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Antenatal Care (ANC) - Complete Overview (OB/GYN)

Definition

• Risk identification
• Prevention and management of pregnancy-related or concurrent diseases
• Health education and health promotion

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Objectives of ANC

1. Promote, protect, and maintain the health of the mother during pregnancy
2. Detect "high-risk" cases and give them special attention
3. Foresee complications and prevent them
4. Remove anxiety and dread associated with delivery
5. Reduce maternal and infant mortality and morbidity
6. Teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation
7. Sensitize the mother to the need for family planning
8. Attend to under-fives accompanying the mother

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Schedule of ANC Visits

Standard Schedule (India / National Guidelines)

Ideally, the mother should attend once a month during the first 7 months, twice a month in the 8th month, and weekly thereafter if everything is normal.

Trimester-Wise Schedule (OB/GYN Reference - Creasy & Resnik)

• Detailed medical and obstetric history
• Evaluation/workup of previous stillbirth (if applicable)
• Genetic counseling if family condition exists
• Diabetes screen
• Acquired thrombophilia testing (lupus anticoagulant, anticardiolipin, β2-glycoprotein IgG and IgM antibodies)
• Smoking, alcohol, and illicit substance cessation counseling
• Weight loss advice in obese women
• Support and reassurance

• Dating ultrasound by crown-rump length (CRL)
• First-trimester screen: PAPP-A, hCG, and nuchal translucency OR cell-free fetal DNA testing
• Support and reassurance

• Fetal sonographic anatomic survey at 18-20 weeks
• Genetic screening if not done in first trimester (or single marker alpha-fetoprotein if first-trimester screening was performed)
• Support and reassurance

• Serial ultrasounds starting at 28 weeks (to rule out fetal growth restriction)
• Fetal movement counting starting at 28 weeks
• Antepartum fetal surveillance starting at 32 weeks (or 1-2 weeks earlier than a previous stillbirth)
• Support and reassurance

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Components of Each ANC Visit

(I) History Taking

• Personal details (name, age, address, occupation)
• Menstrual history (LMP, EDD)
• Obstetric history (gravida, para, previous deliveries, complications, abortions)
• Medical history (hypertension, diabetes, heart disease, anemia, TB)
• Family history
• Current pregnancy symptoms (nausea, vomiting, bleeding, discharge)

(II) General Examination

• Height (measured at first visit only; <145 cm = high risk)
• Weight and weight gain monitoring
• Blood pressure (every visit; ≥140/90 mmHg = danger sign)
• Temperature, pulse, respiratory rate
• Pallor (anemia detection)
• Edema of feet, face, hands
• Fundal height measurement

(III) Abdominal Examination

1. Inspection - shape, size, scars
2. Measurement of fundal height (in cm corresponds to weeks of gestation after 20 weeks)
3. Palpation for fetal lie, presentation, position, engagement
4. Auscultation of fetal heart sounds (normal: 120-160 beats/min)
5. Assessment for multiple pregnancy
6. Detection of abnormalities (polyhydramnios, growth restriction)
7. Inspection of abdominal scar or other relevant findings

(IV) Assessment of Gestational Age

• Gold standard: Early ultrasound (first trimester) with fetal measurements (CRL)
• LMP-based calculation (Naegele's rule): EDD = LMP + 9 months + 7 days
• "Best obstetric estimate" = combination of ultrasound + LMP
• In resource-limited settings: fundal height, clinical assessment

(V) Laboratory Investigations

• Pregnancy detection test (urine hCG)
• Haemoglobin estimation
• Urine for albumin and sugar
• Rapid malaria test

• Blood group + Rh factor
• VDRL/RPR (syphilis)
• HIV testing
• Blood sugar (GDM screening)
• HBsAg (Hepatitis B)
• TB skin test
• Rapid malaria test (if unavailable at sub-centre)

1. History taking
2. Blood pressure measurement
3. Weight measurement
4. Fundal height measurement
5. Fetal heart rate auscultation
6. Urine albumin and sugar

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Immunization During Pregnancy

Tetanus Toxoid (TT) Schedule

Women who have received 2 previous doses within 3 years receive only a booster dose.

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Nutritional Supplementation

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High-Risk Pregnancy Identification

• Age <18 or >35 years
• Height <145 cm / weight <45 kg
• Grand multipara (5 or more pregnancies)
• Previous cesarean section
• History of pregnancy loss (abortion, stillbirth, neonatal death)
• Anemia (Hb <7 g/dL = severe)

• Hypertension / preeclampsia / eclampsia
• Diabetes mellitus
• Heart disease
• Renal disease
• Thyroid disorders
• TB / HIV / Hepatitis B

• Malpresentation after 34 weeks
• Multiple pregnancy
• Polyhydramnios / oligohydramnios
• Intrauterine growth restriction (IUGR)
• Antepartum hemorrhage

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Danger Signs During Pregnancy (ABCDEFG)

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Counseling Topics at ANC

1. Diet and nutrition - protein-rich, iron-rich, calcium-rich foods
2. Rest and work - 8 hours sleep, avoid heavy lifting
3. Personal hygiene - dental hygiene, skin care, breast care
4. Danger signs - when to seek immediate care
5. Birth preparedness - institutional delivery planning, transport, funds
6. Breastfeeding - exclusive for 6 months, initiation within 1 hour of birth
7. Family planning - post-partum contraception
8. Tobacco/alcohol cessation
9. HIV/STI counseling and testing
10. Newborn care
11. Malaria prophylaxis (in endemic zones)

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Antenatal Monitoring (Creasy & Resnik - MFM)

• Cervical length measurement by transvaginal ultrasound (TVU) - predictive of preterm birth; a cervical length ≤25 mm at 22-24 weeks carries RR 6.5 for preterm birth before 35 weeks
• Biophysical profile (BPP) - fetal tone, movement, breathing, amniotic fluid index, NST
• Non-stress test (NST) - weekly/biweekly from 32-34 weeks in high-risk pregnancies
• Doppler velocimetry - umbilical artery, middle cerebral artery, ductus venosus
• Group B Streptococcus (GBS) screening - at 35-37 weeks

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Postpartum / Postnatal Planning (Integrated with ANC)

• Post-natal home visits on Day 0, 3, 7, and 42 for home/sub-centre deliveries
• Day 3, 7, 42 visit for institutional deliveries
• Special attention to low birth weight (<2500 g) babies
• Initiation of early breastfeeding within 1 hour of birth

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Key Schemes (India)

• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery
• PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) - free ANC on 9th of every month
• Surakshit Matritva Aashwasan (SUMAN) - dignified, respectful, quality care
• POSHAN Abhiyan - nutritional support
• LaQshya - Labour Room Quality Improvement Initiative

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• Park's Textbook of Preventive and Social Medicine (primary ANC protocols and Indian guidelines)
• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice (advanced OB/GYN monitoring and trimester-specific care)