1.2 Antenatal consultations

1.2.1 Aims of antenatal monitoring

– Screening for and management of pathologies: hypertension, anaemia, malaria, syphilis, urinary tract infection, HIV infection, malnutrition, vitamin and micronutrient deficiencies, etc.
– Screening for and management of obstetric complications: uterine scar, abnormal presentation, premature rupture of membranes, multiple pregnancy, metrorrhagia, etc.
– Routine prevention of maternal and neonatal tetanus, anaemia, mother-to-child HIV transmission, malaria (in endemic areas), etc.
– Devising a birth plan; counselling; preparation for the birth.

1.2.2 Timing of antenatal consultations

Four antenatal consultations are recommended for uncomplicated pregnancies1.

If the patient does not come in until the sixth month or later, try to have at least two consultations before the birth.

Table 1.2 - Schedule of antenatal consultations

* The gestational age is expressed in weeks since last menstrual period (LMP) or, less precisely, in weeks of pregnancy. Pregnancy lasts 9 months or 40 or 41 weeks LMP, depending on the country.

Closer monitoring may be needed, depending on the problems detected and the patient’s history (Section 1.3).

1.2.3 First consultation

A. Interview

– General feeling about the pregnancy (problems/concerns).

– Social context: living conditions, family situation, activity.

– Date of last menstrual period.

– Obstetric and surgical history:
• Number of prior pregnancies;
• Complications with prior pregnancies/deliveries (haemorrhage, infection, prematurity, etc.);
• Spontaneous or induced abortion(s);
• Children, alive and deceased;
• Caesarean section (find out why) or any other uterine surgery;
• Instrumental delivery;
• Vesicovaginal or rectovaginal fistula.

– Medical history and ongoing treatments: hypertension, diabetes, asthma, epilepsy, heart disease, HIV infection, psychiatric disorder, etc.

– Immunisation status (tetanus).

– Current problems: pelvic pain, contractions, fever, urinary symptoms, vaginal bleeding, etc. If there are signs of a sexually transmitted infection (STI) – e.g., abnormal vaginal discharge or urethral discharge – always look for other concurrent STIs.

B. Estimating the gestational age and due date

The gestational age is estimated by counting the number of weeks since the last menstrual period (weeks LMP) using a calendar or pregnancy wheel.
For example, if the last menstrual period was on 15 December 2014 and the woman is seen on 27 January 2015, the estimated gestational age is 6 weeks LMP.
Always verify that this estimate tallies with the data from the clinical examination (estimate of uterine size) or the ultrasound.

The due date is estimated by counting 40 or 41 weeks from the first day of the last menstrual period.
For example, if the date of the last menstrual period was 15 December 2014, the due date is between 22 and 29 September 2015.

The due date can also be estimated by counting 9 months plus 7 to 14 days from the first day of the last menstrual period.
If the woman does not know the date of her last menstrual period, the presumed gestational age and due date is determined based on clinical examination or ultrasound1 .

C. Clinical examination

In all cases:
– Weight; blood pressure (patient seated and resting).
– Height (only for women < 1.40 m).
– Look for abdominal scar.
– Look for anaemia, oedema, etc.
– Look for foetal heart tone starting at the end of the first trimester.
– Estimate the size of the uterus (gives an estimate of gestational age):
• During the first trimester, the size of the uterus is estimated by bimanual examination. At 7 weeks the uterus is the size of a chicken egg, at 10 weeks the size of an orange, and at 12 weeks the uterine fundus extends beyond the symphysis pubis.
• Starting in the second trimester, the uterus can be felt by abdominal palpation alone; measure the fundal height, which is the distance between the upper edge of the symphysis pubis and the fundus (Figure 1.1).

Figure 1.1 - Measuring the fundal height


The estimate of the gestational age becomes increasingly approximate as the pregnancy advances. As a rough guide:

Table 1.3 - Fundal height according to gestational age

Fundal height

Weeks since last menstrual period

20 cm

18 - 22 weeks LMP

24 cm

22 - 26 weeks LMP

28 cm

26 - 30 weeks LMP

32 cm

30 - 34 weeks LMP

34 cm

33 weeks LMP to term

Note: fundal height and uterine growth may vary with ethnicity. Use the national curves from the Ministry of Health, if they exist.

Only if indicated:
– Genital examination (e.g., to look for mutilation, if complaint of abnormal discharge, etc.).
– Vaginal examination (e.g., if there is doubt about the pregnancy diagnosis).

D. Laboratory tests

Table 1.4 - Recommended screening tests

Tests

Comments

Syphilis

Syphilis screening should be done at the first consultation, as early as possible in pregnancy2. If it was not done at an antenatal consultation, it should be done at delivery.
Use a Treponema-specific rapid test (e.g., SD Bioline®).

Malaria

In endemic areas, perform a rapid test even if there are no symptoms.

HIV infection

Offer a test to all women who do not know their HIV status. Perform rapid tests according to the standard algorithm. Testing cannot be done without the patient’s consent.
Evaluate the immunological status (CD4 count): as soon as possible after seropositivity is detected, or at the first antenatal consultation for women who already know that they are HIV positive.

Anaemia

Measure haemoglobin (HemoCue).

Urinary tract infection

Test for asymptomatic bacteriuria, even if there are no symptoms (urinalysis with reagent test strips).

E. Antenatal care card

Fill an individual card containing information for monitoring the pregnancy (Appendix 1).

1.2.4 Subsequent consultations

A. Interview

– Foetal movement felt by the mother.
– Current problems: pelvic pain, contractions, fever, urinary symptoms, abnormal vaginal discharge, metrorrhagia, etc.

B. Clinical examination

Be careful when examining a woman lying on her back; the weight of the uterus compresses the inferior vena cava, which can cause her to feel faint (easily remedied by placing the patient on her left side).

In all cases:
– Blood pressure, weight, oedema, fundal height.

– Foetal heart tone: should be regular, rapid (120-160/minute), and out of sync with the mother’s pulse.

– Foetal presentation (third trimester):

Palpation:
• Cephalic pole: round, hard and regular; there should be a feeling of ballottement between examiner’s hands; separated from the rest of the body by the indentation of the neck, beyond which the projection of the shoulder can be palpated.
• Pelvic pole: soft; bulkier and less regular than the cephalic pole; no neck indentation.

Types of presentation:
• Cephalic: the cephalic pole points towards the mother’s pelvis.
• Breech: the cephalic pole is in the uterine fundus.
• Transverse: the poles lie in each of the mother’s sides.

– Exploring the foetal back:
Press the uterine fundus downward to bend the foetal spine and explore the lateral surfaces of the uterus. The back is felt as a hard plane, the limbs as small, irregular projections. The back is described with reference to the mother’s right or left.

– In the third trimester, the foetal heart tone is auscultated in the umbilical region along the foetus’ back, at shoulder level.

Only if indicated:
– Genital examination (e.g., if mother complains of abnormal discharge).
– Vaginal examination (e.g., if mother complains of recurring uterine contractions).

Note: the vaginal examination is sometimes used to evaluate the pelvic dimensions in small primiparas. A small pelvis2 is not necessarily predictive for foeto-pelvic disproportion (FPD) and does not justify scheduling a caesarean section. Moreover, FPD can occur with a normal-appearing pelvis. In practice, FPD can only be established during labour.

C. Laboratory tests

Table 1.5 - Recommended screening tests

Tests

Comments

Urinary tract infection

Look for asymptomatic bacteriuria at each consultation.

Malaria

In endemic areas, perform a rapid test at each consultation, unless the woman was tested in the past 4 weeks, the test was positive, and the woman received curative antimalarial treatment as a result.

HIV infection

Offer patients who tested negative during the 1st trimester a new test  in the third trimester. There is increased risk of transmission when seroconversion occurs during pregnancy.

1.2.5 Preventive treatments

Maternal and neonatal tetanus

– Pregnant women not vaccinated against tetanus in childhood or adolescence should receive at least 2 doses of tetanus vaccine (TT) before giving birth:
• the first dose should be administered at the first consultation;
• the second dose should be administered at least 4 weeks after the first dose and ideally at least 2 weeks before the due date to maximize the maternal antibody response and passive antibody transfer to the infant.
– After the birth, continue to a total of 5 doses, according to the schedule below. Once administered, these 5 doses confer lifelong protection.

Table 1.6 - Vaccination schedule for women who are pregnant or of child-bearing age3

Dose

When to give

Level of protection

TT1

At the first contact with medical services
or as early as possible during pregnancy

0%

TT2

At least 4 weeks after TT1
and at least 2 weeks before the delivery due date

80%

TT3

At least 6 months after TT2
or during the next pregnancy

95%

TT4

At least 1 year after TT3
or during another pregnancy

99%

TT5

At least 1 year after TT4
or during another pregnancy

99%

Anaemia

– If there are no clinical signs of anaemia and no abnormal haemoglobin values:

  1. Administer iron and folic acid supplementation, starting as soon as possible after gestation starts and continuing for the rest of the pregnancy. Give either:
    ferrous sulfate/folic acid3  (tablet containing 200 mg of ferrous sulfate, 65 mg of elemental iron + 400 micrograms of folic acid) PO: 1 tablet/day
    or
    multiple micronutrients4  (tablet containing 93.75 mg of ferrous sulfate, equivalent to 30 mg of elemental iron + 400 micrograms of folic acid + other nutrients) PO: 1 tablet/day
    Note: the World Health Organization recommends 30 to 60 mg of elemental iron daily however, a dose of 60 mg of elemental iron daily is preferred over a dose of 30 mg daily in settings where prevalence of anaemia in pregnant women is high (≥ 40%)5 4.

  2. In areas where hookworm is endemic, administer also an antihelminthic treatment as of the second trimester:
    albendazole PO: 400 mg as a single dose (or mebendazole PO: 500 mg as a single dose)

  3. In areas where malaria is endemic, administer also an intermittent preventive antimalarial treatment or an antimalarial curative treatment, depending on the results of malaria screening test (see below).

– If there is clinical evidence of anaemia (pallor of the palms, conjunctivae or tongue) or if haemoglobin is < 11 g/dl: see Chapter 4, Section 4.1.

Malaria

In areas with moderate to high falciparum malaria transmission6 in Africa, prevention consists of:

  1. The use of insecticide-treated mosquito nets (2 bed nets should be provided);

  2. Malaria testing at each antenatal consultation:
    • If the test is negative, as of the second trimester:
    Administer an intermittent preventive treatment with sulfadoxine-pyrimethamine (SP)5. Allow an interval of at least one month between two treatments.
    This treatment helps reduce the effects of malaria (maternal anaemia and low birth weight). The SP dose for each treatment is 3 tablets as a single dose.
    Do not administer intermittent treatment with SP to HIV-infected women receiving cotrimoxazole prophylaxis.

    • If the test is positive, throughout pregnancy:
    Administer curative malaria treatment (Chapter 4, Section 4.3.1).
    Wait one month after curative treatment before screening for malaria again.

Urinary tract infection

Treat asymptomatic bacteriuria to reduce the risk of pyelonephritis6 (Chapter 4, Section 4.2.6).

HIV infection

To prevent mother-to-child transmission, administer antiretroviral therapy to the mother (Chapter 4, Section 4.4.4).

Vitamin and micronutrient deficiencies

– Vitamin K1
For women being treated with an enzyme inductor (e.g. rifampicin, rifabutin; carbamazepine, phenobarbital, phenytoin), administer phytomenadione PO: 10 mg/day in the 15 days preceding the due date.

– Calcium
Supplementation is recommended for7:
• All pregnant adolescents (less than 20 years);
• All pregnant women with low calcium intake AND at high risk of pre-eclampsia (history of pre-eclampsia or eclampsia, twin pregnancy, chronic hypertension).
Start supplementation before 20 weeks LMP and continue throughout the pregnancy:
calcium carbonate PO: one 1.25 g tablet (equivalent to 500 mg of calcium element) 3 times per day (= 1500 mg calcium element daily in 3 divided doses).
Wait two hours between the administration of calcium and ferrous salts.

– Vitamin D
Some national protocols may include vitamin D to prevent neonatal hypocalcaemia:
ergocalciferol (vitamin D2) or colecalciferol (vitamin D3) PO: 100 000 IU as a single dose in the sixth or seventh month of pregnancy.

– Iodine
Iodine deficiency during pregnancy increases the risk of miscarriage, prematurity, severe mental and growth retardation in the child, and neonatal or infant death. In areas where iodine deficiency is endemic, iodine supplementation is necessary. Follow national protocol.

Malnutrition

– Even in absence of signs of malnutrition, food supplementation is recommended:
• For all pregnant women throughout their pregnancy in situations where food is scarce;
• For all pregnant adolescents (less than 20 years).

– If there are clinical signs of malnutrition, place the woman into a therapeutic feeding programme.

Others

The above measures apply to most contexts. Other tests and preventive measures relevant in a specific context or included in the national protocol (e.g. Rhesus factor testing and alloimmunization prophylaxis, screening for cervical cancer) should be taken into account.

1.2.6 Preparation for the birth

Group sessions

Group sessions (10 to 15 women) should be organized to encourage information sharing between patients, promote the use of available services and weigh upon:
– Importance of skilled birth assistance.
– The purpose of antenatal consultations.
– The recommended tests and treatments during pregnancy (screening tests, tetanus vaccination and prevention of mother-to-child HIV transmission, etc.).
– Danger signs during pregnancy and delivery, and the importance of quickly seeking medical care.
– The use of insecticide-treated mosquito nets.
– The use of the “birth kit”7 , depending on the context.
– The purpose of the postnatal consultation.

Individual sessions

Individual sessions are an opportunity to revisit the subjects discussed in the group sessions and offer advice tailored to the individual's medical and social situation.

The choice of topics depends on the stage of pregnancy and the woman’s specific circumstances:
– Birth plan (see below).
– Danger signs during pregnancy and delivery, and the importance of quickly seeking medical care.
– Contraception, especially for grand multiparas and women at high obstetrical risk.

Birth plan

With the patient, work out a personalised plan appropriate to her medical and social situation:
– Preferred site for birth: CEmONC or BEmONC facility, depending on the course of the pregnancy and the history;
– Any necessary arrangements: transportation, family arrangements, etc.

Table 1.7 - Obstetric care facilities

Facility

Minimum package

BEmONC
Basic Emergency Obstetric and Newborn Care

  • Open 24/7
  • Skilled birth attendant(s)
  • Possibility of:
    • parenteral antibiotics
    • uterotonics
    • anticonvulsants if pre-eclampsia or eclampsia
  • Possibility of:
    • manual removal of the placenta
    • uterine evacuation (vacuum aspiration)
    • instrumental delivery (vacuum extraction)
    • basic neonatal resuscitation

CEmONC
Complete Emergency Obstetric and Newborn Care

  • Same as BEmONC facility
    PLUS
  • Possibility of:
    • surgical management (caesarean section, hysterectomy, etc.)
    • blood transfusion



Footnotes
Ref Notes
1 Ultrasound allows accurate estimation of gestational age in the first trimester, with a margin of error of approximately 7 days. The margin of error is larger in the second and third trimesters (about 15 and 20 days, respectively).
2 The pelvis is considered small if the top of the sacrum (promontory) can be reached with the fingers and/or the lateral edges of the pelvis can be felt along their entire length.
3

200 mg ferrous sulfate (65 mg elemental iron) + 400 micrograms folic acid tablets may be replaced by 185 mg ferrous fumarate (60 mg elemental iron) + 400 micrograms folic acid tablets.

4

If using multiple micronutrients, make sure that the amount of iron salts (sulfate or fumarate) is equivalent to 30 mg of elemental iron per tablet and the amount of folic acid is 400 micrograms per tablet (UNU/UNICEF/WHO formulation). For the complete composition of these tablets, see Medical catalogue, MSF.

5

According to the World Health Organization (1993-2005), the  prevalence of anaemia in pregnant women is 57.1% for Africa, 48.2% for South-East Asia, 44.2% for the Eastern Mediterranean region, 30.7% for the Western Pacific region, 25% for the European region and 24.1% for the Americas.

6

“Moderate transmission” areas: zones where prevalence rate of malaria is 11–50% during most of the year among children 2–9 years. “High transmission” areas: zones where prevalence rate of malaria is over 50% during most of the year among children 2–9 years.

7 Individual kit given to women that might deliver at home due to limited travel possibility (remote or insecure situations). It contains a plastic-coated cloth to be spread out on the floor (for cleaning the woman’s genitals and washing the midwife’s hands), a string and a razor blade for tying and cutting the cord and, in some cases, a cloth for drying the infant.