*****ANTENATAL CARE a) Define , Aims & objectives b) Write in brief examination c) Antenatal investigations d) Antenatal advice e) Follow up

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Antenatal Care: Topic Map

Definition, aims and objectives
- Meaning of antenatal care
- Goals for maternal and fetal health
- Early identification of high-risk pregnancy
Antenatal examination
- History taking
- General physical examination
- Obstetric abdominal examination
- Pelvic examination when indicated
- Assessment of fetal well-being
Antenatal investigations
- Routine blood and urine tests
- Screening for anemia, blood group/Rh status, infections, diabetes, and hypertension
- Ultrasound and other tests when indicated
Antenatal advice
- Diet, iron-folic acid and calcium supplementation
- Exercise, rest, hygiene, sexual activity, travel, and avoidance of harmful substances
- Immunization
- Danger signs requiring immediate care
- Birth preparedness and complication readiness
Follow-up
- Schedule of antenatal visits
- What is reassessed at every visit
- Referral and high-risk monitoring

Overview: Antenatal care is planned supervision of a pregnant woman from conception until onset of labour. It promotes a healthy mother and baby, detects complications early, provides preventive services, and prepares the woman and family for safe birth and newborn care.

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antenatal care

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WHO antenatal care recommendations routine antenatal contact schedule 2024

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https://www.who.int/news/item/07-11-2016-new-guidelines-on-a…

Antenatal Care

Definition

Antenatal care (ANC) is the systematic care, supervision, examination, investigation, health education, and support given to a pregnant woman from early pregnancy until the onset of labour, with the aim of ensuring the best possible health of both mother and fetus.

It includes:

Early registration of pregnancy
Assessment of maternal and fetal health
Identification of high-risk pregnancy
Prevention, early detection, and treatment of complications
Nutritional supplementation and immunization
Health education, counselling, birth preparedness, and referral where necessary

Park defines ANC as skilled health-professional care for pregnant women and adolescent girls to secure the best health conditions for mother and baby, including risk identification, prevention and management of disease, and health promotion.

A. Aims and Objectives of Antenatal Care

Aims

To ensure a healthy pregnancy, safe delivery, and healthy mother and baby.
To promote and maintain the physical, mental, and social well-being of the pregnant woman.
To identify maternal, fetal, obstetric, medical, and social risks early.
To prevent, detect, and manage pregnancy complications promptly.
To prepare the woman and family for labour, delivery, newborn care, breastfeeding, and family planning.
To reduce maternal morbidity, maternal mortality, perinatal morbidity, and perinatal mortality.

Objectives

Promote maternal health
- Maintain adequate nutrition, weight gain, rest, hygiene, and mental well-being.
- Detect and treat anemia, infections, hypertension, diabetes, and other illnesses.
Assess fetal growth and well-being
- Confirm gestational age.
- Detect multiple pregnancy, fetal growth restriction, malpresentation, congenital anomaly, and fetal distress risk.
Identify high-risk pregnancy
- Previous cesarean birth, previous stillbirth, recurrent abortion, postpartum hemorrhage, pre-eclampsia, diabetes, hypertension, heart disease, anemia, teenage pregnancy, advanced maternal age, and multiple gestation.
Prevent complications
- Give iron-folic acid, calcium, tetanus-containing vaccine, deworming where locally recommended, and malaria prevention in endemic areas.
- Counsel regarding danger signs and timely referral.
Provide health education
- Teach nutrition, hygiene, breastfeeding, newborn care, contraception, and family planning.
- Encourage institutional delivery and a skilled birth attendant.
Reduce anxiety and promote emotional preparation
- Address fears about pregnancy and childbirth.
- Encourage family support and respectful maternity care.
Prepare for birth and emergencies
- Identify place of delivery, transport, blood donor if needed, finances, and a support person.
Provide continuity of care
- Maintain records, schedule follow-up, and refer high-risk women to an appropriate facility.

The WHO recommends at least eight antenatal contacts for uncomplicated pregnancy, beginning in the first trimester, to improve maternal experience and reduce perinatal deaths. The suggested contact points are before 12 weeks and at 20, 26, 30, 34, 36, 38, and 40 weeks, as described in the WHO ANC recommendations.

B. Antenatal Examination

A complete antenatal assessment includes history taking, general examination, systemic examination, obstetric examination, and relevant investigations.

1. History Taking

A. Personal details

Record:

Name, age, address, occupation, education, socioeconomic status
Date and time of first visit
Gravida, parity, living children, abortions, and stillbirths
Last menstrual period (LMP)
Expected date of delivery (EDD)
Gestational age
Blood group and Rh status, if known

Calculation of EDD

Use Naegele's rule:

EDD = First day of LMP + 9 months + 7 days

This rule is best applied when menstrual cycles are regular and the LMP is reliable.

B. Present pregnancy history

Ask about:

Amenorrhea and pregnancy confirmation
Nausea, vomiting, appetite, heartburn, constipation
Vaginal bleeding or spotting
Vaginal discharge, itching, leaking of fluid
Lower abdominal pain or uterine contractions
Headache, blurring of vision, swelling of face/hands
Fever, cough, breathlessness, urinary symptoms
Fetal movements:
- Usually felt around 18 to 20 weeks in primigravida
- Often felt around 16 to 18 weeks in multigravida
Medication use, radiation exposure, alcohol, tobacco, substance use, or exposure to toxins

C. Past obstetric history

For each previous pregnancy, ask:

Year and outcome
Duration of pregnancy
Place and mode of delivery
Live birth, stillbirth, abortion, ectopic pregnancy, or molar pregnancy
Birth weight and sex of child
Neonatal death or congenital anomaly
Complications:
- Hypertension or eclampsia
- Gestational diabetes
- Antepartum hemorrhage
- Postpartum hemorrhage
- Obstructed labour
- Cesarean section
- Instrumental delivery
- Preterm birth
- Puerperal sepsis

D. Menstrual and gynecological history

Ask about:

Age at menarche
Cycle regularity and duration
Dysmenorrhea or excessive bleeding
Previous infertility treatment
History of sexually transmitted infection, pelvic inflammatory disease, fibroids, or cervical procedures
Use of contraceptives before conception

E. Medical, surgical, family, and social history

Ask about:

Hypertension, diabetes, heart disease, kidney disease, epilepsy, thyroid disease, tuberculosis, asthma, anemia, hepatitis, HIV, and psychiatric illness
Previous surgery, especially uterine surgery or cesarean section
Family history of diabetes, hypertension, multiple pregnancy, congenital anomalies, thalassemia, and genetic disorders
Drug allergy
Tobacco, alcohol, substance use, domestic violence, food insecurity, and lack of family support

2. General Physical Examination

Perform at the booking visit and repeat relevant observations at each follow-up visit.

A. General condition

Assess:

Level of consciousness and general appearance
Nutrition and body build
Height and weight
Body mass index, where used
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal edema or generalized edema
Dehydration

B. Vital signs

Measure and record:

Temperature
Pulse rate and rhythm
Respiratory rate
Blood pressure

Blood pressure measurement is essential at every visit. New hypertension, especially after 20 weeks, may indicate gestational hypertension or pre-eclampsia.

C. Height and weight

Record height at the first visit.
Short stature, especially below 145 cm, may suggest risk of cephalopelvic disproportion, though height alone cannot diagnose it.
Record weight at every visit and assess the trend rather than relying only on a single value.
Inadequate gain may suggest poor nutrition or fetal growth restriction.
Excessive gain may be associated with edema, multiple pregnancy, obesity, or diabetes.

D. Head-to-toe examination

Check:

Face and eyes: pallor, edema, jaundice
Teeth and gums: dental caries, gingivitis
Neck: thyroid enlargement
Breasts: nipples, inversion, cracks, lumps, and readiness for breastfeeding
Hands and legs: pallor, edema, varicose veins
Skin: rashes, scars, infection
Spine and gait: deformities or disability that may affect labour

3. Systemic Examination

Perform examination of:

Cardiovascular system: heart sounds, murmurs, signs of heart failure
Respiratory system: breath sounds, wheeze, signs of respiratory infection
Central nervous system: if headache, seizures, or neurological disease is present
Abdomen: liver enlargement, tenderness, surgical scars
Urinary system: renal angle tenderness, bladder distension

4. Obstetric Abdominal Examination

Ask the woman to empty her bladder. Position her comfortably in dorsal recumbent position with knees slightly flexed. Maintain privacy.

A. Inspection

Observe:

Size and shape of abdomen
Scars from previous surgery
Striae gravidarum
Linea nigra
Umbilicus
Visible fetal movements
Dilated veins
Hernia
Any asymmetry

B. Measurement of symphysis-fundal height

Measure from the upper border of symphysis pubis to the uterine fundus using a non-stretch tape.

Approximate fundal height landmarks:

Gestational age	Fundal height
12 weeks	Just above symphysis pubis
16 weeks	Midway between symphysis pubis and umbilicus
20 weeks	At umbilicus
24 weeks	About 2 fingerbreadths above umbilicus
28 weeks	Midway between umbilicus and xiphisternum
32 weeks	About 3 fingerbreadths below xiphisternum
36 weeks	At xiphisternum
40 weeks	Slightly lower due to lightening

After about 24 weeks, fundal height in centimeters roughly corresponds to gestational age in weeks, within a range of about 2 cm.

A fundal height smaller than expected may indicate wrong dates, fetal growth restriction, oligohydramnios, or transverse lie. A larger measurement may suggest wrong dates, multiple pregnancy, polyhydramnios, large fetus, or fibroid.

C. Palpation: Leopold maneuvers

First maneuver: Fundal grip

Palpate the uterine fundus to identify the fetal pole.

Head: hard, round, smooth, ballotable
Breech: soft, broad, irregular, less ballotable

Second maneuver: Lateral grip

Palpate both sides of uterus.

Fetal back: smooth, firm, resistant surface
Limbs: small, irregular, mobile parts

This helps locate the fetal back and determine fetal position.

Third maneuver: Pawlik's grip

Palpate just above the symphysis pubis to identify the presenting part.

Determines whether the presenting part is head or breech.
Assesses mobility or engagement of the presenting part.

Fourth maneuver: Pelvic grip

Face the woman's feet and palpate the lower abdomen with both hands.

Determines descent and engagement of the fetal head.
Helps assess degree of flexion of the head.

D. Auscultation of fetal heart sounds

Use a Doppler device or fetoscope.
Normal fetal heart rate is approximately 110 to 160 beats/minute.
Listen over the fetal back:
- Below the umbilicus in cephalic presentation
- Above the umbilicus in breech presentation
Record rate, rhythm, and regularity.

E. Assessment of fetal movements

Ask the mother about daily fetal movements. A clear reduction or absence of movements requires urgent assessment.

F. Vaginal examination

Vaginal examination is not routine at every antenatal visit. It is done only when indicated, for example:

Vaginal bleeding
Suspected preterm labour
Suspected rupture of membranes
Assessment near term when clinically necessary
Pelvic assessment in selected cases

Avoid digital vaginal examination in suspected placenta previa until placental location is confirmed and the setting is safe.

C. Antenatal Investigations

Investigations vary according to national policy, available resources, maternal risk factors, and gestational age.

1. Routine Investigations at Booking Visit

Investigation	Purpose
Urine pregnancy test	Confirmation of pregnancy
Hemoglobin or complete blood count	Detect anemia, infection, platelet abnormality
Blood group and Rh typing	Identify ABO group and Rh-negative mother
Antibody screening, where available	Detect red-cell alloimmunization
Urine routine microscopy and culture where indicated	Detect proteinuria, glycosuria, urinary infection
Blood glucose testing	Screen for pre-existing diabetes or hyperglycemia
HIV test with counselling and consent	Prevent mother-to-child transmission and provide treatment
Syphilis screening	Prevent congenital syphilis
Hepatitis B surface antigen	Detect maternal hepatitis B and plan neonatal prophylaxis
Hepatitis C test	Offered according to national policy or risk
Rubella immunity	Depends on local policy; vaccination is given after pregnancy if non-immune
Malaria test	In endemic areas or if fever/symptoms occur
Tuberculosis screening	Symptom-based or targeted screening in high-burden settings
Hemoglobinopathy screening	Thalassemia/sickle-cell screening in high-prevalence populations or if family history is present

Urine testing for protein and sugar is commonly done at antenatal visits. Proteinuria with hypertension is a warning sign of pre-eclampsia. Glycosuria may require assessment for diabetes.

2. Ultrasound Examination

Early ultrasound

An ultrasound scan before 24 weeks is recommended by WHO for:

Accurate dating of pregnancy
Confirmation of viability
Detection of multiple gestation
Detection of some structural anomalies
Placental localization
Improved planning for post-term pregnancy

The WHO guidance on early ultrasound recommends one scan before 24 weeks where ultrasound is available.

Common timing

Scan	Usual timing	Main purpose
Dating/viability scan	6 to 13+6 weeks	Viability, number of fetuses, gestational age, early anomaly assessment
Nuchal translucency and first-trimester screening	11 to 13+6 weeks	Aneuploidy risk assessment where offered
Anomaly scan	18 to 22 weeks	Detailed fetal structural assessment, placenta, amniotic fluid
Growth and Doppler scan	As indicated	Fetal growth restriction, placental insufficiency, hypertension, diabetes, reduced movements
Placental localization scan	Often around 32 weeks if low-lying placenta found earlier	Assess persistence of placenta previa

3. Screening for Gestational Diabetes Mellitus

Screen according to local protocol, commonly at 24 to 28 weeks.

Earlier testing is appropriate for women with risk factors such as:

Previous gestational diabetes
Obesity
Previous large baby
Strong family history of diabetes
Polycystic ovary syndrome
Previous unexplained stillbirth
Glycosuria
High-risk ethnic background

Methods include fasting plasma glucose, oral glucose tolerance test, or locally approved screening protocol.

4. Repeat Investigations

Repeat tests as clinically indicated:

Hemoglobin at around 28 weeks or earlier if anemia is suspected
Urine protein and sugar at each visit or when indicated
Blood pressure at every visit
Repeat HIV, syphilis, and hepatitis testing according to risk and national policy
Repeat antibody screen in Rh-negative women according to protocol
Blood glucose testing at 24 to 28 weeks
Growth scan and Doppler studies for high-risk pregnancy

5. Special Investigations for High-Risk Pregnancy

May include:

Liver function tests, renal function tests, serum uric acid, platelet count for suspected pre-eclampsia
Thyroid function tests
ECG and echocardiography for cardiac disease
Cervical-length assessment for preterm birth risk
Non-stress test, biophysical profile, and Doppler velocimetry for fetal surveillance
Genetic counselling and diagnostic testing such as chorionic villus sampling or amniocentesis when indicated

D. Antenatal Advice

Counselling should be individualized, respectful, culturally appropriate, and reinforced at every visit.

1. Diet and Nutrition

Advise a balanced diet containing:

Cereals and whole grains
Pulses, legumes, eggs, fish, meat, or other protein sources
Milk or dairy products if tolerated
Green leafy vegetables
Fruits and vegetables
Nuts and seeds where affordable
Adequate safe drinking water

Key points

Pregnancy does not require “eating for two,” but requires better quality food.
Encourage an additional meal or snack, especially during the second and third trimesters.
Include protein-rich foods daily.
Prevent constipation with fibre, fluids, fruits, vegetables, and physical activity.
Avoid unpasteurized milk and milk products.
Avoid raw or undercooked egg, meat, fish, and shellfish.
Wash fruits and vegetables thoroughly.
Limit highly processed food, excessive sugar, and excess salt.

2. Iron and Folic Acid

Iron-folic acid supplementation prevents nutritional anemia and neural tube defects.

Folic acid: ideally started before conception and continued in early pregnancy.
Women at high risk of neural tube defects may need high-dose folic acid under medical supervision.
Iron-folic acid: usually started after the first trimester or according to national policy and continued through pregnancy and postpartum.

Advise taking iron tablets with water or citrus-containing drinks if tolerated. Avoid taking them together with tea, coffee, or calcium tablets because absorption may decrease.

Possible side effects:

Nausea
Constipation
Dark stools
Gastric irritation

The woman should not stop treatment without discussing side effects with a health worker.

3. Calcium and Vitamin D

Calcium supplementation is commonly advised, especially where dietary calcium intake is low or pre-eclampsia risk is high.
Take calcium and iron tablets at different times of day.
Encourage safe sun exposure and dietary vitamin D sources as appropriate.
Vitamin D supplementation should follow local policy or clinician advice.

4. Rest, Sleep, and Exercise

Encourage adequate rest and sleep.
Avoid heavy physical exertion, long periods of standing, and heavy lifting.
Moderate physical activity, such as walking, stretching, and pregnancy-appropriate exercise, is generally beneficial in uncomplicated pregnancy.
Avoid contact sports, activities with a high risk of falling, and overheating.
Stop exercise and seek advice if there is bleeding, dizziness, chest pain, painful contractions, fluid leakage, or reduced fetal movements.

5. Personal Hygiene

Advise:

Daily bathing and clean clothing
Regular handwashing
Good oral and dental hygiene
Safe drinking water and hygienic food preparation
Wearing comfortable, non-restrictive clothes
Comfortable low-heeled footwear to prevent falls

6. Sexual Activity

Sexual intercourse is usually safe in an uncomplicated pregnancy.

Avoid intercourse and seek medical advice when there is:

Vaginal bleeding
Placenta previa or low-lying placenta after medical advice
Leaking of fluid
Threatened or established preterm labour
Cervical insufficiency
Other obstetric contraindication advised by the clinician

7. Travel

Travel is generally safer in the second trimester for uncomplicated pregnancy.
Avoid unnecessary long-distance travel near term.
During long journeys, take breaks, walk regularly, stretch legs, use seat belts correctly, and maintain hydration.
The lap portion of a seat belt should lie low across the hips and below the abdomen.

8. Medicines and Harmful Substances

Advise the woman:

Do not take any medicine, herbal preparation, or traditional remedy without consulting a qualified health professional.
Avoid alcohol completely.
Avoid tobacco in all forms, vaping, and exposure to second-hand smoke.
Avoid illicit drugs.
Limit caffeine according to clinician or national recommendations.
Avoid radiation exposure unless medically necessary.
Inform the health worker about all medicines used for chronic disease.

9. Immunization

Give tetanus-containing vaccine according to the national immunization schedule and previous vaccination history.

This protects mother and newborn against tetanus. WHO includes tetanus vaccination as a routine component of antenatal care, as summarized in the WHO ANC guidance.

Other vaccines, such as influenza, pertussis, COVID-19, hepatitis B, or others, should follow local guidelines and individual risk assessment.

10. Breast Care and Breastfeeding Preparation

Reassure that routine nipple manipulation is unnecessary.
Inspect for inverted nipples and provide advice where needed.
Discuss early initiation of breastfeeding within one hour after birth.
Explain exclusive breastfeeding for the first 6 months, unless a medical exception applies.

11. Birth Preparedness and Complication Readiness

By the third trimester, help the woman and family prepare:

Preferred place of birth
Skilled birth attendant
Transport arrangement
Emergency contact numbers
Money for emergency expenses
Blood donor or blood bank information if high risk
Companion/support person
Necessary records, investigations, and hospital bag
Plan for newborn care and breastfeeding
Postpartum contraception choices

12. Danger Signs in Pregnancy

Tell the woman and family to seek urgent medical care for any of the following:

Vaginal bleeding
Leakage or gush of fluid per vagina
Severe abdominal pain
Severe headache
Blurred vision, flashing lights, or loss of vision
Convulsions or loss of consciousness
Swelling of face or hands, especially if sudden
Fever or chills
Severe vomiting or inability to eat/drink
Difficulty breathing, chest pain, or palpitations
Severe weakness or fainting
Burning micturition, reduced urine output, or severe urinary symptoms
Reduced or absent fetal movements after movements have been established
Regular painful contractions before 37 weeks
Any concern that the woman feels is unusual or serious

E. Antenatal Follow-up

1. Schedule of Visits

WHO contact schedule for uncomplicated pregnancy

Contact	Timing
First contact	Before 12 weeks
Second contact	20 weeks
Third contact	26 weeks
Fourth contact	30 weeks
Fifth contact	34 weeks
Sixth contact	36 weeks
Seventh contact	38 weeks
Eighth contact	40 weeks

This schedule should be increased for women with high-risk pregnancy, symptoms, complications, or social vulnerability.

In some settings, the minimum practical schedule is four visits:

First visit: before 12 weeks
Second visit: 14 to 26 weeks
Third visit: 28 to 34 weeks
Fourth visit: 36 weeks or later

However, eight or more contacts are preferred where feasible.

2. Assessment at Every Follow-up Visit

At each visit, assess and document:

Maternal assessment

General health and new complaints
Blood pressure
Weight trend
Pallor and edema
Symptoms of pre-eclampsia:
- Headache
- Blurring of vision
- Epigastric pain
- Sudden swelling
Symptoms of infection:
- Fever
- Urinary complaints
- Vaginal discharge
Adherence to iron-folic acid, calcium, and other treatment
Immunization status
Diet, rest, work load, mental health, and safety at home

Fetal assessment

Symphysis-fundal height
Fetal lie, presentation, and engagement in later pregnancy
Fetal heart rate
Fetal movements
Growth pattern
Need for ultrasound or fetal surveillance if growth is abnormal or risk is present

Urine testing

Albumin/protein for possible pre-eclampsia
Sugar for possible diabetes
Other urine tests if urinary infection is suspected

3. Follow-up by Trimester

Period	Main focus
First trimester	Confirmation and dating of pregnancy, booking tests, risk assessment, folic acid, management of nausea/vomiting, early ultrasound where available
Second trimester	Anomaly scan, fetal growth, anemia prevention, blood pressure monitoring, diabetes screening at 24 to 28 weeks, fetal movements education
Third trimester	Fetal presentation, growth, blood pressure and proteinuria, anemia reassessment, birth preparedness, breastfeeding counselling, danger-sign education, referral planning

4. Management of Missed Visits

If a woman misses an appointment:

Contact her through community health worker, telephone, or home visit if possible.
Encourage early return without blame.
Assess barriers such as cost, transport, domestic violence, work, family restrictions, or fear.
Screen for complications and update investigations.
Reinforce the importance of regular follow-up and institutional delivery.

5. Referral of High-Risk Pregnancy

Refer promptly to a higher facility if there is:

Severe anemia
Hypertension, pre-eclampsia, or eclampsia
Diabetes or uncontrolled medical illness
Heart, renal, thyroid, or neurological disease
Antepartum hemorrhage
Rh-negative pregnancy with antibodies
Multiple pregnancy
Previous cesarean section with complications or multiple scars
Previous stillbirth or recurrent pregnancy loss
Suspected fetal growth restriction
Malpresentation near term
Placenta previa
Preterm labour or rupture of membranes
Reduced fetal movements
Any maternal or fetal danger sign

Short Conclusion

Antenatal care is not merely examination and investigations. It is continuous, woman-centered care that combines risk assessment, prevention, treatment, counselling, nutritional support, immunization, mental preparation, birth planning, and timely referral. Regular antenatal contacts help identify complications early and improve outcomes for both mother and baby.

Create a quick-reference PDF on antenatal care

Reading File

Browsing Directory

Running Command

mkdir -p "/tmp/workspace/antenatal-care-quick-reference/src" "/tmp/workspace/antenatal-care-quick-reference/output" && python -c "import reportlab; print('reportlab available')"

Writing File

~/antenatal-care-quick-reference/src/create_pdf.py

from reportlab.lib import colors
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, KeepTogether, PageBreak
from reportlab.pdfbase.ttfonts import TTFont
from reportlab.pdfbase import pdfmetrics
from reportlab.lib.colors import HexColor

OUT = '/tmp/workspace/antenatal-care-quick-reference/output/Antenatal_Care_Quick_Reference.pdf'

NAVY = HexColor('#12355B')
TEAL = HexColor('#007C83')
PALE_TEAL = HexColor('#E8F5F5')
PALE_BLUE = HexColor('#EAF2F8')
PALE_RED = HexColor('#FDECEC')
RED = HexColor('#B42318')
DARK = HexColor('#1D2939')
MID = HexColor('#475467')
LIGHT = HexColor('#D0D5DD')

styles = getSampleStyleSheet()
styles.add(ParagraphStyle(name='Title2', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=21, leading=25, alignment=TA_CENTER, textColor=NAVY, spaceAfter=6))
styles.add(ParagraphStyle(name='Subtitle', parent=styles['Normal'], fontName='Helvetica', fontSize=9.5, leading=13, alignment=TA_CENTER, textColor=MID, spaceAfter=12))
styles.add(ParagraphStyle(name='H1x', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=13.5, leading=16, textColor='white', spaceBefore=10, spaceAfter=6, backColor=NAVY, borderPadding=(5,7,5,7)))
styles.add(ParagraphStyle(name='H2x', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=10.5, leading=13, textColor=TEAL, spaceBefore=7, spaceAfter=3))
styles.add(ParagraphStyle(name='Bodyx', parent=styles['BodyText'], fontName='Helvetica', fontSize=8.5, leading=11.4, textColor=DARK, spaceAfter=3))
styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontName='Helvetica', fontSize=7.6, leading=9.5, textColor=DARK, spaceAfter=1))
styles.add(ParagraphStyle(name='Alert', parent=styles['BodyText'], fontName='Helvetica-Bold', fontSize=8.5, leading=11.2, textColor=RED, spaceAfter=3))
styles.add(ParagraphStyle(name='Footer', parent=styles['Normal'], fontName='Helvetica', fontSize=7.5, leading=9, textColor=MID, alignment=TA_CENTER))

P = lambda text, style='Bodyx': Paragraph(text, styles[style])
BUL = lambda items: [P('&bull; ' + item, 'Bodyx') for item in items]

def section(title): return [Spacer(1, 3), P(title, 'H1x')]

def mini_table(rows, widths, header=True, font=7.5):
    data=[]
    for r_i,row in enumerate(rows):
        data.append([P(str(x), 'Small') for x in row])
    t=Table(data, colWidths=widths, repeatRows=1 if header else 0, hAlign='LEFT')
    ts=[('VALIGN',(0,0),(-1,-1),'TOP'),('GRID',(0,0),(-1,-1),0.35,LIGHT),('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4)]
    if header:
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    for i in range(1 if header else 0, len(rows)):
        if i % 2 == 0: ts.append(('BACKGROUND',(0,i),(-1,i),PALE_BLUE))
    t.setStyle(TableStyle(ts)); return t

def header_footer(canvas, doc):
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    canvas.drawRightString(A4[0]-doc.rightMargin,0.75*cm,f'Page {doc.page}')
    canvas.restoreState()

story=[]
story += [Spacer(1, 7), P('ANTENATAL CARE', 'Title2'), P('Quick-reference guide for routine low-risk pregnancy care', 'Subtitle')]
intro = Table([[P('<b>Purpose:</b> support safe, respectful, continuous care of the pregnant woman and fetus. Use local protocols and individual clinical assessment for all decisions.', 'Bodyx')]], colWidths=[17.2*cm])
intro.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),PALE_TEAL),('BOX',(0,0),(-1,-1),0.5,TEAL),('LEFTPADDING',(0,0),(-1,-1),8),('RIGHTPADDING',(0,0),(-1,-1),8),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)])); story += [intro]

story += section('1. Definition, Aims and Objectives')
story += [P('<b>Definition:</b> Antenatal care (ANC) is skilled, planned care provided throughout pregnancy to optimize maternal and fetal health. It includes risk identification; prevention, detection and management of pregnancy-related or concurrent conditions; health education; support; and referral when required.'),
P('<b>Aims:</b> healthy mother and fetus, safe birth, positive pregnancy experience, and reduced maternal and perinatal illness and death.'),
P('<b>Core objectives</b>', 'H2x')]
story += BUL(['Register pregnancy early and establish gestational age.', 'Identify high-risk pregnancy and arrange timely referral.', 'Prevent and treat anemia, infection, hypertension, diabetes and nutritional deficiency.', 'Monitor fetal growth, wellbeing, lie and presentation.', 'Provide immunization, supplements, counselling, birth preparedness, breastfeeding and family-planning advice.', 'Recognize danger signs early and ensure prompt care.'])

story += section('2. Antenatal Examination')
story += [P('<b>At booking:</b> take a complete history and establish baseline maternal and fetal status. At each follow-up, reassess maternal symptoms, blood pressure, urine where indicated, fetal growth, fetal heart rate and fetal movements.'), P('<b>History</b>', 'H2x')]
story += BUL(['Current pregnancy: LMP, EDD, symptoms, bleeding, fluid loss, pain, fetal movements, medicines and exposures.', 'Obstetric history: parity, abortions, preterm birth, cesarean birth, postpartum hemorrhage, stillbirth, neonatal death and complications.', 'Medical and surgical history: hypertension, diabetes, cardiac/renal/thyroid disease, epilepsy, anemia, infections and allergies.', 'Family and social history: genetic disorders, smoking, alcohol/substances, nutrition, safety, mental health and support.'])
story += [P('<b>General and systemic examination</b>', 'H2x')]
story += BUL(['Measure blood pressure, pulse, temperature, weight trend and height at booking.', 'Look for pallor, jaundice, edema, cyanosis, thyroid enlargement, varicosities and dental problems.', 'Examine cardiovascular and respiratory systems; assess relevant pre-existing disease.', 'Breast examination and counselling when indicated.'])
story += [P('<b>Abdominal and fetal examination</b>', 'H2x')]
story += BUL(['Inspect abdomen for size, scars, striae, shape and visible movements.', 'Measure symphysis-fundal height and plot growth after 24 weeks.', 'Palpate: fundal grip, lateral grip, Pawlik grip and pelvic grip to determine lie, presentation, position and engagement.', 'Auscultate fetal heart rate: usual baseline 110-160 beats/minute.', 'Ask specifically about fetal movements. Reduced movements require urgent assessment.', 'Vaginal examination only when clinically indicated. Avoid digital examination in suspected placenta previa until placental location is safely assessed.'])]

story += section('3. Routine Antenatal Investigations')
story += [mini_table([
['Test / assessment','Purpose / timing'],
['Hemoglobin or CBC','Detect anemia; repeat later in pregnancy per protocol or clinical need.'],
['Blood group, Rh type and antibody screen','Identify Rh-negative status and red-cell alloimmunization risk.'],
['Urine protein and glucose','Screen for proteinuria and glycosuria; repeat as clinically indicated.'],
['Urine microscopy/culture','If symptoms, history or local protocol suggest urinary infection.'],
['HIV, syphilis, hepatitis B','Offer according to national policy, with counselling and prompt linkage to treatment/prevention.'],
['Blood glucose / GDM screening','Commonly 24-28 weeks; earlier if high-risk.'],
['Ultrasound before 24 weeks','Dating, viability, multiples, anatomy and placental location.'],
['Targeted tests','Hemoglobinopathy, TB, malaria, hepatitis C, thyroid, genetic testing, renal/liver tests and fetal surveillance when risk or policy indicates.']
],[4.4*cm,12.8*cm])]
story += [P('<b>High-risk investigations:</b> may include renal and liver function, platelet count, urine protein quantification, Doppler studies, non-stress testing, biophysical profile, echocardiography, cervical-length assessment or genetic diagnostic tests.', 'Small')]

story += [PageBreak()]
story += section('4. Antenatal Advice')
story += [P('<b>Nutrition and supplements</b>', 'H2x')]
story += BUL(['Eat a varied diet: grains, pulses/other protein, fruit, vegetables, dairy or alternatives, and safe fluids. Encourage an additional nutritious meal or snack in later pregnancy where needed.', 'Take folic acid early in pregnancy and iron-folic acid, calcium and other supplements as prescribed by local protocol. Separate iron and calcium doses when advised.', 'Avoid alcohol, tobacco, vaping, illicit drugs and unprescribed medicines or herbal remedies.', 'Avoid unpasteurized dairy and raw or undercooked eggs, meat, fish and shellfish. Wash produce and maintain safe food hygiene.'])
story += [P('<b>Daily living</b>', 'H2x')]
story += BUL(['Encourage rest, sleep and regular moderate activity such as walking in uncomplicated pregnancy. Avoid heavy lifting, high-fall-risk activities and overheating.', 'Maintain oral and personal hygiene; wear comfortable clothing and low-heeled footwear.', 'Travel is usually safest in uncomplicated pregnancy during the second trimester. On long trips: hydrate, walk/stretch regularly and wear a seat belt low across the hips.', 'Sexual activity is generally safe if pregnancy is uncomplicated. Seek advice or avoid intercourse with bleeding, leaking fluid, placenta previa, preterm labour risk or clinician-directed restriction.'])
story += [P('<b>Preventive care and preparation</b>', 'H2x')]
story += BUL(['Give tetanus-containing vaccine and other vaccines according to local schedule and individual risk.', 'Discuss early and exclusive breastfeeding, newborn care, postpartum contraception and postnatal follow-up.', 'Make a birth plan: place of delivery, skilled attendant, transport, records, emergency funds, support person and blood plan where appropriate.', 'Screen support needs: mental health concerns, domestic violence, substance use, food insecurity and access barriers.'])

story += section('5. Danger Signs: Urgent Assessment / Referral')
alert_items=['Vaginal bleeding or suspected rupture/leakage of membranes.', 'Severe abdominal pain, regular painful contractions before 37 weeks, or trauma.', 'Severe headache, visual disturbance, epigastric/right upper abdominal pain, sudden face/hand swelling, seizure or loss of consciousness.', 'Fever, chills, severe vomiting, breathing difficulty, chest pain, fainting or marked weakness.', 'Burning urination with systemic illness, markedly reduced urine output or severe urinary symptoms.', 'Reduced or absent fetal movements once movements have been established.', 'Any symptom the woman considers alarming or unusual.']
alert_tbl=Table([[P('RED FLAGS', 'Alert')]] + [[P('• '+x, 'Alert')] for x in alert_items],colWidths=[17.2*cm])
alert_tbl.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),PALE_RED),('BOX',(0,0),(-1,-1),0.7,RED),('LEFTPADDING',(0,0),(-1,-1),8),('RIGHTPADDING',(0,0),(-1,-1),8),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4)])); story += [alert_tbl]

story += section('6. Follow-up Schedule and Every-Visit Checklist')
story += [P('<b>WHO routine contact schedule for uncomplicated pregnancy:</b> first contact before 12 weeks, then at 20, 26, 30, 34, 36, 38 and 40 weeks. More visits are needed for symptoms, medical disease, obstetric risk or social vulnerability.'), mini_table([
['At every contact','Key actions'],
['Ask and assess','New symptoms, danger signs, fetal movements, medicines/supplement adherence, nutrition, wellbeing, safety and birth plan.'],
['Measure','Blood pressure; weight trend; fundal height after 24 weeks; fetal heart rate; lie/presentation in later pregnancy.'],
['Test as indicated','Urine protein/glucose, hemoglobin, glucose, infection screening and targeted tests per protocol.'],
['Counsel','Diet, supplements, immunization, danger signs, breastfeeding, delivery plan and postnatal contraception.'],
['Document and refer','Update ANC record. Escalate promptly for high-risk findings, abnormal growth, hypertension, bleeding, reduced movements or abnormal tests.']
],[4.2*cm,13*cm])]
story += [P('<b>Suggested focus by trimester:</b> <b>1st</b> - dating, booking tests, early risk assessment and folate. <b>2nd</b> - anomaly scan, growth, anemia prevention and GDM screening. <b>3rd</b> - presentation, growth, BP/proteinuria, delivery planning and referral readiness.', 'Bodyx')]

story += section('7. Immediate Referral: Common High-Risk Features')
story += BUL(['Severe anemia, hypertension/pre-eclampsia, diabetes, significant cardiac, renal, thyroid or neurological illness.', 'Antepartum hemorrhage, preterm labour, prelabour rupture of membranes, suspected infection or severe hyperemesis.', 'Multiple pregnancy, placenta previa, fetal growth restriction, malpresentation near term or non-reassuring fetal assessment.', 'Previous major obstetric complication, previous cesarean birth requiring specialist planning, recurrent losses or previous stillbirth.', 'Rh-negative pregnancy with antibodies or any significant abnormal investigation.'])
story += [Spacer(1,5), P('<b>Clinical note:</b> This is a study and point-of-care summary, not a substitute for local guidelines, obstetric review or emergency assessment. Adapt investigations, supplements, vaccines and referral thresholds to national policy and patient-specific risk.', 'Small'), Spacer(1,4), P('Sources: Park’s Textbook of Preventive and Social Medicine, ANC section (definition and objectives); World Health Organization, Antenatal care for a positive pregnancy experience (routine contact schedule and early ultrasound guidance).', 'Footer')]

doc=SimpleDocTemplate(OUT,pagesize=A4,rightMargin=1.25*cm,leftMargin=1.25*cm,topMargin=1.55*cm,bottomMargin=1.2*cm,title='Antenatal Care Quick Reference',author='Orris')
doc.build(story,onFirstPage=header_footer,onLaterPages=header_footer)
print(OUT)

Running Command

python "/tmp/workspace/antenatal-care-quick-reference/src/create_pdf.py" && python -c "from pypdf import PdfReader; p='/tmp/workspace/antenatal-care-quick-reference/output/Antenatal_Care_Quick_Reference.pdf'; r=PdfReader(p); print('pages=',len(r.pages)); print('chars=',sum(len(x.extract_text() or '') for x in r.pages)); print('size=',__import__('os').path.getsize(p))"

Reading File

Editing File

~/antenatal-care-quick-reference/src/create_pdf.py

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/antenatal-care-quick-reference/src/create_pdf.py'

Running Command

python "/tmp/workspace/antenatal-care-quick-reference/src/create_pdf.py" && python -c "from pypdf import PdfReader; import os; p='/tmp/workspace/antenatal-care-quick-reference/output/Antenatal_Care_Quick_Reference.pdf'; r=PdfReader(p); text=''.join(page.extract_text() or '' for page in r.pages); print('pages=',len(r.pages)); print('chars=',len(text)); print('size=',os.path.getsize(p)); print('has_danger=', 'Danger Signs' in text); print('has_followup=', 'Follow-up Schedule' in text)"

Created a 4-page quick-reference PDF covering definition, objectives, examination, investigations, antenatal advice, danger signs, follow-up, and referral criteria.

Antenatal Care Quick Reference

PDF Document · PDF

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