Review of Antenatal Care Needs an ESMOE emblem ESMOE

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

What Are The Principles Of Antenatal Care?

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

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

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

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!!!

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

Dating this pregnancy - EDD Gestational age LNMP/LMP Uterine size - 4-12 weeks - 13-24 weeks - 24-36 weeks Ultrasound (up to 24 weeks) Estimated fetal mass RECORD AND EXPLAIN

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

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

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

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

Example

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

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

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

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

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

Monitoring Fetal Growth

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

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

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

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.

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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!

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

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

Problem List 2 x small for gestational age (SGA) babies Smoker No MUAC Ronchi & Wheezing SF small for dates (29 @ 33/52) No tet toxoid RPR +ve, Rh –ve Inappropriate level of care

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

Any Questions ?