FIRST ANTENATAL VISIT

Between 10–20 weeks

Goal

  • Risk assessment
  • Health education
  • Plan for delivery

History taking

  • Record name, age, marital status, occupation, education, ethnic origin, residence
  • Enquire if patient has any problems, and obtain details

Social history

  • Smoking, alcohol, drug use habits

Medical history

  • Personal and Family history of HIV, diabetes, hypertension, TB, hereditary diseases, multiple pregnancy
  • Surgical history
  • Current illnesses and medication

Obstetric and gynaecological history

  • Record for each previous pregnancy: Date, place, maturity, labour, delivery, weight, sex and fate of the infant, and any puerperal morbidity

Current pregnancy

  • Record history of current pregnancy: date of (first day of) last menstrual period (LMP), date of conception
  • Confirm period of gestation/present maturity (=number of weeks from LMP)
  • Calculate estimated delivery date (EDD)
  • Any problems encountered, for example, bleeding
  • Contraceptive use
  • Check for sexually transmitted infections

Physical exam

General physical examination

  • BP, weight, breasts

Obstetric examination

  • Symphysio-fundal height (SFH), lie, presentation, foetal heart sounds, presence of multiple gestation
  • Vaginal (vulval) examination (only carry out if indicated; use a speculum) as follows:
    • In early pregnancy: To confirm and date the pregnancy and detect any anatomical abnormalities
    • In late pregnancy: To assess pelvic adequacy
    • In labour: To confirm diagnosis and monitor
    • Other times: To evaluate symptoms/ complaints
  • Abdominal examination: To look for Caesarian scar, rule out multiple pregnancy

Investigations

Blood

  • ABO and rhesus grouping, RPR (syphilis), Hb, HIV (partner testing), HBsAg
    • If RPR positive, see section 3.2.7
    • If HBsAg positive, see section 6.5.2.2
    • If HIV positive, see section 16.2.2
    • If Rhesus negative, refer for delivery to regional hospital for anti-D immunoglobulin administration

Urine

  • For albumin, glucose

Other tests

  • As appropriate for the individual patient to assess maternal well-being, e.g., ultrasound, amniotic fluid, foetal
    heart/movements, blood slide/RDT for malaria parasites, sickling test in case of anaemia

Note: Calculate EDD

  • Add 7 days to the LMP and 9 months to the month of LMP, e.g. LMP =1/1/2012, EDD =8/10/2012
  • Where the months total is >12, subtract 12 from this, e.g. LMP =5/5/2012, add 9 months =5+9 =14, subtract
    12 months =14-12 =2, therefore EDD =12/2/2013
  • OR subtract 3 from the month if the addition would be greater than 12, e.g. LMP =5/5/2012, subtract 3
    from the month and add 1 year to the current year =5-3 =12/2/2013

Routine medications in pregnancy

Record all medications given on the ANC card.

MEDICINE INDICATION AND DOSES
Folic acid
5 mg
  • All pregnant women should take
    folic acid throughout the first
    trimester (ideally from before
    conception)
Tetanus
toxoid
  • Check on tetanus toxoid
    (TT) immunization status
    and vaccinate if required – see
    immunization
Mebendazole During the second trimester,

  • De-worm with mebendazole
    500 mg single dose
Ferrous
200 mg +
folic acid
+ 400
microgram
Throughout pregnancy

  • Ferrous (200mg) + folic acid
    (400 microgram) once daily to
    prevent iron and folate deficiency
Sulphadoxine/
Pyrimethamine
(SP)

Intermittent preventive treatment
of malaria (IPTp):

  • SP single dose (3 tabs) every
    month from 13 weeks to end of the
    pregnancy

    • IPTp can be given all the way up
      to term (with an interval of one
      month between doses). There are
      no restrictions after 36 WOA
    • Since most HIV positive pregnant
      women will be on Cotrimoxazole,
      there is NO NEED for IPTp
Caution
  • Do not give SP if patient is allergic to sulphonamide

Use of drugs in pregnancy

  • Because any medication can cause a risk in pregnancy, and because not all risks are known, in general, it is safer to try and avoid drug use during pregnancy, delivery, and breastfeeding
  • Always carefully weigh the desired benefits of any drug, against possible harm to the mother and baby especially for patients with underlying medical conditions that require medication throughout pregnancy
  • Sometimes, it maybe necessary to adjust the dose and type of medications to maximise effectiveness, while
    minimising foetal risks. This should be accompanied by adequate counselling on medication usage
  • Give information on the risks of taking medication without medical advice

Health promotion

  • Address any problems
  • Involve husband in ANC (partner HIV Testing)
  • Draw up delivery plan
  • Discuss future family planning (FP)
  • Discuss symptoms of miscarriage, pregnancy-induced hypertension (PIH)
  • Educate and counsel on PMTCT of HIV and malaria prevention, and use of Long-Lasting Insecticide-treated
    Nets (LLINs)
  • Educate on danger signs
  • Proper nutrition:
    • Eat more and greater variety of foods, have an extra meal each day
    • Advise against any taboos regarding nutritionally important foods
  • Encourage adequate hygiene
  • Start breastfeeding and breast care counselling
  • Discuss sexual activity during pregnancy, protection for HIV
  • Avoidance of smoking and alcohol