become pregnant.

11. Preparation for Delivery: Guidance on what to prepare for childbirth.

12. Signs of Labor: Recognizing the signs of labor onset.

13. Skilled Birth Attendance: Benefits of delivering with a skilled provider in a health facility.

14. Postpartum Family Planning: Family planning methods for postpartum mothers.

15. Breastfeeding Benefits: Highlighting the advantages of breastfeeding.

Steps in Planning Maternal Health Client Education Sessions

✔ Identify Target Group: Define the specific audience for the education session.
✔ Identify Target Group Needs: Determine the needs of the target group, such as:
1. Current knowledge and practices related to Reproductive Health (RH).
2. Priority health messages relevant to identified problems.
✔ Choose Best Media & Language: Select the most effective communication methods and appropriate language.
✔ Identify Resources: Determine available resources, including:
1. Community leaders.
2. Influential supporters of RH services (e.g., satisfied clients).
3. Educational materials/visual aids.
4. Suitable venue for effective RH client education.

Preparation for Education Sessions:

1. ✔ Prepare Venue: Ensure the venue is conducive for the session.

2. ✔ Notify Target Group: Inform the target group through community leaders.

3. ✔ Self-Preparation: Ensure you are well-prepared with the information.

4. ✔ Identify Satisfied Clients: Involve satisfied clients to share their experiences.

5. ✔ Prepare Influential Supporters: Engage influential supporters of RH services.

6. ✔ Prepare Materials/Visual Aids: Gather necessary materials and visual aids.

7. ✔ Prepare Content & Channels: Plan the session content and delivery methods (e.g., talk, song).

Steps in Conducting Education Session Talks:

1. Introduction: Introduce yourself and colleagues.

2. Acknowledge Leaders & Group: Recognize community leaders and the group present.

3. State Session Purpose: Clearly state the purpose of the session in an engaging way using slogans, posters, or short stories.

4. Deliver Content: Present the information, encouraging group participation and using visual aids as needed.

5. Q&A: Allow time for questions and answers.

6. Evaluate Session: Assess the session’s effectiveness through observation, questions, and understanding participant feelings and learning.

7. Summarize Key Points: Recap the main points of the session.

8. Follow-up Information: Provide information on where to get individual attention or further services.

9. Topic Selection: Allow participants to choose a topic for a future RH session.

10. Announce Next Session: Inform participants about the time and location of the next session.

11. Thank Participants: Express gratitude to the group for their participation.

Antenatal Risk Assessment

Antenatal risk assessment is a systematic evaluation of pregnant women during antenatal care to identify those at higher risk of adverse pregnancy outcomes during childbirth. It also involves detecting and managing any illnesses or pregnancy complications as they arise.

First Antenatal Visit/Booking Visit

The primary goal of the first antenatal visit is to establish baseline information for each woman, against which subsequent findings will be compared and assessed throughout her pregnancy.

This baseline information is obtained through:

1. ✔ History Taking

2. ✔ Physical Examination: General, systemic, and abdominal examination.

3. ✔ Investigations (laboratory tests).

1. History Taking

A structured and comprehensive history is essential to evaluate the health status of both the mother and the fetus. Key components of the history include:

✔ Demographic Information: Name and place of residence, noting accessibility to healthcare and maternity services.
✔ Age: Identifying high-risk age groups (under 18 and over 35 years).
✔ Parity: Noting young and elderly primigravidas, women with parity above 4, and closely spaced pregnancies (less than 2 years apart).
✔ Social History: Marital status, sources of social and financial support, education level, history of female genital mutilation (where applicable), alcohol and tobacco use, and partner’s health status.
✔ Medical History: Prior medical conditions such as hypertension, renal disease, epilepsy, diabetes mellitus, sickle cell disease, asthma, Tuberculosis (TB), and HIV. Surgical history, including operations, blood transfusions, skeletal deformities, and fractures of the pelvis, spine, or femur.
✔ Obstetric and Gynecological History: Details of previous pregnancies and their outcomes, such as prior Cesarean sections, retained placenta, PPH, stillbirth, prolonged labor, early maternal death, ectopic pregnancies, Dilatation and Curettage (D&C), APH, pre-eclampsia, etc.
✔ Family History: Family history of conditions like hypertension, diabetes, multiple pregnancies (twins), and sickle cell disease.
✔ Menstrual History:
1. Detailed menstrual history including age at menarche, cycle length and regularity, duration and amount of menstrual flow.
2. Contraceptive history: Past use of modern contraceptive methods and dates of discontinuation.
✔ History of Present Pregnancy: Information about the first day of the Last Normal Menstrual Period (LNMP) to calculate the Estimated Date of Delivery (EDD). This helps in comparing gestational age with fundal height during examinations. If pregnancy is beyond 20 weeks, note the dates of quickening (first fetal movements felt by the mother). Inquire about any problems experienced since becoming pregnant, such as bleeding, vomiting, hospitalization, HIV sero-status, fever, cough, or diarrhea.

2. Physical Examination

General Examination:

A head-to-toe physical examination to assess overall health and identify any non-pregnancy-related illnesses:

✔ Weight Measurement: Note underweight (below 45 kg) or overweight (above 80 kg) women.
✔ Height Measurement: Identify women with short stature (below 159 cm) and check for skeletal deformities or limping.
✔ Blood Pressure Measurement: Identify women with elevated blood pressure (BP ≥ 140/90 mmHg).
✔ Anemia and Jaundice Assessment: Examine conjunctiva, tongue, palms, and capillary refill in nail beds to check for anemia and jaundice.
✔ Edema Assessment: Check for swelling (edema) in feet, hands, face, and sacral area.
✔ Systemic Examination: Systematic examination of respiratory and cardiovascular systems to rule out abnormalities.
✔ Breast Examination: Examine breasts for masses and signs of malignancy. Educate women on nipple care and breast self-examination.
✔ Physical Abuse Assessment:
1. Screen for drug abuse.
2. Check for unexplained bruising.
✔ Assessment of Any Complaints: Address any specific complaints reported by the woman.