Antenatal Care (ANC): Objectives, Clinical, Laboratory, and Counseling Services

Definition

Objectives of Antenatal Care

1. To promote, protect and maintain the health of the mother during pregnancy.
2. To detect "high-risk" cases and give them special attention.
3. To foresee complications and prevent them.
4. To remove anxiety and dread associated with delivery.
5. To reduce maternal and infant mortality and morbidity.
6. To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation.
7. To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy.
8. To attend to the under-fives accompanying the mother.

Services Provided to the Antenatal Mother

A. Clinical Services

1. History-Taking (First Visit)

• Confirm the pregnancy
• Record date of the last menstrual period (LMP) and calculate the expected date of delivery (EDD = LMP + 9 months 7 days)
• Identify complications from previous pregnancies/confinements
• Identify current medical/surgical/obstetric conditions
• Record symptoms indicating complications: fever, persistent vomiting, abnormal vaginal discharge or bleeding, palpitation, breathlessness, generalized swelling, severe headache, blurring of vision, decreased fetal movements
• History of systemic illness: hypertension, diabetes, heart disease, tuberculosis, renal disease, epilepsy, asthma, jaundice, malaria, RTI, STI, HIV/AIDS
• Family history of hypertension, diabetes, tuberculosis, thalassaemia, twins, congenital malformations
• History of drug allergies and habit-forming drugs

2. Physical Examination (Every Visit)

• Pallor: Examine conjunctiva, nails, tongue, oral mucosa, and palms to detect anaemia
• Pulse: Normal 60-90 beats/minute; persistent abnormality requires medical attention
• Respiratory rate: Normal 18-20 breaths/minute; check if breathlessness is reported
• Oedema: Physiological oedema disappears after sleep; facial/hand/vulval oedema is abnormal and requires referral
• Blood pressure: Measured at every visit; hypertension diagnosed if systolic ≥140 mmHg or diastolic ≥90 mmHg on two consecutive readings
• Weight: Baseline at first visit; normal gain is 9-11 kg over pregnancy (~2 kg/month after first trimester); excessive gain (>3 kg/month) raises suspicion of pre-eclampsia, twins, or diabetes
• Breast examination: Shape and size of nipples for breastfeeding suitability

3. Abdominal Examination

• Fundal height measurement:
  • 12 weeks - uterine fundus just palpable per abdomen
  • 20 weeks - fundus at lower border of umbilicus
  • 36 weeks - fundus at level of xiphisternum
• Fetal heart sounds: Audible after 6th month; normal rate 120-140/min
• Fetal movements: Palpable from 18-22 weeks onwards
• Fetal parts: Distinguishable (head, back, limbs) after 28 weeks
• Fetal lie and presentation: Assessed after 32 weeks
• Multiple pregnancy: Suspected if uterus is larger than gestational age or multiple fetal parts palpated
• Inspection: Any abdominal scars noted

4. Gestational Age Assessment

• Mainly by LMP and fundal height; gold standard is early ultrasound with fetal measurements (ideally in the first trimester)

B. Laboratory Investigations

• Haemoglobin (Hb) estimation (first and third trimester)
• Urine test for albumin (proteinuria)
• Urine test for sugar (glycosuria)
• Blood grouping and Rh typing
• Rapid HIV test (with pre/post-test counseling)

• VDRL/RPR test for syphilis
• Rapid malaria test (if unavailable at sub-centre)
• Blood sugar testing
• HBsAg for hepatitis B infection
• TB skin test (if available)

C. Counseling Services

Interventions and Counseling at each visit include:

1. Iron and Folic Acid (IFA) supplementation - prescribed and supplied as per need
2. Immunization against tetanus (TT injection schedule)
3. Nutrition counseling - ensuring adequate dietary intake to achieve 9-11 kg weight gain; food supplementation for those at risk of intrauterine growth retardation
4. Group or individual instruction on:
   • Nutrition and diet
   • Family planning
   • Personal hygiene and self-care
   • Preparation for delivery and parenthood
5. Breastfeeding counseling - nipple care, preparation for breastfeeding
6. Danger signs counseling - teach mother to recognize warning signs (e.g., bleeding, severe headache, blurred vision, reduced fetal movements) and seek prompt help
7. HIV counseling - pre- and post-test counseling with complete confidentiality
8. Family planning counseling - sensitization about spacing and limiting births
9. Safe motherhood counseling - information about Janani Suraksha Yojana (JSY) and other government incentives for institutional delivery
10. Home visiting by a female health worker/trained dai to reinforce advice and follow up
11. Referral services - identification and prompt referral of high-risk cases (elderly primigravida, short stature, malpresentation, APH, pre-eclampsia, anaemia, twins, previous caesarean, pregnancy with systemic diseases, etc.)

Key principle: The risk approach is central to ANC - identifying high-risk mothers as early as possible and providing them with skilled, specialized care, while delivering appropriate care to all pregnant women. - Park's Textbook of Preventive and Social Medicine