1. Review of Antenatal Care
Needs an ESMOE emblem
ESMOE

2. What is the aim of Antenatal Care?
To end up with a happy mum and healthy baby

3. What Are The Principles Of Antenatal Care?

4. The Principles of Basic Antenatal Care (BANC)
Simple checklist for problem identification
Risk assessment & appropriate level of care
Balancing visit: benefit ratio
Only doing appropriate On-site testing
Having a definite plan for ANC
Respectful care

5. It is essential to understand the importance of antenatal care and realise that a poorly planned ANC programme is little better than no antenatal care

6. Past obstetric history
Past pregnancy performance is the single most important outcome predictor for the current pregnancy
Past perinatal death
Previous preterm labour
Previous caesarean section (C/S)
History of ante- or postpartum haemorrhage

7. You cannot manage a problem if you have not identified it!!!
The Bottom Line Is…….
You cannot manage a problem if you have not identified it!!!

8. Booking visit Full history (including TB screen) Examination
Pregnancy duration established and recorded
Screening tests
First assessment of risk factors (Problem list)

9. Dating this pregnancy - EDD
Gestational age
LNMP/LMP
Uterine size weeks
weeks
weeks
Ultrasound (up to 24 weeks)
Estimated fetal mass
RECORD AND EXPLAIN

10. Number of previous pregnancies
Definitions
Gravidity (G)
Number of previous pregnancies
Parity (P)
Number of pregnancies to reach viability irrespective of outcome or number

11. General examination General impression
Pulse, BP, temperature, respiratory rate
System examination
Abdominal examination
Per vaginal examination (PV) if indicated
Side room investigations

12. Routine testing – must be done on-site
Rapid RPR
Rapid Rh
Anaemia screen
HIV
MUAC
Dipstix for protein and glucose

13. Identification of problems and risks Antenatal care plan
Final assessment
Identification of problems and risks Antenatal care plan

16. Example

18. Subsequent Visits
Screen card History (including TB screen) Check EDD Examination Update the problem list Modify the plan
Screen card to also check if any problem was treated at the previous visit
History: Greet pt and ask if any complaints – also follow-up on previous problems
Examination consists of 4 items: BP, SF & FM, Dipstix and follow-up of presenting and/or previous problems

19. Example; will be corrected to come in line the new BANC plus guidelines

20. Educational Opportunity
Encourage ANC attendance
Pregnancy warning signs:
Reduced fetal movements
Vaginal bleeding
Rupture of membranes
Abdominal pain (not discomfort)
Severe headache
Report early in labour
Self care & delivery
Breast feeding
Immunization
Contraception
HIV & STD’s
MOM connect

21. Why Is It Important To Complete The Card?
Because if it is not done problems will be not be identified The patient will not be treated correctly

22. Problem List & Notes
Be aware that the problems change as pregnancy progresses
Short and to the point!
Alert HCW at next visit to intervention

23. Monitoring Fetal Growth

24. Measuring The SFH Make sure the bladder is not full
Let the woman lie comfortably on her back
Identify highest point of fundus. This might not be in the midline

26. Measuring The SFH
Mark the highest point of the fundus with with a ball-point pen (ask for permission first)
Do not correct dextroversion of the uterus or exert pressure on the fundus

28. Measuring The SFH
Fix the zero of the tape measure at the top of the symphysis and stretch the tape over the curve of the uterus up to the pen mark
Read the measurement to nearest cm

30. if the EDD is the 30th September, and the date of the visit is the 22nd July, then the gestational age at the time of the visit is 30 weeks gestation.
Circle 30 weeks on the gestation line.

31. The SF measurement was 28 cm.
Go the 28 cm on the SF measurement line and follow it across (blue line) until it meets the 30 week line (red).
Mark where they meet with a circle.

33. If the dates are unknown. SF is 26 cm.
Go to 26cm on SF line. Draw line across until it meets the 50th percentile line.

34. Go up the verticle line to the gestation line
Go up the verticle line to the gestation line. Circle the gestation line. That is the estimated gestation.
From now on start at the gestation line and plot the SF as if the gestational was certain.

35. Enter The Following Information
LMP - certain Now 21 weeks SF 22 cm BP 110/70 mmHg

36. What Is The 1st Question To Ask?
Do we have certain gestation?
Yes
Why?
Because we have certain dates (21 wks)

39. Enter The Following Data
LMP?
SF 28 cm
B/P 120/70
Urine 1+ glucose

40. What Is the 1st Question To Ask?
Do we have certain gestation? No
So?
Use the SF measurement

43. Enter The Following Data
Certain dates - 34 wks SF 37 cm BP 150/100 mmHg Urine 2++ Protein Haemoglobin 8 g/dl

44. What is the 1st question to ask?
Do we have certain gestation?
Yes
So?
Enter at 34 weeks

47. Is the card now complete?
No Why? No problem list!

49. Enter The Following Data
Unsure dates Ultrasound 21 wks SF 22 cm BP 110/70 mmHg

50. What Is The 1st Question To Ask?
Do we have certain gestation?
Yes
Why?
Because we have early ultrasound

53. Enter The Following Information
Certain dates 34 weeks SF 28 cm BP 110/75 mmHg

56. What Is The Problem? Certain dates and SF do not correspond So?
IUGR or incorrect dates and a late booker

57. Enter The Following Information
38 yr old G6 P5 ( 2x prev C/S) LMP ??? Ultrasound 32 weeks SF 34 cm BP 155/100 mmHg Urine: Protein –ve, 2+ glucose

58. 1st Question? Do we have certain dates? So? Why not U/S? No
But U/S = 32 weeks
So?
Use SF
Why not U/S?
Because late U/S is not accurate!

62. Work out problem lists for the following antenatal card, and start SF graph

64. Problem List Previous IUD
Pregnancy was complicated by hypertension (HT) with no follow-up
Advanced maternal age (AMA)
Unsure dates & late booker
HT and obesity (BMI = 40, UMAC = 37)
Rh –ve (no Ab titre done)
Inappropriate level of care

66. Problem List 2 x small for gestational age (SGA) babies Smoker No MUAC
Ronchi & Wheezing
SF small for dates 33/52)
No tet toxoid
RPR +ve, Rh –ve
Inappropriate level of care

68. Problem List Unsure dates? Poor social circumstances
Small and underweight – no UMAC
Lymphadenopathy and vaginal candidiasis
No Rx of candidiasis or Pap smear taken
RPR +ve – no treatment
No HIV counseling or testing

69. Any Questions ?