From the Department's antenatal care lecture (photographed slides), organised as a visit-by-visit guide. Visit schedules differ between the WHO 2016 model and the focused (FANC) model used in many Kenyan facilities: know both.
The reasoning chain: confirm the pregnancy and the due date → decide whether she needs basic or specialised care → screen and treat what can harm her or the baby → prevent (tetanus, iron and folate, malaria, HIV transmission) → prepare a birth and emergency plan → repeat, and watch for danger signs at every visit.
1. What antenatal care (ANC) is, and why it matters
ANC is the general health care given to pregnant women to promote and maintain the health of mother and baby through pregnancy, labour and the puerperium, and to help her have and rear a healthy baby. There are two models: routine and focused.
What it achieves: through timely, evidence-based health promotion, disease prevention, screening and treatment, ANC reduces complications of pregnancy and childbirth, reduces stillbirths and perinatal deaths, and delivers integrated care throughout pregnancy.
Purpose of focused ANC (FANC):
- Promote and maintain the physical, mental and social health of mother and baby, through education on nutrition, rest, sleep and personal hygiene.
- Detect and treat medical, surgical or obstetric conditions that complicate pregnancy.
- Ensure the delivery of a healthy full-term baby with minimal stress or injury to mother and baby.
- Prepare the mother to breastfeed, have a normal puerperium and care for the child physically, psychologically and socially.
2. Routine versus focused ANC
| Routine (risk-approach) model | Focused (FANC) model | |
|---|---|---|
| Idea | Sort women into high risk and low risk; more visits for the high-risk group | Goal-oriented: do what matters at each visit for every woman |
| Visits | Every 4 weeks to 28 weeks (5–6 visits), every 2 weeks to 36 weeks (4 visits), then weekly to delivery | At least four scheduled visits |
| Problem | The risk approach failed: most women who have an obstetric emergency were assessed as not at risk; it cannot tell who will develop complications; it gives a false sense of security to low-risk women; identifying a need does not guarantee action | Screens to detect a problem rather than to predict one, and treats any problem that can complicate the pregnancy |
The lesson of FANC: every pregnant woman is at risk of a complication, so every woman gets a birth plan and knows the danger signs.
3. Timing of visits
| Model | Schedule |
|---|---|
| WHO 2016 (eight contacts) | 1st within 12 weeks; then at 20, 26, 30, 34, 36, 38 and 40 weeks |
| WHO focused ANC (four visits) | 1st within 16 weeks; 2nd at 24–28 weeks; 3rd at 32 weeks; 4th at 36 weeks |
| Visits as taught locally | 1st at 8–12 weeks, 2nd at 24–26 weeks, 3rd at 32 weeks, 4th at 36–38 weeks |
4. What happens at each visit
| Visit | Gestation | Activities |
|---|---|---|
| First | 8–12 weeks | Confirm the pregnancy and the EDD; classify the woman for basic ANC (four visits) or specialised care; screen, treat and give preventive measures (anaemia, syphilis, malaria, HIV); start the birth plan and immunisation schedule; counsel on ITN use; give iron and folic acid whether anaemic or not |
| Second | 24–26 weeks | Assess maternal and fetal well-being; exclude pregnancy-induced hypertension (PIH) and anaemia; give preventive measures; review the birth and emergency plan; advise and counsel |
| Third | 32 weeks | Assess well-being; exclude PIH, anaemia and multiple pregnancy; preventive measures; review the plan |
| Fourth | 36–38 weeks | Assess well-being; repeat the HIV test; exclude PIH, anaemia, multiple pregnancy and malpresentation; review the plan; counsel on labour, delivery and newborn care |
| Subsequent | Any | Confirm fetal life, detect abnormalities, finalise the birth plan. The ANC card is the basic tool of FANC |
5. The first visit in detail
History
Welcome the woman and ensure a quiet, private place. Take: personal and social history, menstrual history (LNMP, EDD), current problems with the pregnancy, obstetric history (see the note on assessment of the obstetric patient), medical and surgical history and family history.
Examination (clinical)
General examination, weight, blood pressure, oedema, pallor, breast examination, and the obstetric examination: symphysis-fundal height, fetal heart, number of fetuses, lie and presentation. The aim: detect undiagnosed physical problems and set baseline values to guide treatment through the pregnancy.
Investigations
| Group | Tests | The question it answers |
|---|---|---|
| Haematological | Blood group, rhesus, sickle cell screen, haemoglobin and red cell indices | Rhesus incompatibility? Anaemia (iron, sickle cell)? |
| Common conditions | Blood pressure and urine protein (pre-eclampsia), malaria slide or rapid test, stool microscopy (worms), OGTT (gestational diabetes) | Is there a treatable condition now? |
| Infections | HIV, syphilis, asymptomatic bacteriuria, hepatitis B, asymptomatic bacterial vaginosis, group B streptococcus | Prevent transmission to the baby (PMTCT), prevent preterm labour and pyelonephritis |
| Fetal anomalies | Ultrasound, amniocentesis, chorionic villus sampling | Neural tube defects, Down syndrome |
| Fetal growth and well-being | Ultrasound, symphysis-fundal height, biophysical profile, non-stress test, electronic fetal monitoring, fetal movement counts, fetal blood sampling, L/S ratio and phosphatidylglycerol (lung maturity) | Is the baby growing and healthy? |
6. Prevention: what every woman should be given
- Tetanus toxoid (to prevent neonatal and maternal tetanus).
- Iron and folic acid supplements.
- PMTCT of HIV (testing, antiretrovirals, safe infant feeding).
- Region-specific measures: iodine supplements, presumptive treatment for hookworm, and for malaria, intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs).
7. Early detection and treatment: at every visit
| Condition | How it is found |
|---|---|
| Severe anaemia | Pallor, haemoglobin |
| Pre-eclampsia / eclampsia | Blood pressure and urine protein |
| HIV | Voluntary counselling and testing |
| STIs, including syphilis | Testing |
| Malaria | History and examination (fever and signs); test and treat |
| Complicated versus uncomplicated | Decide who needs referral |
8. Health education: the topics
Nutrition, care for common discomforts, avoiding harmful substances (alcohol, smoking, drugs, unprescribed medicines), hygiene, rest and activity, sexual relations and safer sex, early and exclusive breastfeeding, prevention of tetanus and anaemia, HIV counselling and testing, prevention of other endemic diseases and deficiencies, and PMTCT.
Objectives of health education: inform the woman with messages suited to her needs and her gestational age, based on the commonest health issues; support her in making decisions and solving real or expected problems; involve her partner and family.
9. Birth preparedness and complication readiness
Objective: a birth plan, an exact plan for a normal birth and for possible complications. It is made in advance by the woman and her family with a skilled provider, usually not a written document, reviewed at every visit, and it reduces disorganisation at the time of birth or in an emergency so that timely, appropriate care is given.
Essential elements of a birth plan
- Place of birth (home or facility) and the facility for emergencies.
- A skilled provider to attend the birth.
- Contact information for the provider and the facility.
- Transport: reliable and available at any hour.
- Funds: savings and emergency funds, NHIF, Linda Mama and other insurance.
- Decision-making: who decides in an emergency (a delay in deciding is the first of the "three delays").
- Blood donor and a companion, and clean delivery items.
Complication readiness: know the danger signs and what to do
- Vaginal bleeding
- Difficulty breathing
- Fever
- Severe abdominal pain
- Severe headache or blurred vision (pre-eclampsia)
- Convulsions or loss of consciousness (eclampsia)
- Rupture of membranes or labour pains before 37 weeks
- Reduced or absent fetal movements
10. Record keeping and communication
Record on the ANC chart and clinic card: dates of visits, interim history, targeted examination and tests, care given, counselling (including the birth plan and ITN use), and the date of the next visit.
Inter-personal skills: speak in a quiet, gentle voice; listen and respond; encourage questions; let her show she understood; explain every procedure and obtain permission; respect cultural beliefs; be empathetic and non-judgemental; avoid distractions.
11. Barriers to effective ANC
Inadequate infrastructure and supplies, poor quality of care and poor treatment of clients, ignorance of the value of ANC, no tradition of ANC in some communities, cultural, traditional and religious practices, women's lack of control over decisions about their own health, poverty (transport and treatment costs), household responsibilities and illiteracy.
Examiner questions
- Compare routine and focused antenatal care. Why was the risk approach abandoned?
- What do you do at the first, second, third and fourth ANC visits?
- List the essential elements of a birth plan and the danger signs a woman must know.
- Which preventive measures does every pregnant woman receive in an area with malaria?
Practice questions
1. The WHO focused antenatal care model recommends at least: A. Two visits · B. Three visits · C. Four visits · D. Six visits · E. Weekly visits Answer: C.
2. The "risk approach" to antenatal care failed mainly because: A. It was too cheap · B. Most women who had obstetric emergencies were assessed as low risk · C. It needed no staff · D. It detected too many problems · E. Women disliked it Answer: B.
3. Which action belongs to the FIRST ANC visit? A. Repeat HIV test at 38 weeks · B. Confirm pregnancy and EDD, screen for anaemia, syphilis, malaria and HIV, and start iron and folic acid · C. Plan induction · D. Assess for malpresentation only · E. Give anti-D Answer: B.
4. Which is a danger sign of pregnancy that demands immediate attention? A. Mild nausea · B. Backache · C. Severe headache with blurred vision · D. Frequency of micturition · E. Mild ankle swelling in the evening Answer: C.
5. Which intervention is used for malaria prevention in pregnancy? A. Chloroquine only · B. Quinine daily · C. Intermittent preventive treatment and insecticide-treated nets · D. Doxycycline · E. Primaquine Answer: C.