Antenatal care or prenatal care is an important part of preventive medicine. If conducted properly, it helps to establish contact and promote understanding between the pregnant woman and those healthcare workers who will eventually look after her in the pregnancy, labour and delivery. The major challenges most antenatal hospital clinics especially in developing countries have been reported to have include
- Being impersonal and overcrowded.
- Long waiting times.
- Uncomfortable furnishings and decorations.
- Lack of privacy.
- Poor facilities for children.
- Inadequate time for the women to talk to the doctor or midwife.
The main objective of antenatal care is to maintain the woman’s health of mind and body during pregnancy. It also helps the obstetrician to anticipate difficulties and complications of labour and delivery that may arise, to ensure the birth of a healthy infant and also provide necessary tips that will help the mother to rear the child.
The number of times a woman needs to visit the antenatal clinic during her pregnancy varies but the first visit must be as early as possible in the pregnancy. In the case of a woman who is having her first pregnancy, she is expected to be visiting the antenatal clinic monthly (every 4 weeks) up till the 28th week, after which she will start visiting the clinic every 2 weeks till the 36th week and finally every week until the onset of labour when she will be admitted for delivery. A woman who has had at least one normal uncomplicated pregnant before may not need so many visits.
THE FIRST VISIT
The first antenatal visit is very crucial to the entire process of antenatal care for both the obstetrician and the woman. It is this first visit that will determine the nature and frequency of the subsequent visits. The following parameters are important to find out during the first visit which involves history taking, physical examination and laboratory investigations.
General medical history
This helps to find out whether the woman has had any significant illness, including cardiac diseases, renal diseases, diabetes, rubella or a blood transfusion. Tactful enquiries about possible exposure to HIV infection, drug, alcohol and cigarette smoking, as well as a brief survey of her general social and environmental circumstances are made. Previous surgical treatment especially gynaecological operations are also relevant enquiries.
Any disease with hereditary tendency including diabetes and hypertension is recorded. A family history of twins is also relevant.
Past obstetric history
The doctor will like to know if the woman has been pregnant before. She is questioned about her previous pregnancies and labour which will help in the care of the current pregnancy. For example, a history of repeated abortion or preterm labour might suggest cervical incompetence and a history of intrauterine fetal demise might suggest the possibility of hypertension, diabetes, or rhesus incompatibility. A history of raised blood pressure might also suggest hypertension and the possibility of recurrence..
The history of previous labours is a guide to knowing what may be expected in the coming labour. If the woman has had a long labour which ended in instrumental delivery or perhaps the birth of a dead or injured child, it is possible that she has pelvic contraction. A history of post partum haemorrhage would be a warning for possible recurrence.
The birth weights of any previous children and the cause of any stillbirth or neonatal death should be ascertained. It is also important to know whether the children were breastfed properly so that appropriate advice can be given curb any breastfeeding difficulty.
History of present pregnancy
The date of the first day of the last menstrual period, the woman’s normal cycle or any irregularities are noted down. Oral contraceptive use, history of infertility and form of treatment used are all very relevant questions being asked here. The doctor will also like to find out about any episode of vaginal bleeding or pain in early pregnancy, or any current illness and drug treatment.
The woman is weighed and her height is noted, including her gait or any deformity. The breasts are examined to rule out tumours and to check nipples for breastfeeding. The woman’s blood pressure is recorded and her heart and lungs are examined. The teeth are also inspected for the presence of gum infection and caries, and dental care encouraged. The legs are examined for the presence of varicose veins, edema and other abnormalities.
A complete inspection, palpation, percussion and auscultation of the abdomen is done for evidence of pregnancy or any other abnormalities aside the pregnancy which can pose serious threat to the progress of the pregnancy. The fetal heart sounds are also checked as indicated by the gestational age during the first visit.
In some clinics, a vaginal exam is done at the first visit. The position of the uterus (anteverted or retroverted) and the size in relation to the menstrual history is determined. Extra-uterine abnormalities such as ovarian cyst and fibroid may be discovered. A cervical smear can be taken for cytological examination and some idea of the general shape of the pelvis can be gained during the vaginal examination.
Most obstetricians however, forgo the vaginal examination during the woman’s first visit since the fetal size and the absence of other pelvic masses will be checked at the first ultrasound scan.
The initial investigations done at the first antenatal visit serve as baseline marker for the subsequent ones which will be done or repeated later on in the pregnancy. They include
- Blood type and antibody
- Rhesus type
- Hematocrite or haemoglobin levels
- Random blood sugar
- Urine analysis
- HbSag test
- HIV 1 and HIV 2 test
- Pap smear
- Rubella test
- VDRL test for syphilis
- Gonorrhoea and chlamydia screening test
- Alpha-FetoProtein test (if first visit is around 16 – 18 weeks gestation) to rule out congenital abnormalities.
At every subsequent visit after the first visit, history taking, physical examination and investigations are done and any abnormalities found will demand further investigations and treatment with more frequent visits to the clinic or even admission to the hospital for observation may be necessary.
Routine investigations and examinations done during the subsequent antenatal visits include
- Blood pressure checking
- Urine analysis
- Woman’s weight
- Haemoglobin concentration level
- Random blood sugar test
- Ultrasound scan at intervals
- Fetal heart sounds
- Height of funds of the uterus
- From 36 weeks onward, the presentation of the fetus is noted
- After 36 weeks, descent of the fetal head is examined together with the estimates of amniotic fluid.
Routine drugs given during antenatal visits include multivitamins, folio acid, iron and calcium supplements. At the proper gestational age, malaria and tetanus prophylaxis are administered to the woman as she attends her antenatal clinic.
Geoffrey Chamberlain : “Antenatal care” Obstetrics by Ten Teachers (16th edition).