Antenatal care dr rabi

Antenatal Care Antenatal Care

Dr. Rabi Narayan Satapathy Assistant

Professor Dept. of Obst. & Gyn.

S.C.B. Medical College,Cuttack.

Mail; drrabisatpathy@yahoo.comMob; 9861281510/8270088880

Evolution of ANCEvolution of ANC

“ Hints to Mothers for the Management of Health during the Period of Pregnancy and in the Lying-in Room with an Exposure of Common Errors in Connection with these Subjects”

Thomas Bull (1937)

● 1901 Paper by Ballantyne entitled “A plea for a pro-maternity hospital”

Led to establishment of the first antenatal bed at the Edinburgh Royal Maternity Hospital.

● 1915 First antenatal clinic at Edinburgh.

● 1950 2000 antenatal clinics in England & Wales

● ANC as we know it today emerged

in the 1960s.

● Sought to prevent or cure most of

the hazards of pregnancy.

● Promised to make pregnancy and

subsequent delivery as smooth as

possible

● Development of new technologies

aided this aim

Early incorporation into India’s MCH services

ANC now became more streamlined

Benefits felt immediately in succeeding years

MMR from 2000/100,000 live births in 1938

1000/100,000 live births in 1959

Promote,protect & maintain the

physical, mental and social well-

being of both mother & child.

To detect high-risk cases

To foresee complications

To remove the anxiety & dread

associated with delivery

To educate mother regarding child

care, nutrition, personal hygiene,

environmental sanitation etc.

To sensitise the mother to the need

for family planning.

To reduce MMR & IMR

To maintain the “normal”

status of a normal

physiological event.

Components of ANCComponents of ANC

§ A set of professional check-ups§ Tetanus & other immunizations§ Iron & folic acid prophylaxis§ Regular blood-pressure check-

ups§ Risk-approach§ Advice regarding delivery

methods, nutrition, personal hygiene etc.

§ Maintenance of records§ Home visits.

Successes OF ANC

Routine antenatal care is an example of preventive health care at its best

Drastic reduction of MMR in the last five decades

Considerable improvement in PNMR

High cost-effectiveness

Successes of ANC…contd.

78%women covered by tetanus prophylaxis

Introduction of screening & early detection of foetal abnormalities using biochemistry & ultrasound.

( detection of anomalies by USG AT 19 wks. Had 85% sensitivity & 99.9% sensitivity)

AT THE CROSS-ROADS

» The MMR,though dipping in the past decades has not reached an ideal figure. It still stands at an alarming 407/100,000 live births.

MMR in some countries : UK – 13 USA -17 Bangladesh – 380 Sri Lanka - 92

At the Cross - roads

40% maternal deaths due to haemorrhage, sepsis

12% maternal deaths due to eclampsia 20% due to indirect causes (notably

anaemia)

29%

19%16%

10%

9%

8%9%

Hemorrhage Anemia

Sepsis Obstructed labour

Abortion ToxemiaOthers

At the Cross-Roads

» ANC reaches out to 20-70% of pregnant women,depending on area surveyed,

(urban,semi-urban or rural)» About 80% of these have only one

visit,3/4ths receive their first visit between 6th to 8th month of pregnancy

» About 25% of women who receive ANC have a complication during labour and delivery

At the Cross-Roads

300 women die every day in India during childbirth or due to pregnancy related causes

» MMR in developing countries remains 100 times more than in the developed countries

At the Cross- Roads

Majority of maternal deaths take

place after delivery, most within 24 hrs. after delivery. Yet, only 17% of deliveries taking place outside of a health institution are followed up by PP check-ups; only 14%within the critical two-day period.

Limitations of current ANC Practices

● Low-Outreach – Inability to bring all pregnant women into its fold.

Reasons :a)Not thinking check-ups were

necessary (60%) b) Inability to meet

costs (15%) c)Family or peer

pressure (9%) d)Lack of knowledge

about ANC e)Long distances to

health centre f) Lack of

transportation

LIMITATIONS … contd.

● Competency of health care provider

● Home deliveries unattended by trained health professional

● Disregard for basic hygienic environment

● No change in incidence of preterm labour,despite increased awareness of risk factors and sophisticated diagnostic procedures

● Limited usefulness of high-risk approach

Limitations…contd.

● 70% of adverse perinatal outcomes cannot be predicted by existing assessment methods

● Only 44% of IUGR correctly diagnosed

● 30% of women developing PET presented for the first time in labour

● Despite existing ANC services, emergency admissions far outweigh elective admissions

Limitations…contd.

● Though figures are hard to come by; for every maternal death, there are 10-15 women who survive only to suffer from the sequelae of pregnancy and neglected childbirth

●Onset of unpredictable complications even with full antenatal supervision eg. PROM, vag.bleeding, HTN, cord prolapse, shoulder dystocia etc.

A Way Forward

►Safe Motherhood Programme in 1992

►RCH Programme in 1997.Provision of care for the pregnant woman became a major thrust

.JSY in 2005

A Way Forward…contd.

■ In its Annual Report 2001-2002,the

GOI Planning Commission notes that both the lack of universal screening for risk factors and the lack of appropriate referral are the major reasons that maternal and child mortality and morbidity have not declined in the past two decades.

Future Policy

Goals of the National Population Policy 2000

■ Reducing MMR to <100/100,000 live births

■ Achieving 80% deliveries within health institutions

■ Delivery of all births by trained personnel

■ Adressing the unmet needs for basic reproductive and child health services, supplies and infrastructure

A Way Forward

● Continuity of ANC by health care provider. The set of competencies necessary for adequate ANC is more important than the cadre of the health care provider

● Screening and detection of existing diseases (eg. HTN, TB, HIV, DIABETES )will have a direct impact on pregnancy and perinatal outcome

.Antenatal Visits *once / month till 7 mths *twice / month in the 8th mth *weekly thereafterRevised visit schedule *1st visit as soon as pre

detected/20th

wk

*2nd visit at 32 wks *3rd visit at 36 wks

Aims of Pre-pregnancy Care

To bring the woman to pregnancy in the best possible health.

To provide the means of ensuring that preventable factors are attended to before pregnancy starts, e.g., Rubella

To discuss relevant issues. To give advice about the effect of: Preexisting disease and its treatment on the pregnancy—

Diabetes , Hypertension the effect of pregnancy on preexisting disease and its

treatment To consider the likelihood and effects of any

recurrence of events from previous pregnancies and deliveries.

Aims of Antenatal Care

1. Management of maternal symptomatic problems.

2. Management of fetal symptomatic problems.

3. Screening and prevention of fetal problems.

4. Preparation of the mother for childbirth.

5. Preparation of the couple for childbearing.

Booking appointment

Ideally by 10 weeks of gestation Identify women who may need

additional care and plan the pattern of care.

Measure the weight (Wt) and height (Ht)

Measure blood pressure (BP) and check urine for proteinuria.

Determine risk for gestational Diabetes and Pre-eclampsia

Booking Visit

History Age Parity Menstrual history Medical history Surgical history Socio-background Obstetric history

Booking Visit

Examination Face; complexion, eyes, teeth Thyroid gland Chest, lungs, Heart and breasts Abdomen, changes of pregnancy, any scars Uterine size Fetal heart Pelvic ???/ vagina

Booking Investigation Offer blood tests: Blood group and Rhesus status Screen for anaemia and haemoglobinopathies Hepatitis B Virus Rubella susceptibility Syphilis Toxoplasmosis Mid stream urine Offer early ultrasound, for gestational age,

structural anomalies Offer screening for Down syndrome???

Supportive Information

Give information supported by written information.

Give an opportunity to discuss issues and ask questions.

Be alert to any factors, social that may affect the health of both mother and fetus/baby.

Offer ante-natal classes

Specific Information

How the baby develops during pregnancy

Nutrition and diet, including Iron supplement.

The pregnancy care pattern Planning the place of birth breastfeeding

Ultrasound Scan (USS) USS to determine gestational age

using: Gestational sac Crown-rump measurement, 10-13 weeks Bipareital diameter (BPD) 14 18 weeks Fetal Biometry: BPD, Head Circumference

(HC), Femur length (FL), Abdominal Circumference (AC) 18-24 weeks

USS to determine fetal growth: using fetal biometry variables USS to determine fetal wellbeing Using:

USS to determine anomalies

10-12 weeks 20 weeks

Down’s syndrome screening

Combined test, 11-14 weeks of gestation

Serum screening (Triple or quadruple test) 15-20 weeks.

Main purpose of visits

History and examination, clarification of uncertain gestation, identification of risk factors for the pregnancy.

Booking blood tests

Subsequent Visits14-16 weeks

Review history, discuss and record screening tests,

Measure BP and test urine, Check Hb level if < 11gm/dl

consider Iron supplement. Examine the fundal height and listen

to the fetal heart.

18-20 weeks

Measure BP and test urine, Examine the fundal height and

listen to the fetal heart. Discuss the structural anomaly scan If placenta extends across the

internal cervical os, offer another scan at ??????

24 weeks

Measure BP and test urine for????? Measure the plot symphysis-fundal

height for nulliparous

28 weeks

Measure BP and test urine Offer another screening for anaemia

and atypical red-cell alloantibodies Investigate a Hb <10gm/dl Offer anti-D prohylaxis to a women

who are Rhesus D-negative Offer screening for gestational

Diabetes Measure symphysis fundal height

32 weeks of gestation

Check the dates from LMP. Review, discuss and record the

results undertaken at 28 weeks. Measure BP and test urine Measure S-F height

34-36 weeks

Check the dates from LMP. Review, discuss and raised issue. Measure BP and test urine Measure S-F height Offer a second does of anti-D prophylaxis Arrange an USS if low-lying placenta at

20 weeks Give specific information on preparation

for labour

36-37 weeks Check the dates from LMP. Review, discuss and record the results

undertaken at 28 weeks. Measure BP and test urine Measure S-F height Check the presentation, if breech offer

external cephalic version(ECV) Give specific information on preparation

for labour Information on breastfeeding

38 weeks

Check the dates from LMP. Measure BP and test urine Measure S-F height Check the presentation, if breech

offer external cephalic version (ECV) Give specific information on

preparation for labour Information on breastfeeding

40 weeks

Check the dates from LMP. Measure BP and test urine Measure S-F height Check the presentation, if breech

offer external cephalic version(ECV), can be difficult

Give specific information on preparation for labour

Information on breastfeeding

41 weeks

Check the dates from LMP. Measure BP and test urine Measure S-F height Give specific information on

preparation for labour Information on breastfeeding Offer membrane sweep Offer induction of laour

Clinical assessment of bony pelvis

It is not important. However if done should include checking the:

Anteroposterior diameter, from the symphysis pubis to the sacral promontory.

Curve of the sacrum. Promimance of the ischial spines. The angle of the greater sciatic notch Subpubic angle

.Prenatal Advice: ● Diet and Nutrition

● Personal hygiene

● Drugs

● Radiation risk

● Warning signs

● Child care

. Specific Health Protection :

Anaemia

Other nutritional deficiencies

Toxaemias of pregnancy

Tetanus immunization

A Way Forward

■ Modification of the “Risk- Approach”.

Current literature strongly suggests that the focus of obstetric care should be shifted from predicting complications to identification of risk factors and detection of signs and symptoms of current problems

A Way Forward

■ Birth-preparedness or a Birth-action plan

* Who attends,who accompanies

* Transportation,decision-makers,finance

* Complication preparedness * Potential blood donors The action plan to be made after

discussion with the woman and her family members

A Way Forward…contd.

■ Easy access to Emergency Obstetric Care

■ To provide useful information to the pregnant woman and her family

■ Universal USG screening■ ? Universal HIV screening■ ? Genetic screening

Conclusion • The current day ANC, though serving an

extremely useful purpose, has not met the expectations of the nation. • Since it is nearly impossible to predict which woman will develop a complication, it is important to work with all women to recognize complications and to establish a plan of action in case they arise. •This will ensure that they arrive earlier at points in the health care system where they can receive appropriate care. Only then can we reach much nearer to the goals we have set for ourselves.