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antenatal care
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Antenatal Care Antenatal Care
Dr. Rabi Narayan Satapathy Assistant
Professor Dept. of Obst. & Gyn.
S.C.B. Medical College,Cuttack.
Mail; [email protected]; 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.
