ANTENATAL CARE IN TANZANIA

• Care given to a pregnant woman.• It is a systematic supervision of a woman

during pregnancy.• It comprises of– Careful history taking and examinations– Ear-marking the high-risk group– Advice given to the pregnant woman.

Aims of ANC

• To screen the ‘high risk’ cases in pregnancy.• To prevent or to detect and treat at the earliest

any complications of pregnancy• To ensure that the pregnant woman reaches the

end of her pregnancy healthy.• To educate the mother about the physiology of

pregnancy and labour • To advice on the place, time and mode of

delivery, provisionally and care of the newborn.

Specific objectives

• To ensure a good standard of health to all pregnant women

• To observe any abnormality in the pregnancy and advise the woman the best course of action thereafter.

• To deal with any common illnesses during pregnancy

• To make the mother aware of the benefits offered by antenatal , postnatal and family planning clinics.

Normal pregnancy

• Delivery of a single baby in good condition at term (between 38-42) , with fetal wt of ≥ 2.5kg and with no complication

1.FIRST VISIT

• Activities include– Registration– Wt and ht measurement – History taking– Physical examination– Lab investigation– Mgt of minor complaints– Prophylactic rx– Immunization– Health education

Physical examination

1. General examination• Pts general appearance– Whether ill-looking or not– Short stature– Whether she walks in a limp.

• Nutritional status– Check signs of wasting- zygomatic bones, wasted

intercostal spaces, and hypothenar and thenar muscles.

• Blood pressure – • BP ≥140/90 is considered abnormal

• Signs of anaemia– Look for clinical anaemia in the conjuctivae,

tongue, mouth, palms, fingernails, soles of the feet and even the vaginal wall.

• Look for oedema of the ankles, sheen of tibia,sacral area, anterior abdominal wall and periorbital area.

2. Systemic examination– CVS- check PR, size of the heart, heart sounds

and murmurs– RS – rule out PTB and any lung lesions.– MSS- check the pelvis structure and the spine,

rule out bony abnormalities.– CNS- should be examined if indicated

Obstetric examination

• Inspection of the abdomen– Check and record any scars, superficial irregularities or over-

distension• Height of the fundus

– The fundal height is compared with the GA in weeks as calculated from L.N.M.P

• Lie of the fetus– Relationship of the long axis of the fetus to that of the mother.– Indicates whether the fetus is upright(longitudinal) or lying

crosswise(transverse) or obliquely.– It is most important after 32 weeks , by which time it should have

settled into a longitudinal lie.

• Presenting part – Part of the fetus that is at the pelvic brim.– It will be either cephalic, or breech( buttocks)

• Attitude of the fetus parts– Relation of the fetal parts to one another.– If the head is bent so that the chin is touching the

chest , it is said to be flexed.– A well flexed head presents the smallest diameter

and delivers easier

Investigations Initial routine investigations for each pregnancy at first antenatal visit(obtain informed consent for each test): include• • Full blood picture-for Hb estimation• • Blood group and atypical antibody screen• • Syphilis serology (VDRL tests)• • Rubella titre• • Hepatitis B surface antigen• • Hepatitis C antibodies• • HIV antibodies for PMTCT• • Random blood glucose (if mod/high risk of diabetes)• • Midstream Urine for protein• • Chlamydia screening• Stool examination for hookworms and ascaris ova.

• Investigations to be considered depending on the woman’s clinical circumstances:

• Early dating ultrasound if dates uncertain • Vitamin D screening if at risk for Vitamin D deficiency

e.g., women who have reduced sun exposure, veiled women and dark skinned women

• Pap smear (if not done within two years) • Diabetes screening as indicated • Haemoglobinopathy Screening if in high-risk group e.g.

high risk ethnic background, FHx of haemoglobinopathy

Management of minor ailments in pregnancy.

1. Morning sicknessa) woman should take small frequent mealsb) She should take lots of fluids c) She should aviod heavy meals or staying hungry for long time.

2. Heart burna) She should use many pillows to raise her head when

sleepingb) To take small sips of milk or warm water c) To avoid over eating and not to go to bed immediately

after eating.d) Liquid antacids may be helpful.

Routine prophylaxis

Malaria Pregnant women should be given sulfadoxine pyrimethamine

(SP) as intermittent preventative treatment (IPT) as follows: First single dose after 16-20 weeks Second single dose after 30 weeks

Anaemia Give iron tablets like ferrous sulphate 600mg daily in divided

doses throughout pregnancy. This should also depend on the Hb level. Hb level < 10.0mg/dl give thrice a day.

Give 5mg folic acid daily throughout pregnancy.

Immunization

Tetanus Toxoid• To prevent tetanus neonatorum.• So it is recommended to give TT to all mothers • WHO TT immunization schedule.

• This should be started for all school attending girls so that by the time they get into reproductive age they are fully immunized against tetanus.

WHO TT IMMUNIATION SCHEDULE.

Dose When to give % of protection Duration of Protection

TT---1 At 1st contact or as early as possible during pregnancy

Nil None

TT--2 At least 4 weeks after TT--1

80% 3 years

TT--3 At least 6 months after TT--2

95% 5 years

TT---4 At least 1 year after TT--3

99% 10 years

TT--5 At least 1 year after TT--4

99% 20 years

• For mothers who have never been vaccinated before, give 3 doses of 0.5 cc IM toxoid at intervals of at least 1 month. The last dose should be given during the last 2 months of pregnancy.

• For those who have been vaccinated before, a booster dose of 0.5cc IM is given in the last trimester.

ARV DRUGS

• It is recommended that pregnant women who are HIV +ve take Nevirapine tablets 200mg during labour and the newborn is given nevirapine syrup 0.2mg/kg body wt within 72 hours after delivery

ANTI-D IMMUNIZATION• Anti-D• It is recommended that anti-D (625 IU) be given to all rhesus negative, antibody

negative women at 28 and 36 weeks gestation. These women will therefore need to be seen at 28 weeks and 36 weeks.

• Anti-D is also given to these women after the birth of their baby if the baby is rhesus positive.

• A blood test for blood group and antibodies needs to performed prior to administering the 28 week dose of anti-D.

• It is recommended that anti-D is given to all rhesus negative and antibody negative women if there is risk of fetal-maternal transfusion of blood, such as a miscarriage.

• Anti-D should be given within 96 hours of the onset of bleeding (the earlier the better)

Anti-D dosage

First trimester – 250 IU (minidose vial).• Indications are threatened or inevitable

miscarriage, termination of pregnancy, chorionic villus sampling and ectopic pregnancy.

• Note: For a multiple pregnancy give 625 IU.

Anti-D dosage

• Second and third trimester, postnatally – 625 IU (full dose vial).

• Indications are at 28 weeks, 36 weeks, postnatally (if baby is rhesus positive) and episodes when a fetal-materal haemorrhage may occur such as amniocentesis, external cephalic version, antepartum haemorrhage or abdominal trauma.

• Note: For second and third trimester, a Kleihauer test should be performed (1-24 hours after the bleeding or sensitising event) so additional anti-D may be given if required.

SUBSEQUENT VISIT

• The pregnant woman should be encouraged to re-visit ANC.

• After each visit the woman should be told the date of her next visit and the date written on her ANC card which she takes home.

• It is every 4 weeks until 28 weeks then every 2 weeks until 36 weeks and weekly thereafter till delivery.

• The activities during re-visit periods are as during the first visit but brief.

• The schedule for seeing pregnant women should be at least 4 according to WHO in developing countries.1. In the 1st trimester around 16 weeks—First visit2. Between 24-28 weeks—2nd visit3. At 32 weeks –3rd visit4. At 36 weeks---4th visit.

Objectives of re-visit

• To assess– Fetal well being– Fetal lie, presentation, position and # of fetuses– Anemia, pre- eclampsia, amniotic fluid volume and

fetal growth• To organise specialist antenatal clinics for pts

at high risks• To select time for USS, amniocentesis or

chorion villus biopsy when indicated.

High- risk group

• Are pregnant women whose pregnancies are at higher-risk of having complications that affect the pregnancy outcome –maternal or perinatal or both.

Factors which put a woman in high-risk group

1. Past obstetric history• Previous c/section, vacuum extraction,

symphysiotomy, laparotomy for ruptured uterus and forceps deliveries

• Retained placenta• PPH• Recurrent miscariage• Previous stillbirths or neonatal deaths• Grand multiparity (4+)• History of 10 + years of involuntary infertility

2. Past gynaecological operationso Repair of VVFo Repair of genital prolapseo Repair of complete perineal tearo Repair of stress incontinence

3. Primigravida Height 150 cm or less Age 35 years and above or below 16 years Deformities of musculo-skeletal system, eg

kyphosis,

4. Maternal diseases– PIH– Blood Pressure of 140/90 mmHg and above – Pre -

eclampsia– Hb level of 8g/dl or less- Anemia– Cardiac diseases, pulmonary diseases (TB), renal

diseases, – Diabetes mellitus– Syphilis and HIV Infection– Uterine Fibroid

5. Abnormal pregnancy Multiple pregnancy Malpresentation of fetus Abnormal lie of the fetus IUFD Polyhydramnios APH IUFGR

6. During labourFetal distressProlonged labourPROMPreterm labourHyperpyrexiaIUFDBreech presentationPre- eclampsia, eclampsia