ANTENATAL CARE (ANC)

It was exactly 2:30am in the night/morning when a pregnant woman was rushed to the clinic in company of family and friends screaming "she wan born oh!" I could hear the conversation from my call room where I was still awake prepping for the elective ceasarian section to take place at 5:30am that day when the nurse came in to inform me about the paient who was taken directly to the delivery room. I came in to take the history as she was an unbooked patient and had never attended an ANC class before. we  took a risk with the patient anyway as examination of the pelvis revealed head on perineum and she delivered the most amazing baby boy I had seen and she developed some complications that could very well have been prevented if she had registered for and attended the antenatal visit. Baby developed neonatal tetanus.….the both had to spend extra weeks on admission for a very straight forward delivery  that she wouldn't have spent a day more in the hospital if the needful had been done.

Hmmmmm…ok.this brings me to the topic of discuss today;ANTENATALCARE.this is a term that we all are very familiar with but there are a few things about it I am hoping we will learn from this discuss.so lets learn a thing or two.

ANC is a term that’s used to describe the care that’s given to a pregnant woman all the way till delivery. Pregnancy is divided into three trimesters in all of the 9months or 41completed weeks of the journey with each trimester consisting of three months or 13weeka.it also refers to the regular medical and nursing care recommended for women during pregnancy meaning that it is nit only medical doctors that can give antenatal care.nurses especially trained midwives and traditional birth attendanrs can but they must know where to handsoff and call for help.

Pregnant women require routine perinatal aka antenatal care tp help ensure their health and that of the growing fetus(S). they are also evaluated as often as required for symptoms and signs of illness.

Ideally antenatal care should begin with the preconception care that ia to say acouple who are planning to start a family should go for proper evaluation and counseling before conception so that risks can be reduce and they can get the best out of the pregnancy and delivery process.e.gs genetic counseling in cases of  hemoglobinopathy like sickle cell disease.

ANC is also seen as a method of preventive care with the goal of providing regular checkups that allow the care givers to manage and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit mother,c hild and father too!(we don’t leave the fathers out because they are very much involved).

The ANC classes gives the woman the privilege of receiving first hand information about her pregnancy and can ask questions .she is also informed of the different physiological and biological changes she is expected to go through, she also learns more about the nutrition she requires and is also given vitamin supplements. she is also taught different ways to live healthy as regards her life style and pregnancy in order for there to be synchronicity and excellent results in the end e. g smoking ,alcohol ,diet etc.

ANC has played a huge role in reducing maternal death rates, miscarriages as well as birth defects, low birth weight, congenital anomalies and other preventable health disorders hence ANC is a form of preventive medicine.

Routine ANC visits are as follows;

·         Initial visit which should occur between 6 – 8 weeks of gestation or just after a missed period. this has however been an issue because many women do not present this early especially in our environment. they tell you they have to wait till the pregnancy advances and they can see the protrusion or even till the feel fetal movement and this takes place usually between 16 -20 weeks of gestation. A lot of awareness is needed in this as the adages goes ‘the earlier ,the better’.  ANC is ideal to commence as soon as she misses her periods and get a positive pregnancy test confirmation using blood!

·         Follow up visits should occur monthly that is every 4weeks up until the 28^th week and 2weekly up until the 36^th week and weekly until delivery. which usually occurs around the 38^th to 40^th week based on the last menstrual period(LMP) .however delivery that occur 2weeks prior to or after the EDD(expected date of delivery) calls for no alarm!

·         Screening for disorders and taking measures to reduce fetal and maternal risks and counseling of patients. This helps classify her into high, low or no risk pregnancy for proper management as no two pregnancies or deliveries are the same even in the same woman. high risks connotes the presences of co morbidities and also the age of the woman. the tests also ascertains the health of the fetus and presence of congenital malformations and any risks for the growing fetus.

A full medical evaluation is carried out for her especially at the first visit aka booking .they include;

·         Biodata which takes into consideration her age

·         Previous and current medical disorders and drug history

·         Presence of risk factors  in the woman that could complicate the pregnancy e.g rhesus isoimmunization.

·         Obstertric history as regards previous pregnancies,terminations,deliveries amd their outcomes including fetal and maternal complications.

·         Family history of the couple which would include all chronic disorders in the family especially those that are hereditary.

·         The woman is also enlightened about warning signs in pregnancy which includes vaginal bleeding or abnormal fluid discharge,headaches,changes in vision,edema of face and fingers,changes in frequency or intensity of fetal movements

Physical examination of the woman is also carried out by the caregiver and this would include;

·         Blood pressure and pulse monitoring as their levels are expected to fall during pregnancy.

·         Look out for nutritional deficiencies as evidenced by palor from anemia which could be due to illnesses ranging from malaria, helminthic infections, also fever is important as well from urinary tract infection as this is common in pregnancy.

·         There is usually breast engorgement with or without tenderness in pregnancy due to increased levels of estrogens and progesterone.

·         Pelvic examination would reveal a softer cervix which will be bluish,there is increase in the size of the uterus,also check for abnormal vaginal discharges,pelvic capacities can also be measured as this can tell the possibilities fir a vaginal delivery based on the diameters using the middle finger e.g if the distance between the undersude of the pubis symphisis to the sacral promontory is >11.5cm,the pelvic inlet is adequateand if the distance between the ischian spines is >9cm,subpubic arch is >90 degrees vaginal delivery is possible and the type of pelvis the woman has is a huge factor is there are 4types of pelvis; gynecoid ,platypelloid, android and anthropoid. with gynecoid and android being the most favorable for vagina delivery.

·         Abdominal examinations are carried out using the leopald maneuveur.it determines the lie,position,presentation amd even the fetalheart rate using the fetoscope which become audible from 20weeks.you can also estimate the gestational age of the pregnancy using landmarks in the abdomen like the 20weeks gestation is around the umbilicus.

·         Ultrasonographic evaluation o the fetus;thia helps in checking for fetal abnormalities especially during the first trimester. The risks of miscarriages,blighted ovum,ectopic pregnancies’polyhydramnions are ruledout here.detailed assessment of the fetal anatomy to rukeout anomalies such as spina bifida,cleftlips and palates can also be done.detection of multy fetal pregnancies, placenta previa ,placenta location ,fetal position,size in relation to gestational age to ruleout IUGR .needle guidance for chorionic villous sampling, amniocentesis and fetal transfusion can be done.

At least one ultrasoundscan  is required during pregnancy usually and ideally between the 16^th to 20^th week of gestation when the EDD can be accurately estimated using ultrasound.

X-rays shouldn’t be used during pregnancy except absolutely necessary and the abdomen should be adequately shielded.

Blood and urine tests are also done.

First trimester	Second trimester	Third trimeter
Confirm pregnancy Urine hCG Ultrasonograohy   Screening investigations Hemoglobin Bloodgroup Blood glucose TSH VDRL HBsAg HIV TORCH Asses pelvic size by clinical examination	Screenfor possible medical complicstions; BP Urine albumin Assess fetal development USS Twin pregnancy Fetal growth parameters Any congenital anomaly Amount of liquor Fetal movement and cardiac activity       GENERAL MANAGEMENT	Plan for safe delivery USS Fetal lie and position Position of placenta Cord abnormalities Sress test test and nonstress test BP Urine albumin Bloodglucose   Screen for perinatal infection UTI Vaginalinfections groupB streps herpes simplex
Folic acid supplementation Iron supplementation and calcium	2doses of T.T (stat,one month later,then 6months later)	Mgt of Rh incomp Mgt of HIV mothers Mgt of HBsAg pos mothers
Antimalaria prophylaxis	Antimalaria prophylaxis	Antimalaria prophylaxis

 

Antimalaria prophylaxis using the intermittent prophylaxis therapy with the use of fansidar(IPT) this is taken at booking,4weeks after and 4weeks after but shouldn’t be taken 4weeksbefore delivery to prevent jaundice in the new born.

The general ANC treatments would now depend on the outcome of the evaluations e.g give antihypertensive if found to be hypertensive. Routine vitamins are however given to all patients to be taken daily which include folate,fesolate and vitamin. Tetanus toxoids are also given, adequate nutrition of about 250kcal extra is needed daily most of which should be protein. maternal diet must be based on the desired weight .physical activities and exercises should also be done, proper shoes should be worn to reduce incidence of backaches ,wearing of loose fitting clothes as well.

She is also prepared to receive her new born and taught how to breast feed and told about things she would need in preparation to receive her baby.

It is also important to talk about drugs in pregnancy because this is not a time when a woman is allowed to go over the counter and purchase drugs as she so desires as drugs can affect tge growing fetus adversely. she should always crosscheck with her care givers especially the doctors before taking any drugs and she should also demand to know the names and type of drugs she is been given at this period and ask whether or not it would affect the baby adversely .it is indeed ok to ask!

In conclusion, ANC is such an important part of all our lives and especially that of the mother and child. adequate care should be taken as no two pregnancies are the same even in the same woman. always seek medical attention when pregnant. for those who have access only to professional TBAs and midwives be sure  that they have access to proper referral facilities in case of an emergency. the aim of ANC is to give rise to a healthy baby, healthy mother and society! Xoxo DR ZEE.