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SECTION 1: ANTENATAL CARE


FIRST VISIT TO THE CLINIC

This visit should include:

  • Registration of the client and advice on clinic procedures
  • Location of any previous obstetric records
  • History taking and screening by midwife to determine whether at high risk
  • Thorough physical examination by nurse and/or doctor to rule out any previous or existing medical condition.
  • Preparation of an antenatal home card to be kept safely, presented at every clinic visit and on admission to the place of delivery.
  • Encouragement of keen participation and questions by male partner.


History Taking

  • Determine date of last normal menstrual period (LMP), its accuracy and regularity of prior menstrual cycles; Calculate and record the estimated weeks of gestation and expected date of delivery (EDD) using Naegele’s Rule
  • Past medical and surgical history e.g. asthma, sickle cell disease, hypertension, diabetes, heart disease, infertility, myomectomy, caesarean section
  • Past obstetrical history to identify any previous complications of pregnancy (e.g. anaemia, spontaneous miscarriage or induced abortion, ectopic pregnancy, preterm labour, rhesus isoimmunization, post-partum haemorrhage, retained placenta, intra-uterine or neonatal demise, fetal anomaly)
  • Family history e.g diabetes mellitus, hypertension, sickle cell anaemia, fetal anomaly
  • Socioeconomic and drug history (e.g home amenities and support, cigarette smoking, alcohol, recreational drugs); Religion, in respect of blood transfusion acceptance, dietary restrictions
  • Diet history including meal frequency and variety, food aversions and supplements
  • Past gynaecological history (e.g menstrual history, contraceptive usage, Pap Smear history, fibroids)
  • HIV status
  • Establish immunization status:
    • An accurate record of tetanus immunization should be available.
    • Td vaccine should be administered after the first trimester.
    • A primary series is only started when there is no documentation and no history of immunization.
    • The first dose is given at 16-23 weeks; the second dose is given at 28-30 weeks.
    • Booster doses should be considered:
      • if there is a history of immunization but no records;
      • if the last immunization was given more than 10 years previously.


Physical Examination

Explain to the client the procedure for the physical examination and establish that the bladder is empty.

General Physical Examination

Check and record

  • Height and Weight
  • Body Mass Index (BMI) = [Weight (kg) ÷ Height2 (m)]
  • Vital Signs: Blood pressure, pulse, respiration, temperature

Examine

  • Head - Scalp, eyes (anaemia, jaundice), mouth (teeth, gums), neck (thyroid gland and lymph nodes)
  • Chest - Heart, lungs, breasts and spine
  • Abdomen - Previous scars, masses
  • Extremities - Pallor, varicosities, ulcers


Abdomen

Assess and record:

  • Height of fundus (compare with gestational age)
  • Fetal lie, position and presentation (if pregnancy is in advanced stage)
  • Fetal heart sounds, rate and regularity

Note: Fetal heart sounds are usually heard from around the 22nd - 24th week of pregnancy using a Pinard’s but much earlier (about 12-14 weeks) using a hand-held Doppler device.


Pelvic Examination during First Trimester

To be done by the midwife, or the doctor:

  • To examine external genitalia for discharge, warts and other vulval lesions
  • To determine any abnormalities of the pelvic organs
  • To determine the uterine size


Laboratory Investigations

Blood

  • Complete Blood Count (CBC) to determine haemogloblin, red cell population, volume and colour, white cell count, platelets
  • Group and Rh factor. If the woman is Rh negative, the spouse’s group and Rh factor
  • Blood Sugar (random or 1h after 50 gm glucose)
    Indications for Blood Sugar Estimation
    • Obesity: BMI > 30
    • Strong family history of diabetes.
    • At least two (2) episodes of glycosuria.
    • A history of premature birth, stillbirth or neonatal death.
    • A history of previous babies weighing 4kg or more.
  • VDRL on first visit; if positive repeat after 4 weeks
  • Sickle Cell test, if positive send for Hb electrophoresis (spouse should be screened if patient has trait, with appropriate counselling).
  • HIV
    • Counseling and HIV testing - on first visit and repeat test at 32 weeks (if HIV negative). If HIV positive, repeat 4 weeks later.


Urine

  • for sugar, albumin, acetone, blood


Stool

  • for ova, cysts and parasites in cases of clients who are anaemic

    Anti-helminthic treatment
    An appropriate anti-helminthic, after the first trimester:

    • Mebendazole 500 mg single dose or 100 mg twice daily for 3 days
    • Albendazole 400 mg single dose


Anaemia

Classification of Anaemia during Pregnancy

Evaluate red cell indices and look for hypochromia (low MCHC) and microcytosis (low MCV) which would indicate iron-deficiency anaemia

Normal Hb 11g/dl or higher
Mild to moderate anaemia 7.0 to 10.9 g/dl
Severe anaemia < 7 g/dl


Use of Iron and Folic Acid Supplementation

Dietary supplementation should ideally commence pre-conception, but certainly upon diagnosis of pregnancy and should continue throughout the pregnancy and for at least 6 weeks postpartum. The following guidelines are useful:

Hb 11 grams and above
  • 60 mg iron daily, 400 ug folic acid daily (1 tablet)
Hb 7 -10.99 grams
  • 60 mg iron daily, 400 ug folic acid daily (1 tablet) and refer patient to physician/haematologist
Hb < 7 grams
  • Refer patient to physician/haematologist
  • <28 weeks and asymptomatic
  • 120 mg iron daily plus 400ug folic acid daily.
  • 28-40 weeks, asymptomatic
  • 120 mg iron daily plus 400ug folic acid daily or Intra muscular iron.
  • >34 weeks, symptomatic
  • Refer to hospital for IV iron or blood transfusion.


Education

Every visit should be an opportunity for discussion and relevant counseling of the mother or couple. Breast-feeding and birth-spacing should be emphasized. Recommend exclusive breastfeeding to age 6 months and continued breastfeeding to 2 years and beyond. At the first visit the client should be made familiar with clinic procedures and about proper nutrition during pregnancy, the need to avoid alcohol and cigarette smoking and other harmful substances. The client should also be educated on the minor conditions in pregnancy and how to prevent and manage them.


Caribbean Public Health Agency © 2014