‫ﻟﻠﯿﺎن ﺳﺮﺳﻢ‬.‫د‬.

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2018-2019
ANTENATAL CARE
Objectives:
At the end of this lecture, the 4th year students will be able to:
Define antenatal care.
List the antenatal care objectives.
Describe the classification of antenatal care.
Identify highlights of current antenatal care, including risk assessment, education,
screening, diagnostic procedures and management of high risk pregnancy.
Summarize the antenatal care visits, including booking visit and follow-up visits.

Antenatal care is a key component of a healthy pregnancy. Early and regular

antenatal care is recommended to improve pregnancy outcomes.

Aims of antenatal care:

The aims of antenatal care are to bring the mother and child to labour in the
best possible condition.
They are:
1. A screening process applied to the entire pregnant population to detect
subgroups at higher risk for complications of pregnancy.
2. Suitable diagnostic procedures to determine who are really at risk.
3. The management of high-risk pregnancies.
4. The educational preparation of the couple for childbirth and the rearing of
the infant.

Classification Of ANC:
 Shared care
 Community-based care
 Hospital-based care

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Shared care: A term given to ANC that is provided jointly by a hospital
maternity team, a general practitioner ( GP ) & community midwife. This
form of care is ideal for those women whose pregnancies are not entirely
straight forward.

Community-based care: Booking appointment is carried out by a

community midwife. Routine scans & investigations are also requested by
the community midwife, performed in hospital & interpreted by the
community team. Ideally only “low risk” women are offered this option.
Community-based care is often accompanied by intrapartum care provided
by the same team of community midwives.

Hospital-based care: Is this form of care, a structured program of visits to a

hospital antenatal clinic which may be highly specialized (e.g. care of
women with diabetes mellitus). It is really an extension of shared care.
Advice, Reassurance and Education:
Rest and Exercise:
Sensible exercise such as walking and swimming or organized exercise to
which the woman is accustomed (e.g. aerobics) should be allowed in
pregnancy.
Nutritional supplements:
‫٭‬Folic acid: Folic acid is found naturally in useful amounts in green leafy
vegetables, and citrus fruits. Folic acid supplements have been shown to
reduce the incidence of neural tube defects (NTDs) when taken
preconceptually and up to 14 weeks’ gestation. The recommended dose is
400 micrograms per day. Also need to increase dietary folate.
‫٭‬Iron supplementation: Should not be offered routinely to all pregnant
women. In the non-pregnant state, about 10% of iron is absorbed and this is
thought to double in pregnancy. When supplementation is given, you should
aim to give at least 100mg of elemental iron a day. It may cause unpleasant
side effects like constipation.
‫ ٭‬Vitamin A: Intake should be limited to approximately 700 microgram/day
because of risk of teratogenicity.

Smoking and alcohol:

Smoking carry specific risks of an increased PNM, placental abruption,
preterm labour, preterm premature rupture of membranes, placenta praevia

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& low birth weight. So benefit of smoking cessation at this stage should be
emphasized.
Excess alcohol has an adverse effect on the fetus.

Prescribed medicines:
Should be used as little as possible and should be limited to circumstances
where benefits outweighs the risk.

Bowels:
Pregnancy tends to make women constipated because of the progestogenic
effect of relaxing smooth muscles. This is best overcome by increasing fluid
intake, fresh fruit and by the use of foods rich in fibre. Laxatives should not
be used unless the constipation becomes symptomatic.

Clothes:
Women should be advised to wear what looks good and feels comfortable.
Maternity brassieres are often not required until late pregnancy, but women
should be advised to move into them as soon as they feel that their present
brassiere is inadequate for support. Tight corsets, should be avoided.

Bathing:
The woman should bathe as she wishes. Avoid vaginal douching in
pregnancy.

Care of breast & teeth:

‫٭‬Flat nipple: Wear nipple shield if nipple is flat to allow them to project.
‫٭‬Teeth & gums: Advise a visit to the dentist reasonably soon for dental care
as there is an increased prevalence of tooth decay and gingivitis in
pregnancy.

Work & coitus: Advice on work & coitus during pregnancy is also needed.

Travel:
The woman should only travel over distances which are comfortable to her.
Air travel is probably better than train for long distances, but airlines can
refuse to carry women over 34 weeks’ gestation for international flights and
over 36 weeks’ gestation for domestic travel.

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 Antenatal Visits

1. The First Antenatal Visit (Booking visit).

2. Subsequent Antenatal Visits (Follow-up visits).

The Booking visit:

Ideally the booking visit should be at 8–12 weeks’ gestation.
• Assessment.
• Education and counseling.
• Routine Laboratory/diagnostic studies.

1. Confirmation of pregnancy.
2. Dating of pregnancy.
The pregnancy can be dated either by using the date of the first day of the
LMP or by Ultrasound scan.
Menstrual EDD: It is customary to estimate the EDD by adding 7 days to
the date of the last normal menstrual period and counting back 3 months
(Naegele’s rule), If the cycle is longer than 28 days, add the difference
between the cycle length and 28 to compensate.
This can be more easily determined by using pregnancy calculators
(wheels).
Dating by Ultrasound: In the late first trimester or early second trimester.
Ideally between 10-14 weeks. Performed before 20 weeks, the ultrasound
scan can be used for dating the pregnancy.
Benefits of a dating scan:
1. Accurate dating in women with poor recollection of or women with
irregular periods.
2. Reduced incidence of induction of labour for prolonged pregnancy.
3. Maximize the potential for serum screening to detect fetal anomalies.
4. Early detection of multifetal pregnancy.
5. Detection of asymptomatic failed intrauterine pregnancy.

It become customary to divide pregnancy into three parts or trimesters of

slightly more than 13 weeks or three calendar months each.

The Booking History:

•Age, gravidity, parity.

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•Menstrual history.
•Past medical /surgical history.
•Past obstetric history.
•Previous gynaecological history
•Family history and social history.
•Allergies.

History has a major impact on risk assessment.

Age: Women at extremes of reproductive ages are at increased risk of
pregnancy complications like chromosomal abnormalities in elderly women.
Racial origion: Special racial groups carry risks of medical conditions both
genetic like thalassaemia & sickle cell anaemia or fibroids in African.
Past medical history: The disease & its treatment may adversely affect the
pregnancy. Medications may be teratogenic or may alter fetal physiology,
with increased risk of placental dysfunction, fetal growth restriction,PIH
and/or PTL. Those with health problems are managed jointly by
obstetricians and physicians in a “high-risk clinics”.
Past obstetric history: Women with previous caesarean delivery need careful
discussion about the mode of delivery in the current pregnancy.
Previous gynaecological history: Of infertility, recurrent miscarriage and
gynaecologic surgery.
Family history: Of thromboembolic disease, DM, mental handicap,
hypertention, hereditary tendency & history of twins.
Social history:
•Smoking.
•Alcohol.
•Drug abuse.

The Booking Examination:

Full physical examination including:
• Height
• Weight
• BMI
• Abnormal gait or deformity
• CVS
• Respiratory system
• Breast examination
• BP assessment
• Abdominal examination: scars, fundal height, masses, pain
• Pelvic examination: cervical cytology if indicated, vaginal examination.

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Investigations:
◆Booking Investigations:
Urine:
1 Proteinuria—renal disease.
2 Glucose—diabetes.
3 White blood cells—response to infection.
4 Nitrite—bacteria.
Mid-stream specimen of urine (MSU) should be sent for culture and
sensitivity at the booking visit to screen for asymptomatic bacteriuria.
Blood:
1. Full blood count: (Hb, HCT, Platelet Count).
2. ABO blood type, Rhesus blood group and antibodies.
3. Test for rubella antibodies.
4. Screening test for syphilis (usually VDRL, Venereal Disease Research
Laboratory test). If positive, more specific tests are required.
5. Hepatitis B serology: Hepatitis B surface antigen (HBsAg).
6. Hepatitis C and HIV serology.
7. Cervical cytology if no normal smear within the previous 18 months.
8. Hemoglobinopathy screening should be offered to individuals of
African, South east Asian and Mediterranean descent. Couples at risk
for having a child with sickle cell disease or thalassemia should be
offered genetic counseling.

◆ First trimester screening:

□ Nuchal Translucency scanning (NT): The median and 95th centile for NT
is 1.2 mm and 2.1 mm with a CRL of 45 mm, and 1.9 mm and 2.7 mm for a
CRL of 84 mm.
□ Measurement of maternal free human chorionic gonadotrophin (β-hCG)
and pregnancy-associated plasma protein-A (PAPP-A):
In trisomy 21 pregnancies (Down syndrome):
1. The concentration of free β-hCG is higher (around two multiples of
median; MoM).
2. The concentration of PAPP-A is lower (approximately 0.5 MoM).
□ Maternal age.
• Detailed ultrasound anomaly scan usually carried out at around 20 weeks.

◆Screening for gestational diabetes

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Patients with the following risk factors should be screening for gestational
diabetes at the first antenatal visit:
• Pre-pregnancy BMI ≥ 30 kg/m.
• Personal history of GDM.
• Known impaired glucose metabolism.
Women who have had previous GDM should be offered a glucose tolerance
test or random blood glucose in the first trimester, with the aim of detecting
preexisting diabetes.

Identification of high risk women:

▬ Women at high risk of developing pre-eclampsia:
NICE currently recommends that women considered to be at high risk of
preeclampsia should have low-dose aspirin (75 mg) treatment initiated early
in pregnancy until delivery. Furthermore, women with two or more
moderate risk factors for pre-eclampsia
are also recommended to commence aspirin early in pregnancy until
delivery.
High risk women:
- Hypertensive disease in a previous pregnancy.
- Chronic renal disease.
- Autoimmune disease such as SLE or antiphospholipid syndrome.
- Diabetes mellitus.
- Chronic hypertension.
Women with moderate risk factors for the development of pre-eclampsia
include:
Primiparity.
Advanced maternal age (>40 years).
Pregnancy interval of more than 10 years.
BMI ≥35 kg/m2 at booking visit.
Family history of pre-eclampsia.
Multifetal pregnancy.
All women should be screened at each antenatal visit for pre-eclampsia by
blood pressure measurement and urinalysis for protein.
▬ Women at high risk of preterm birth:
These women may be offered serial cervical length screening with or
without the use of fetal fibronectin to detect increased risk of preterm birth.
High risk women for preterm birth:
- Previous preterm birth
- Late miscarriage,
- Multifetal pregnancies

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- Cervical surgery such as previous cone biopsy.
▬ Fetal growth restriction:
Symphysis–fundal height (SFH) measurements (from 24 weeks gestation,
at each antenatal visit).
Dating scans, anomaly scans and third trimester growth scans.
▬ Vitamin D deficiency:
The RCOG advises that there are no data to support routine screening for
vitamin D deficiency in pregnancy
NICE guidance states that all pregnant and breastfeeding women should be
advised to take 10 μg of vitamin D supplements daily.

Second trimester care:

- Anomaly scan: a detailed structural scan between 20 and 22 weeks’
gestation is recommended to assess fetal anatomy.
- Gestational diabetes mellitus: Either Universal screening or risk-based
screening.
Risk factors for GDM are:
1. Women with previous gestational diabetes
2. Previous macrosomia (≥4.5 kg)
3. Raised BMI (≥30 kg/m2)
4. First-degree relative with diabetes
5. Women of Asian, black Caribbean or Middle Eastern origin.
The woman should be offered a 2-hour 75 g oral glucose tolerance test
(OGTT) at 24–28 weeks’ gestation. Women with a previous history of GDM
should have an oral glucose tolerance test at 16–18 weeks’ gestation. The
test should be repeated at 24–28 weeks of pregnancy.

Frequency of Visits:
o Advise first visit at 8-10 weeks of pregnancy or earlier.
o Every 4 weeks for first 28 weeks.
o Every 2 weeks (fortnightly) until 36 weeks gestation.
o Every week after 36 weeks gestation.
• Minimum number of “Visits” is (Five), according at 12, 20, 28-32, 36,
and 40-41 weeks.

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 • Frequency of visits is determined by individual needs and assessed
risk factors.

Factors indicating the need for additional specialist care

in pregnancy:
1. Conditions such as:
Hypertention.
Diabetes mellitus.
Cardiac disease.
Renal disease.
Psychiatric disorders.
Haematological disorders.
Epilepsy.
Autoimmune disease.
Cancer.
HIV.
2. Factors that make woman vulnerable such as those who lack social
support.
3. Age ≥ years and ≤18 years.
4. BMI ≥ 35 or < 18.
5. Previous caesarean section.
6. Severe pre-eclampsia or eclampsia.
7. Three or more miscarriages.
8. Previous preterm births or midtrimester loss.
9. Previous psychiatric illness or puerperal psychosis.
10.Previous neonatal death or stillbirth.
11.Previous baby with congenital anomaly.
12.Previous small-for-gestational or large-for-gestational aged baby.
13.Family history of genetic disorder.

Follow-up visits:
Follow-up visits Contents:
1. General questions regarding maternal wellbeing.
2. Enquiry regarding fetal movements (from 24 weeks).

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3. BP measurement (to screen for PIH).
4. Urinanalysis (for protein, blood sugar, infection detection, PET or
Gestational diabetes).
5. Examination for oedema (Is an insensitive marker for PET).
6. Abdominal palpation: fundal height, lie, presentation, position,
engagement, repeated symphysis-fundal height to ensure that uterine
size is appropriate for the gestational age, liquor volume abnormality;
Assessment of amniotic fluid volume is made to ensure there is no
polyhydramnios or oligohydramnios, this made by clinical diagnoses
and confirmed by ultrasound .
7. Fetal heart auscultation.
8. Haemoglobin level should be rechecked at about 28 weeks of
gestation in order to allow time for the correction of anaemia if
detected. If women is rhesus-negative, a second check of antibodies
should be done at 28 weeks.
9. Screening for Gestational diabetes at 28 weeks.
10. From 36 weeks of gestation onwards, examine the lower abdomen for
fetal head engagement particularly in primiparous woman as descent
of fetal head is measured in fifths. Assess for fetal well being
including fetal growth (clinically or by comparing serial ultrasound
readings of previous antenatal visits with the current one) and ask
about fetal movements.
11. Decision made regarding mode of delivery.
12.At 41 weeks: Discussion about induction of labour for prolonged
pregnancy.
13.Routine Anti D prophylaxis (at 28 and 34 weeks, recommended for all
non-sensitised Rh-ve pregnants).
14.Education about Delivery & infant feeding.

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