4. 1. Choice on contraception – to ensure that individuals
and couples have the information and services to plan
the timing, number and spacing of pregnancies
2. Antenatal care – For the identification of risk factors
and early diagnosis of pregnancy complications and
appropriate management, and health education
3. Clean and safe delivery – to ensure that all health
workers have the knowledge, skills and equipment to
perform clean and safe delivery and provide
postpartum care to mother and baby
4. Essential obstetric care – to ensure that essential
care for high-risk pregnancies and complications is
made available to all women who need it
5. Choice on termination of pregnancy – to provide
women who have unwanted pregnancies with a legal,
safe and acceptable choice
5. to ensure that pregnancy causes no harm to the mother
to keep the fetus healthy during the antenatal period.
to provide health education.
This may be achieved by:
Screening for pregnancy problems
Assessment of pregnancy risk
The fetal condition must be repeatedly assessed
Treatment of problems that may arise during the antenatal
Giving medications that may improve pregnancy outcome
Provision of information to pregnant women
Physical and psychological preparation for childbirth and
First visit: On confirmation of
Second visit: 20-28 weeks
Third visit: 34-36 weeks
Fourth visit: before expected date of
delivery or when the pregnant woman
feels she needs to consult health worker
7. FIRST ANC VISIT
Confirm that the patient is
pregnant before beginning
History of missed
Can be as soon as a woman
suspects pregnancy, even as early
as the first missed menstrual
Urine pregnancy tests must be
If found to be pregnant must be
issued with an antenatal card and
receive first visit antenatal care.
Those who request termination of
pregnancy should be appropriately
counselled and referred.
9. A full history must be taken.
A full physical examination
must be done.
The duration of pregnancy
must be established.
Important screening tests
must be done.
Some high-risk patients can
The first estimation of gestational
age, with the expected date of
delivery, should be used for the
remainder of the pregnancy and
must not be changed unless
important new information
Indicate on the antenatal card
how the gestational age was
13. This is used for estimation of
gestational age after 24
weeks if the dates from the
last menstrual period are
unknown or wrong, in the
presence of a normal
The SFH measurement is of
little value for estimation of
gestational age at less than
20 weeks and term.
14. A difference between the
gestational age according to
the menstrual dates and the
size of the uterus is usually
the result of incorrect dates.
15. An ultrasound scan for gestational age estimation
should be requested for women who are unsure of
dates with SFH measurement less than 24 cm.
Fetal measurements by ultrasound give reasonably
accurate gestational age estimates before 24 weeks of
gestation. Ultrasound after 24 weeks is less reliable.
16. A uterus bigger than dates
A fetus which is large for
the gestational age.
17. A uterus smaller than dates
Rupture of the
Establish the number of
the number of previous
number of miscarriages and
ectopic pregnancies that
the patient may have had.
19. A full history, containing the
The previous obstetric
The present obstetric
A medical history.
History of medication and
A surgical history.
A family history.
The social circumstances of
Grande multiparity (i.e., five
or more pregnancies which
have reached viability).
Miscarriages: 3 or more
miscarriages suggest a
possible genetic abnormality
in the father or mother. A
miscarriage suggests a
possible incompetent internal
Ectopic pregnancy: ensure
that the present pregnancy is
Multiple pregnancy: non-
identical twins tend to recur.
The birth weight,
gestational age, and
method of delivery of each
previous infant as well as of
previous perinatal deaths.
Previous complications of
pregnancy or labor.
22. Complications in previous
pregnancies tend to recur in
patients with a
death are at high risk
of another perinatal
patients with a
preterm labor are at
high risk of preterm
labor in their next
23. The first day of the last
normal menstrual period
must be determined as
accurately as possible.
Any medical or obstetric
problems which the patient
has had since the start of
this pregnancy, for example:
Pyrexial illnesses (such as
influenza) with or without
Symptoms of a urinary tract
Any vaginal bleeding.
24. Attention must be given to minor symptoms which
the patient may experience during her present
pregnancy, for example: Nausea and vomiting,
Heartburn, Constipation, Oedema of the ankles and
Is the pregnancy planned and wanted, and was there
a period of infertility before she became pregnant?
If the patient is already in the third trimester of her
pregnancy, attention must be given to the condition
of the fetus.
Some medical conditions
may become worse during
pregnancy, e.g., a patient
with heart valve disease
may go into cardiac failure
while a hypertensive
patient is at high risk of
26. Ask the patient if she has had any of the following:
2. Diabetes mellitus.
3. Rheumatic or other heart disease.
7. Psychiatric illness.
8. Any other major illness.
27. It is important to ask whether the patient
knows her HIV status.
If she had an HIV test, both the date and
result need to be noted.
If she is HIV positive, record whether she is
on ARV treatment and which drugs she is
If she is not on ARV treatment, note whether
she knows her CD4 count and when it was
Ask about the regular use of any
medication. This is often a pointer
to an illness not mentioned in the
Certain drugs, e.g., efavirenz,
can be teratogenic (damage to
the fetus) during the first
trimester of pregnancy.
Some drugs, such as Warfarin,
can be dangerous to the fetus if
they are taken close to term.
Drug allergies are also
important, and the patient
must be specifically asked if
she is allergic to penicillin
29. Operations on the urogenital
tract, e.g., Caesarean section,
myomectomy, a cone biopsy of
the cervix, operations for stress
incontinence, and vesicovaginal
Cardiac surgery, e.g., heart valve
30. Close family members with a
condition such as diabetes,
multiple pregnancy, bleeding
tendencies or mental
retardation increases the risk
of these conditions in the
patient and her unborn
infant. Some birth defects
31. Ask if the woman smokes cigarettes or drinks alcohol.
Smoking may cause intra-uterine growth restriction (fetal
growth restriction) while alcohol may cause both intrauterine
growth restriction and congenital malformations.
32. An unmarried mother may need help to
plan for the care of her infant.
Unemployment, poor housing, and
overcrowding increase the risk of
tuberculosis, malnutrition, and intra-
uterine growth restriction.
Patients living in poor social conditions
need special support and help.
33. Do a general examination including
weight, height, heart rate, color of
mucous membranes, blood pressure, a
check for edema, and palpate for
Do a systemic examination including
the following systems or organs:
The thyroid gland.
Lymph nodes in the neck, axillae
(armpits) and inguinal areas.
The respiratory system.
The cardiovascular system.
Both external and internal
34. Examine the pregnancy
including inspection and
palpation of the pregnant
uterus, with measurement of
the symphysis-fundal height
(SFH) in cm. Listen to the
fetal heart from 26 weeks
35. ‘After extensive discussion and consultation, the National
Committee on Conﬁdential Enquiries into Maternal Deaths
(NCCEMD) has included MUAC in the national Maternal
Death Notiﬁcation Form. The MUAC gives useful
information on nutritional status and pregnancy risk and is
easily done during the antenatal period or during labour.
Use of the MUAC in pregnancy is supported by research
done in a number of African countries and elsewhere’
36. ‘MUAC is advantageous over body-mass index because
height does not need to be measured, accurate scales are not
required, the woman does not have to stand up straight, no
calculations need be done, and MUAC, unlike weight, does not
normally increase signiﬁcantly during pregnancy’
37. An MUAC ≥33 cm:
Is associated with an increased risk of pre-eclampsia and
Is associated with an increased risk of delivery of a larger
than normal infant
Indicates that blood pressure measurement with a normal-
sized adult cuff may be an overestimation
38. An MUAC<23 cm:
Suggests undernutrition or a chronic wasting illness
Is associated with delivery of a smaller than normal infant
39. Syphilis serology. Nonspeciﬁc reagin tests (RPR, WR, VDRL) are
performed, using a rapid card test.
Rhesus (D) blood group, using a rapid card test
Hemoglobin (Hb) level, using a portable haemoglobinometer or copper
sulphate screening method
Human immunodeﬁciency virus (HIV) serology, using rapid test kit.
This must follow National guidelines on routine counselling and
Urine dipstick testing for protein and glucose
All of the above tests can be performed by midwives or appropriately
trained auxiliary staff at the clinic ‘on site’, with the results available to
the pregnant women before they complete the ﬁrst visit.
40. Inform pregnant women
that the following
screening tests are not
routinely offered, but
may be indicated in
ABO blood group
Triple screen for Down’s
syndrome and neural
Rubella serology Blood glucose screening
Urine culture Ultrasound scan
41. The following are given to all pregnant women:
Ferrous sulphate tablets 200 mg daily, to prevent anaemia
Calcium tablets 1000 mg daily, to prevent complications of pre-eclampsia
Folic acid tablets 5 mg daily, to help prevent fetal neural tube defects
Tetanus toxoid (TT) immunization, to prevent neonatal tetanus:
First pregnancy: TT1 at ﬁrst antenatal visit, TT2 4 weeks later and TT3 6
Later pregnancies: Two TT boosters, one in each pregnancy at the ﬁrst visit,
for the two subsequent pregnancies, at least one year apart.
A total of five properly spaced doses of TT provide life-long protection against
If in a subsequent pregnancy, there is no record of previous immunization,
treat as for a ﬁrst pregnancy
42. Five danger signs and symptoms of pregnancy
Abdominal pain (not discomfort)
Drainage of liquor from the vagina
Reduced fetal movements
A woman that experiences any of these symptoms should
report immediately to her clinic or hospital with her antenatal
44. A delivery plan
At the end of the ﬁrst visit, all pregnant women should be given a
provisional delivery plan:
• The expected date of delivery, based on the best estimate of gestational age
• The expected place of delivery, whether community health centre or
• The expected mode of delivery, whether vaginal or caesarean section
• Who will deliver the baby, whether midwife or doctor
• Pain relief options including nonpharmacological methods.
• A transport plan for emergency or delivery, including important contact
• Preparation for possible home delivery
45. Newborn and infant care
Plans for infant feeding and techniques, whether breast or
Details of follow up care: immunization and where this can be
Future pregnancies and contraception
Information on genetic disorders and birth defects
Contraception that will be used after the pregnancy
46. Following an early booking visit (<12 weeks), return visits
should be scheduled for 20, 26, 32, and 38 weeks, and 41
weeks if still pregnant.
This is not applicable for women with risk factors, whose
return visits schedules will depend on their speciﬁc
47. Ask about general well-being, fetal movements, danger symptoms and
Check the blood pressure, heart rate and colour of the mucous
Measure the symphysis-fundal height (SFH) in cm. Plot the SFH on the
graph against the gestational age and compare with the 10th, 50th
and 90th centiles for gestational age and with previous measurements
Palpate carefully for breech presentation at 38 weeks
Test the urine for protein, glucose, blood and ketones
Repeat HIV test at 32 weeks for all women who tested negative at
48. Repeat blood tests: Hb at 32 and
38 weeks, and a repeat RPR at
±36 weeks if the ﬁrst test was
negative before 20 weeks of
Repeat information for danger
signs of pregnancy, and review
delivery and transport plans, as
well as feeding and contraception
choices at 32 and 38 weeks.
At 38 weeks, remind the woman
to bring her antenatal card when
she presents to the clinic or
hospital in labour
49. DENTAL CARE:
The teeth should be brushed carefully in the morning and
after every meal.
Encourage the woman the to see her dentist regularly for
routine examination & cleaning.
Encourage the woman to snack on nutritious foods, such as
fresh fruit & vegetables to avoid sugar encountering the teeth.
A tooth can be extracted during pregnancy, but local
anesthesia is recommended.
Woman should avoid wearing tight cloths such as belt or
constricting bans on the legs, because these could delay lower
Suggest wearing shoes with a moderate to low heel to
minimize pelvic tilt & possible backache.
Loose, and light clothes are the most comfortable.
Many women have questions about travel during pregnancy.
Early in normal pregnancy, there are no restrictions.
Late in pregnancy, travel plans should take into consideration
the possibility of early labor.
52. SEXUAL ACTIVITY:
Sexual intercourse is allowed with moderation, is absolutely
safe and normal unless specific problem exist such as: vaginal
bleeding or ruptured membrane.
If a woman has a history of miscarriage, she should avoid
sexual intercourse in the early months of pregnancy.
Exercise should be simple. Walking is ideal, but long period of
walking should be avoided.
The pregnant woman should avoid lifting heavy weights as it
may lead to abortion.
She should avoid long period of standing because it
predisposes her to varicose vein.
She should avoid sitting with legs crossed because it will delay
54. Maintain adequate fluid intake.
Warm up slowly, use stretching exercises but avoid over
stretching to prevent injury to ligaments.
Avoid jerking or bouncing exercises.
Be careful of loose thrown rugs that could slip& cause injury.
Exercises on regular basis (three times per week).
After first trimester, avoid exercises that require supine
The pregnant woman should lie down to relax or sleep for 1 or 2 hours during the
At least 8 hours sleep should be obtained every night & increased towards term,
because the highest level of growth hormone secretion occurs at sleep.
Advise woman to use natural sedatives where needed such as: warm bath &
glass of warm milk.
A good sleeping position is sims’ position, with the top leg forward. This puts the
weight of the fetus on the bed, not on the woman, and allows good circulation in
the lower extremities.
avoid resting in supine position, as supine hypotension syndrome can develop.
57. -Daily requirement in pregnancy about 2500 calories.
- Women should be advised to eat more vegetables, fruits,
proteins, and vitamins and to minimize their intake of fats.
Maintain mother health.
Physical strength & vitality in labor.