Guideline on

Antenatal Care (ANC)

Maternal Neonatal Child &Adolescent Health (MNC&AH)

Directorate General of Health Services (DGHS)
 Guideline on
Antenatal Care (ANC)

Maternal Neonatal Child &Adolescent Health (MNC&AH)

Directorate General of Health Services (DGHS)

i
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Phone : 49357726, 58313186
E-mail: [email protected]

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 Message

The Government of Bangladesh is committed to ensure health services for every citizen of this country. The
4th sector-wide Health, Population and Nutrition Program 2017-2022 has already started its journey. All
concerned bodies of the Government, NGOs, CBOs, the private sector, and civil society are working
hand-to-hand for ensuring healthcare for all. To strengthen the health system various strategies have been
adopted for the best use of all available resources and restructuring management systems. We have
successfully reached the targets of the Millennium Development Goals (MDGs), which were really challenging
in the context of our limited resources. We have to achieve the targets of Sustainable Development Goals
(SDGs) by 2030 on time.
The practice of having checkups during pregnancy is very low in developing countries compared to
developed countries. In developed countries, majority (97%) of pregnant mothers have access to ANC. In
Bangladesh, there has been an increase in the percentage of women receiving at least 1 ANC, which rose from
51% to 79% during the years 2011 and 2014 but this is still very low compared to developed countries.
Good antenatal care can detect pregnancy complications early and timely intervention helps mothers stay
healthy. Thus provision of regular ANC throughout pregnancy can ensure normalcy to achieve a healthy
pregnancy outcome to both mother and child. It can also contribute to reduce maternal and infant mortality.
According to World Health Organization (WHO), a package often called focused antenatal care – providing
essential evidence based interventions – is a pre requisite to achieve the full life-saving potential that
antenatal care (ANC) promises for women and babies.
I am happy to know that the new Antenatal Care (ANC) guidelines to ensure best health condition for both
mother and baby during pregnancy are being published. As this guideline is the primary tools for health
service providers, we hope they will find this useful.
I would like to take this opportunity to congratulate my colleagues in the Directorate General of Health
Services as well as experts from development Partners, OGSB, members of the Core Committee and reviewers,
who have made their valuable contributions in developing this guideline.
We are grateful to the contribution of OGSB for providing technical and WHO for providing technical and
financial support for development and dissemination of this guideline.

Prof. Dr. Abul Kalam Azad

Director General
Directorate General of Health Services (DGHS)

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 Foreword

Proper care during antenatal period needs innovative, evidence-based approaches for all women. I welcome
this guideline, which aims to put women at the centre of care, enhancing their experience of pregnancy and
ensuring that babies have the best possible start in life.
WHO has released several recommendations to address specific aspects of antenatal care in response to the
need of the country. The focus of the global agenda has gradually expanded beyond the survival of women
and their babies to also ensuring that they thrive and achieve their full potential for health and well-being.
This guideline is a consolidated set of new and existing recommendations on ANC during the whole
pregnancy period that should be provided to all pregnant women during pregnancy irrespective of
socio-economic setting. It will promote a package of pregnancy care and safe childbirth to ensure that giving
birth is not only safe but also a positive experience for women and their families. It highlights how
woman-centred care can optimize the quality of antenatal care through a holistic, human rights-based
approach. By outlining a new model of antenatal, intra partum and postnatal care that is adaptable to
individual country contexts, the guideline enables substantial cost-savings through reduction in unnecessary
interventions during labour and childbirth.
We encourage health care providers to adopt and adapt these recommendations, which provide a sound
foundation for the provision of person-centred, evidence-based and comprehensive care for women and their
newborn babies.

Dr Sultan Md. Shamsuzzaman

Director, DGHS and
Line Director, MNC&AH
Directorate General of Health Services (DGHS)

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 Acknowledgement

Bangladesh is on track to achieve SDG by 2030 though a considerable number of women still die each year
from pregnancy and childbirth related complications. MMR is an indicator of the quality of health care
available during pregnancy, childbirth and in the postpartum period. Maternal mortality is the proverbial tip
of the iceberg as for every maternal death 15 women suffers severe morbidity globally. Of all maternal deaths,
80% can be potentially avoided by interventions during pregnancy, childbirth and postpartum period by
quality obstetric care.
Bangladesh Government is committed to provide wide coverage of antenatal, intra partum & postnatal care.
WHO Bangladesh decided to develop a guideline on ANC and IPC for quality service in the facility and
community level. To develop this guideline help was taken from New WHO ANC Guideline 2016; Pocket book
of Hospital Care for Mothers (WHO; 2017); EMEN guideline, (UNICEF; 2018); EmONC Protocol (UNICEF; 2018)
and standard textbook on ANC.
As this guideline is the primary tools for service providers, we hope they will find this very useful in their
everyday practice. Many experts from GOB, OGSB, Development Partners, group of professionals, members of
the Core Committee and reviewers have made their valuable contributions in developing this ANC guideline.
This up-to-date, comprehensive and consolidated guideline on antenatal care will ensure quality and
evidenced based care irrespective of the setting at all levels of health facilities.
We greatly acknowledge the relentless efforts of the group of professionals who have worked very hard in
preparing this guideline. This is to acknowledge the contribution of all those individuals who have
contributed, helped, assisted, and commented at various stages of developing this guideline.
We appreciate the feedback from large number of national stakeholders meeting during the scoping exercise
that took place as part of the development of this guideline. We are grateful to Directorate General of Health
Services for their support in preparing this guideline.
We are grateful to the contribution of WHO for providing technical and financial support for development and
dissemination of this guideline.

Prof Laila Arjumand Banu Prof Firoza Begum

President Secretary General
OGSB OGSB

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 Abbreviations
AFI Amniotic Fluid Index
ANC Antenatal Care
ARV Antiretro Virus
ASB Asymptomatic Bacteriuria
BMI Body Mass Index
BP Blood Pressure
bpm Beats Per Minute
CTG Cardiotocography
DFMC Daily fetal movement count
DM Diabetes Mellitus
EB Evidence base
EDD Expected Delivery Date
EMEN Every Mother Every Newborn
FANC Focus Antenatal Care
FHR Fetal Heart Rate
FIGO The International Federation of Gynecology and Obstetrics
GDM Gestational Diabetes Mellitus
Hb Haemoglobin
HIV Human Immunodeficiency Virus
IPC Interpersonal communication
IPV Intimate Partner Violence
IUD Intrauterine Device
IUGR Intrauterine Growth Restriction
LMICs Low- and Middle-Income Countries
LMP Last Menstrual Period
MLCC Midwife-Led Continuity of Care
OGSB Obstetrical and Gynaecological Society of Bangladesh
PITC Provider Initiated Testing &Counselling
PLA Participatory Learning and Action
PMR Perinatal Mortality Rate
PROM Premature Rupture of Membranes
PWGs Participatory Women’s Groups
SDG Sustainable Development Goal
SFH Symphysio –fundal Height
STD Sexually Transmitted Disease
TB Tuberculosis
TT Tetanus Toxoid
UHC Upazilla Health Complex
USG Ultrasonogram
UN United Nations
UTI Urinary Tract Infection
VDRL Venereal Disease Research Laboratory
WHO World Health Organization

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 List of Contributors
Not according to the seniority
1. Dr. Sultan Md Shamsuzzaman
Director-DGHS & LD-MNC&AH, DGHS, Mohakhali, Dhaka
2. Dr. Md. Moshair-ul Islam
Program Manager, MH, DGHS, Mohakhali, Dhaka
3. Dr. Md. Abdul Majid
DPM-EOC and Program Manager, BAN-MPS, WHO
4. Dr. Prodip Kumar Saha
Deputy Program Manager, (DSF), MH, MNC&AH, DGHS
5. Dr. Nasima Khatun
Deputy Program Manager, (Monitoring), MH, MNC&AH, DGHS
6. Dr. Noor Riffat Ara
Deputy Program Manager, (CSBA & Midwifery), MH, MNC&AH, DGHS
7. Dr. Mahbuba Khan
TNP-MPS,WHO BAN.
8. Prof. Laila Arjumand Banu
President, OGSB
9. Prof. Firoza Begum
Secretary General, OGSB
10. Prof. Rowshan Ara Begum
Past President, OGSB
11. Prof. Sameena Chowdhury
President Elect-OGSB
12. Prof. Ferdousi Begum
Head, Dept. of Obs & Gynae, BIRDEM MCH
13. Prof. Farhana Dewan
Immediate Past Sec. Gen. OGSB
14. Prof. Ratu Rumana Binte Rahman
OGSB Member
15. Prof. Salma Rouf
Head, Dept. of Obs & Gynae, DMCH
16. Prof. NahreenAkhtar
Prof. of Feto Maternal Medicine, BSMMU
17. Dr. Tabassum Parveen
Assoc. Professor, Fetomaternal Medicine,BSMMU
18. Prof. Shahin Rahman Chowdhury
Head, Dept. Of Obs & Gynae, Holy FRCMC
19. Prof. Kishwar Sultana
Dept. of Obs & Gynae, Holy Family Red Crescent MCH
20. Prof. Sk Zinnat Ara Nasreen
Head, Dept of Obs & Gynae, ZH Sikder MCH
21. Prof. Dipi Barua
Dept. of Obs & Gynae, Holy Family Red Crescent MCH
22. Dr. Alpana Adhikary
Assoc. Prof. of Obs & Gynae, Shaheed Suhrawardy MCH
23. Dr. Fahmida Sharmin Joty
Asstt. Prof. of Obs & Gynae, CARe Medical College

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 Content

1. Introduction 1

2. Maternal Assessment 3

 • WHO recommended Schedule for ANC 4

• FANC Plus model 2016 6
• History Taking 8
• General physical Examination 10
• Abdominal Examination 11

3. Foetal Assessment 14

• Daily foetal movement counting 14

• Symphysio-fundal height (SFH) measurement 14
• Auscultation of FHR 14

4. Investigation 15

5. Management 16

 • Dietary Advice 16
• Nutritional Supplements (drugs) 16
• Preventive measures 17
• Intervention for common physicological symptoms 17
• Antenatal Advice 19
• Antenatal counselling 21

6. Health system intervention to improve the utilization and quality of ANC 27

References 32

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 Introduction
Antenatal Care (ANC) can be defined as the care provided by skilled health-care professionals to women and
adolescent girls during pregnancy in order to ensure the best health conditions for the mother and the baby.
The components of ANC include: risk identification; prevention and management of pregnancy-related or
concurrent diseases; health education and health promotion.
ANC reduces maternal and perinatal morbidity and mortality both directly, through detection and treatment
of pregnancy-related complications, and indirectly, through the identification of women and girls at
increased risk of developing complications during labour and delivery, thus ensuring referral to an
appropriate level of care. The indirect causes of maternal morbidity and mortality, contribute to
approximately 25% of maternal deaths and near-misses. ANC also provides an important opportunity to
prevent and manage concurrent diseases through integrated service delivery.
In low and middle-income countries (LMICs), ANC utilization has increased since the introduction of the WHO
ANC modelin 2002, known as focused ANC (FANC) or basic ANC, which is a goal-orientated approach to
deliver evidence-based interventions carried out at four critical times during pregnancy. However, globally,
during the period 2007–2014, only 64% of pregnant women attended the WHO-recommended minimum
four contacts for ANC, suggesting that much more work needs to be done to address ANC utilization and
quality care.
The World Health Organization (WHO) envisions a world where every pregnant woman and newborn receives
quality care throughout the pregnancy, childbirth and the postnatal period. Within the continuum of
reproductive health care, ANC provides a platform for important health-care functions, including health
promotion, screening and diagnosis, and disease prevention. It has been established that by implementing
timely and appropriate evidence-based practices, ANC can save lives. Crucially, ANC also provides the
opportunity to communicate with and support women, families and communities at a critical time in the
course of a woman’s life. The process of developing these recommendations on ANC has highlighted the
importance of providing effective communication about physiological, biomedical, behavioural and
socio-cultural issues, and effective support, including social, cultural, emotional and psychological support, to
pregnant women in a respectful way. These communication and support functions of ANC are the key, not
only to saving lives, but to improving lives, health-care utilization and quality of care. Women’s positive
experiences during ANC and childbirth can create the foundations for healthy motherhood.
Women want a positive pregnancy experience from ANC. A positive pregnancy experience is defined as
maintaining physical and socio-cultural normality, maintaining a healthy pregnancy for mother and baby
(including preventing or treating risks, illness and death), having an effective transition to positive labour and
birth, and achieving positive motherhood (including maternal self-esteem, competence and autonomy).
The emotional, psychological and social needs of adolescent girls and vulnerable groups (including women
with disabilities, women with mental health concerns, women living with HIV, sex workers, displaced and
war-affected women, ethnic and racial minorities, among others) can be greater than for other women.
Therefore, the aim of this guideline is to provide a clear, evidence-based framework for ANC practices that
empowers all pregnant women and adolescent girls to access the type of person-centered care that they
want and need, in accordance with a human rights-based approach. This ANC guideline is part of the ongoing
work of WHO in developing evidence-based guidelines to improve quality of care for mothers and their
babies throughout the antenatal, intrapartum and postnatal continuum.

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The WHO guideline development group, emphasizing the evidence indicating increased foetal deaths and
lesser satisfaction of women with the four-visit model (also known as focused or basic ANC), decided to
increase the recommended number of contacts between the mother and the health-care providers at time
points that may facilitate assessment of well-being and provision of interventions to improve outcomes if
problems are identified.
The WHO guideline development group made 39 recommendations related to five types of interventions: A.
Nutritional interventions, B. Maternal and foetal assessment, C. Preventive measures, D. Interventions for
common physiological symptoms, and E. Health system interventions to improve utilization and quality of
ANC.Interventions were either recommended, not recommended, or recommended under certain conditions
based on the GDG’s judgements according to the DECIDE criteria(Developing & Evaluating Communication
strategies to support Informed Decisions & Practice based on Evidence), which informed both the direction
and context, if any, of the recommendation.

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 Maternal Assessment
Antenatal Care
Antenatal care (ANC) can be defined as the care provided by skilled health-care professionals to pregnant
women and adolescent girls in order to ensure the best health conditions for both mother and baby during
pregnancy. ANC reduces maternal and perinatal morbidity and mortality both directly, through detection
and treatment of pregnancy-related complications, and indirectly, through the identification of women and
girls at increased risk of developing complications during labour and delivery, thus ensuring referral to an
appropriate level of care. ANC also provides an important opportunity to prevent and manage concurrent
diseases through integrated service delivery.
ANC schedule
Generally, antenatal checkup is done at interval of 4 weeks up to 28 weeks; at interval of 2 weeks up to 36
weeks and thereafter weekly till delivery. Ideally, this should be more flexible depending on the need and the
convenience of patient. In the developing countries, as per WHO recommendation, the visit may be curtailed
to at least 4; first visit in first trimester around 8 - 12 weeks, second between 24 and 26 weeks,the third visit at
32 weeks and the fourth visit at 36 – 38 weeks.
In focused antenatal care plus (FANC Plus) model all pregnant women should have a minimum of eight ANC
visits. These visits should be goal-orientated, with the first visit scheduled to take place before 12 weeks’
gestation, and subsequent visits taking place at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation. The
principle of FANC Plus is to provide an ANC delivery system that enables a positive experience and may
facilitate identification of medical problems and may reduce the risk of stillbirths as well.

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WHO recommended Schedule for ANC

WHO FANC model FANC Plus model 2016

First trimester
Visit 1: 8–12 weeks Contact 1: before12 weeks
Second trimester
Visit 2: 24–26 weeks Contact 2: 20 weeks
Contact 3: 26 weeks
Third trimester
Visit 3: 32 weeks Contact 4: 30 weeks
Visit 4: 36–38 weeks Contact 5: 34 weeks
Contact 6: 36 weeks
Contact 7: 38 weeks
Contact 8: 40 weeks
Return for delivery at 41 weeks if not given birth.

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 WHO FANC model Task during each visit (Registration of pregnant woman, if had/has not any problem or not yet registered)

1st visit 2nd visit 3rd visit 4th visit

History taking Menstrual history - Assess significant symptoms. Check - Assess significant symptoms. Check - Assess significant symptoms.
- LMP and EDD Calculation record for previous complications record for previous complications Check record for previous
- Past Obstetric history (if any) and treatments during the and treatments during the complications and treatments
- Family history pregnancy. pregnancy. during the pregnancy.
- Medical history - Re- categorize (if needed) - Re-categorize (if needed) - Re- categorize (if needed)
- History of TT immunization

- Blood Pressure, Pulse, weight

Physical - Blood Pressure, Pulse, weight, height, - Blood Pressure, Pulse, weight - Blood Pressure, Pulse, weight - Anaemia, Jaundice,Oedema
examination BMI - Anaemia, Jaundice, Oedema - Anaemia, Jaundice, Oedema - Obstetrical examination
- Anaemia,, jaundice, Oedema - Obstetrical examination - Obstetrical examination
- Obstetrical examination - Hb%
- Urine test for albumin
- Blood sugar (if indicated)
Investigation - CBC( If not available Hb%) - Hb% - Hb% - USG –to see fetal growth,
- ABO & Rh grouping - Urine for albumin - Urine for albumin placental localization & AFI
- VDRL - Blood sugar - Blood sugar F & 2 hrs after 75 gm
- Glucose-F & 2 hrs after 75 gm glucose - USG (Anomaly scan) glucose
- HbsAg
5

- Urine RME
- USG- to see gestational age and number
of pregnancy & fetal anomaly (if
available)

- Folic acid
Treatment - Treatment of minor illness during - Iron and folate
pregnancy - Calcium
- Anti-emetics (If needed) - Treat all problems in pregnancy as
per availability of competent
providers and comprehensive
facilities. - Reinforcement of previous
- Refer women for treatment of any counselling (3rd visit)
complications, as needed
- Importance of routine check up
Advice & - Take rest, avoid heavy work & Safer sex - Reinforcement of previous - Reinforcement of previous
counseling - Stop smoking, Tobacco, gul, shadapata counselling (1st visit) counselling (2nd visit)
etc. - Pregnancy, delivery &postpartum - Counselling on essential newborn
- Pregnancy, delivery and postpartum danger signs care, postnatal care, early initiation of
danger signs breast feeding and postpartum
- Birth planning and emergency family planning and birth spacing
preparedness - Counseling on Misoprostol
- Nutrition and Home care
 FANC Plus model 2016

History taking Physical Examination Investigation 4th visit

1st visitbefore 12 - Menstrual history - Blood Pressure, Pulse, - CBC (If not available Hb%) - Iron, Calcium, Folic acid from 12 mg in
weeks - LMP and EDD Calculation weight, height,BMI - ABO & Rh grouping week supplementation
- Past Obstetric history(if any) - Anaemia, Jaundice, - VDRL - asymptomaticbacteriuria (ASB), syphilis
- Family history Oedema - 2 hrs after 75gm Glucose and severe anaemia(if needed)
- Medical history - HbsAg
- History of TT immunization - USG- to see gestational age and Advice &Counselling
- Ask about risk factors and number of pregnancy & fetal - Importance of routine check up
refer women needing anomaly (if available) - Take rest, avoid heavy work & Safer sex
additional ANC - Test for HIV & tuberculosis (if - Stop smoking, Tobacco, gul, shadapata
necessary) etc.
- Pregnancy, delivery and postpartum
danger signs
- Birth planning and emergency
preparedness
- Nutrition and Home care
- Ask about maternal
symptoms - Iron Folic acid&calcium supplementation
6

- Check and discuss results of - asymptomaticbateriuria (ASB), syphilis

2nd visit at tests not dealt with in the - Blood Pressure, Pulse, - urine R/M/E (ASB, protein, and severe anaemia(if present treat)
20 weeks previous visits weight, glucose) - tetanus toxoid vaccination if indicated
- Refer women needing - Anaemia, Jaundice, - USG to exclude congenital - Advice &counselling as before
additional care Oedema anomalies and multiple
- Obstetrical examination pregnancy
- SFH measurement

- Iron, Folic acid &calcium supplementation

- Ask about maternal - asymptomaticbacteriuria (ASB), syphilis
symptoms and symptoms and severe anaemia (if present treat)
related to pre-eclampsia, - tetanus toxoid vaccination if indicated
and fetalmovements - Advice &counseling as before
3rd visit at - Check and discuss results of - Blood Pressure, Pulse, - Hb% - Refer women needing additional care
26th weeks tests weight, - Urine test for albumin,sugar,
- Anaemia, Jaundice, - ASB
Oedema - Perform ultrasound if not done
- Obstetrical examination earlier
- SFH measurement
 FANC Plus model 2016 (cont’d)

History taking Physical Examination Investigation 4th visit

4th visit at - Ask about maternal - Blood Pressure, Pulse, - Urine R/M/E (ASB, protein, - continue Iron, Folic acid& calcium
30th weeks symptoms and symptoms weight, glucose) supplementation
related to pre-eclampsia, - Anaemia, Jaundice, - Discussbirth preparedness and review
and fetalmovements Oedema emergency plan
- Check and discuss results of - Obstetrical examination - Treat all problems in pregnancy as per
blood tests with further test - SFH measurement availability of competent providers and
or treatment if appropriate - abdominal palpation comprehensive facilities.
- Refer women needing additional care

- Ask about maternal - continue Iron, Folic acid& calcium

5th visit at symptoms, symptoms - General exam- - Urine R/M/E (ASB, protein, supplementation
34th weeks related to pre-eclampsia, Blood Pressure, glucose) - Refer women needing additional care
and decreased fetal - SFH measurement USG to see foetal growth,
movements - abdominal palpation placental localization & AFI

- Ask about maternal - continue Iron, Folic acid& calcium

6th visit at symptoms, symptoms General exam- - Urine R/M/E (ASB, protein, supplementation
36th weeks related to pre-eclampsia, Blood Pressure, glucose) - Offer treatment for ASB if indicated
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and decreased fetal - SFH measurement - Review and modify birth and emergency
movements - Abdominal palpation plan
- Check fetal presentation and - Give individualized advice and support
refer for ECV if breech - Refer women needing additional care

- Ask about maternal - Continue Iron, Folic acid & calcium

7th visit at symptoms, symptoms General exam- - Urine R/M/E (ASB, protein, supplementation
38th weeks related to pre-eclampsia, Blood Pressure, glucose) - Offer treatment for ASB if indicated
and decreased fetal - SFH measurement - Review and modify birth and emergency plan
movements - Abdominal palpation - Give individualized advice and support
- Check fetal presentation - Refer women needing additional care
and refer if breech
- Ask about maternal continue Iron, Folic acid& calcium
8th visit at symptoms, symptoms General exam- - Urine R/M/E (ASB, protein, supplementation
40th weeks related to pre-eclampsia, Blood Pressure, glucose) - Offer treatment for ASB if indicated
and decreased fetal - SFH measurement - Review and modify birth and emergency
movements - Abdominal palpation plan
- Check fetal presentation - Give individualized advice and support
and refer if breech - Refer women needing additional care

If undelivered, return for delivery at 41 weeks’ gestation.

 Remember

- No other drug will be given before 12 weeks except strongly indicated

- Tetanus toxoid 2 doses (If 5 doses completed ,then not required)
- Anti helmenthics after 3 months of pregnancy
- Intermittent preventive treatment for malaria during pregnancy ( IPTP) (In Malaria endemic area)
- Provision of ARVs to HIV positive women in some settings

HISTORY TAKING
The provider receives and treats the pregnant woman and her husband or companion cordially and
respectfully for antenatal contact.Accurate history taking helps to assess the pregnant woman’s health status,
progress of her pregnancy, any factors which might place her or the foetus at risk and to plan and counsel with
the women and her family for a healthy pregnancy, safe delivery and steady postpartum recovery. In order to
do this successfully, providers’ primary task is to establish a good rapport with the pregnant woman, greet her
and talk to her cordially.
During the first visit, a complete history should be taken.
Personal information
• Name Husband’s /Father’s name
• Age-A woman having her first pregnancy at the age of 30 or above (FIGO – 35 years) is called elderly
primigravida. Pregnancy at extremes of age (teenage and elderly) is at risk.
• Address
• Mobile Number

Current Pregnancy
• Duration of pregnancy
• First day of last period and calculation of EDD(9 calendar months and 7 days from LMP)
• Nausea and vomiting
• Problems in current pregnancy
• Vaginal Discharge
• Vaginal Bleeding

LMP means the 1st day of last menstrual period

EDD is calculated by counting 9 months 7 days from the 1st day of LMP in woman with regular
menstruation cycle.
Example: 1st day of LMP = 15th January 2018
EDD = (15th January 2018+9 calendar months+ 7 days)
= 22nd October 2018

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Previous pregnancies (Number and detail of previous pregnancies)
• Number of previous deliveries with live births and stillbirths.
• Labour at term/preterm labour
• Previous caesarean/forceps/vacuum delivery
• Number of living children and birth weight(<2.5kg or> 4 kg)
• Number of miscarriages or abortion
• Presence of hypertension, bleeding, any complications in previous pregnancies
Medical/Surgical History
• Hypertension,Diabetes mellitus (DM)
• Heart disease, Liver diseases, Kidney diseases, Thyroid problem & Autoimmune disease e.g. SLE
• Infectious disease-Tuberculosis (TB),Sexually transmitted diseases(STD), HIV
• History of surgery, trauma/accidents
• Thalassemia/other haematological disorders
• Asthma,allergies and epilepsy
• H/O renal/liver transplant
• Others

Socioeconomic History
• Occupation and daily activities
• Education
• Smoking, exposure to passive smoking, use of drugs and alcohol
• Clinical enquiry about the possibility of intimate partner violence
Family History
• Hypertension
• Diabetes
• Renal disease
• Tuberculosis
• Thalassemia
• Twin Pregnancy
• Congenital malformations
• Any genetic disorder
• Others
Contraceptive History
Previous or recent history of contraception
before pregnancy

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 GENERAL PHYSICAL EXAMINATION
• Vital signs
o Blood pressure
o Body temperature
o Pulse rate
o Respiratory rate
• Body weight
• Height
• BMI
• Anaemia
• Jaundice
• Oedema
• Thyroid
• Heart
• Lung
• Breast (for lumps)
Anaemia
It must be observed at day light. Anaemia can be seen in the following sites.
• Lower palpebral conjunctiva
• Dorsum of the tongue
• Buccal mucous membrane
• Nail bed
• Palm of the hand
• Sole of the foot
Pulse
• Assist patient to a comfortable & relaxed position
• Wait 5 minutes if patient was active
• Do not use your thumb as it has a pulse, which can be mistaken for a patient’s pulse.
• Place fingertips of first 2 or middle 3 fingers over the radial pulse area: Thumb side of patient’s forearm at
the wrist
• Lightly press your fingertips on the pulse area
• Begin to count rate when pulse is felt regularly
• Count for 60 sec
Blood Pressure
• The sitting position is acceptable for blood pressure measurement
• Choosing the proper BP cuff size
• Placing the BP cuff on the patient's right arm
• Remove all tight clothes from around the arm. Tight clothes may partially block the artery and give a
falsely low reading.
• Wrap cuff firmly around upper right arm. The cuff must be at least 2-3 cm/ 1 inch above the elbow.
• Make sure your patient is relaxed and comfortable.
• Positioning of the stethoscope over the brachial pulse.
• Listening for the Systolic and Diastolic reading
• Record the findings

10
Oedema
By pressing the thumb over the distal end of Tibia, just above the medial malleolus for 30 seconds & keep the
record.

Weight (Kg)
• Scales which is locally supplied.
• Shoes and excess clothing should be removed.
ABDOMINAL EXAMINATION
Inspection
• Describe the abdominal enlargement (pyriform)
• Previous operative(Caesarean)scars
• Striaegravidarum or stretch marks
• Linea niagra- a dark vertical line appearing on the abdomen from the pubis to above the umbilicus
Palpation
• Symphysio-fundal height
• Foetal poles
• Foetal lie
• Presentation- cephalic (head), breech, etc.
• Level of engagement of presenting part (Rule of 5)
• Liquor volume
• Foetal movements

Fundal height
Uterine fundal height can be measured by palpation

Gestational Uterine fundal height

age by palpation
12 weeks Palpable just above the pubic symphysis
16 weeks In between the pubic symphysis
and umbilicus
20 weeks Lower border of umbilicus
24 weeks Upper border of the umbilicus
28 weeks Lower one third of the distance between
the umbilicus and xiphisternum
32 weeks Two third of the distance between
the umbilicus and xiphisternum
36 weeks At the level of Xiphisternum

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Symphysio-fundal height
Symphysio fundal height measured by tape.After 24 weeks, the SFH measured in cm usually corresponds to
gestational age.

Symphysio-fundal height
• Palpate down from xiphi-sternum to determine
the highest part of the uterus (fundus), may not
always be in the midline.
• A measuring tape turned upside-down is then
placed from the mid-point on the uppermost
border of the symphysis pubis over the curve of
the uterus to the highest point of the fundus of
uterus.
• The tape is then turned and actual measurement in
cm is recorded.

Abdominal girth- measured at the level of umbilicus

Abdominal grip
Abdominal palpation using Leopold’s manoeuvres I-IV or grips as shown below to assess fetalpresentation
from 28 weeks/ third visit onwards

The fundal grip

Both hands placed over the fundus and the
contents of the fundus are determined, if there is-
- A hard smooth, round pole - foetal head, or
- A softer triangular pole continuous with the
foetal body - foetal buttocks (breech).
The lateral grip
Fix your left hand on the patient’s right side
A B
and feel the foetal part of the left side with your
right hand. Repeat on the opposite side.
1st Pelvic grip
This examination is done facing the patient feet. 4
fingers of both hands are placed over the lower
pole of uterus parallel to the inguinal ligament to
feel the presenting part.
2nd Pelvic grip
This examination is done facing the patient.
The thumb and middle fingers of the right hand are
placed wide apart over the supra pubic area to
C D
determine the presenting part is engaged or not.

Obstetric grips:
(A) Fundal grip, (B) Lateral grip
(C) 1st pelvic grip, (D) 2ndPelvic grip

12
 Auscultation

Auscultation of the foetal heart

• Auscultated with a stethoscope
• Best place to listen is over the foetal back, closer to the cephalic pole.
• The normal foetal heart rate is between 110 -180 bpm. But for Bangladesh country context rate
taken as120 - 160 bpm( for early referral )

INVESTIGATIONS
Perform routine laboratory tests for all women on the first visit:
• Complete blood count(CBC) ,if it is not available then onlyHb%
• Blood for Grouping & Rh typing
• Midstream Urine for R/M/E in each visit for albumin, sugar. (Culture to detect asymptomatic bacteriuria at
16 & 24-28 weeks & further if indicated)
• Blood for Fasting & 2 hours after 75 g - oral glucose tolerance test – at booking & subsequently between
24-28 weeks and further if indicated
• Screening for syphilis and Hepatitis B virus ( VDRL & HbsAg)
• USG- at booking, at 22-24 weeks & subsequently if indicated
Additional consideration-1
• In High prevalence area Provider Initiated Testing and Counseling (PITC) for HIV should be considered
• In tuberculosis prevalence area(100/100000 population or higher) ,systematic screening for active
disease should be considered.
• Thyroid Stimulating hormone and Thalassemia screening (if available ,if not available high suspect refer
cases)

Additional consideration-2

Auscultation of the foetal heart

• Hyperglycaemia first detected at any time during pregnancy should be classified as either
gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to WHO criteria.
It has been adapted and integrated from the 2013 WHO recommendation, which states that GDM should be
diagnosed at any time in pregnancy if one or more of the following criteria are met:
• fasting plasma glucose 5.1–6.9 mmol/L (92–125 mg/dL)
• 2-hour plasma glucose 8.5–11.0 mmol/L (153–199 mg/dL) following a 75 g oral glucose load
Diabetes mellitus in pregnancy should be diagnosed if one or more of the following criteria are met:
• Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL)
• 2-hour plasma glucose ≥11.1mmol/L (200 mg/dL) following a 75 g oral glucose load
• Random plasma glucose ≥11.1mmol/L (200 mg/dL) in the presence of diabetes symptoms.

13
 Fetal Assessment

Perform
Assessment of fetal growth and well-being is an important part of ANC.Early detection of fetal compromise
could lead to timely interventions to reduce poor perinatal outcomes. Followings are important tools to
assess fetal growth and well-being.

DAILY FOETAL MOVEMENT COUNTING

Maternal perception of fetal movements is important tool of fetal assessment. Reduced fetal movements are
associated with poor perinatal outcomes, including fetal death.
Daily fetal movement counting, using kick charts, is a way of screening for fetal well-being.

Additional consideration-2

‘Cardifcount 10’ formula:

The mother counts fetal movements starting at 9 am. The counting comes to an end as soon as 10
movements are perceived.
She is instructed to report the physician if—
(i) less than 10 movements occur during 12 hours on 2 successive days or
(ii) no movement is perceived even after 12 hours in a single day.
Daily fetal movement count (DFMC)
Three counts in one hour duration (morning, noon and evening) are recommended. The total counts
multiplied by four gives daily (12 hour) fetal movement count (DFMC).
If there is diminution of the number of ‘kicks’ to less than 10 in 12 hours (or less than
3 in each hour), it indicates fetal compromise.

SYMPHYSIO-FUNDAL HEIGHT (SFH) MEASUREMENT

SFH measurement is a commonly-practiced method of fetal growth assessment that uses a tape measure to
measure the SFH, from 24 weeks of gestation(with an allowance of a 2-cm difference either way). It has the
potential to detect intrauterine growth restriction (IUGR),multiple pregnancy, macrosomia, polyhydramnios
and oligohydramnios.

AUSCULTATION OF FHR
Range: 120-160 bpm and regular

14
 Investigations

1. Ultrasound Scan
Routine ultrasound scan is advisable at booking (1st visit)and at 22-24weeks and subsequently if
indicated in order to detect-
(i) Booking USG
• Estimate gestational age
• Number of pregnancy
(ii) Anomaly scan (22-24 weeks)
• To detect fetal anomalies
• Placental localization (if needed follow up USG)
(iii) Late ultrasound scan to pregnant women who have not had an early ultrasound scan, for the
purposes of identifying -
• The number of fetuses
• Presentation
• Placental location
• Fetal growth
• AFI
2. Cardiotocography(CTG)
May be done if and when required (after 32 weeks) provided the facility is available
3. Doppler USG
If indicated and must be done by experts where facilities are available

15
 Management

It includes-
1. Dietary advice
2. Nutritional intervention
3. Preventive measures
4. Interventions for common physiological symptoms
5. Antenatal advice
6. Antenatal counselling

Notes:

• The patient is advised to attend for antenatal check-up positively on schedule date of visit.
• She is instructed to report to the physician even at an early date if some unwanted symptoms
arise.
• She is advised to come to the hospital for admission if painful uterine contractions at interval of
about 10 min or earlier, sudden gush of watery fluid per vagina & active vaginal bleeding.

DIETARY ADVICE
• A healthy diet containing adequate energy, protein,vitamins and minerals obtained through the
consumption a variety of foods, green and coloured vegetables, meat , fish, beans,nuts,whole grains and
fruits
• Take balanced diet with adequate food to meet the calorie requirement of extra demand of mother and
baby during pregnancy and lactation.
• Women with normal BMI should eat adequately so as to gain the optimum weight (11kg). Overweight
(BMI 27-29) mothers should limit weight to 7 kg and obese woman (BMI>29) should gain less weight.
• Take three major meals and two additional meals every day. The mother should take at least one fistful of
rice & pulse in addition to her pre pregnancy meals.
• Take food from major three food groups (protein, carbohydrate, fat) and food containing enough
vitamins and minerals (vegetables and raw fresh fruits) every day.
• Take adequate amount of water (8-12 glasses, depending on temperature and the weather).
• Take iodized salt.
• Take iron (green leafy vegetables, animal liver, egg) and vitamin C (lemon, tomato, amla) rich food

NUTRITIONAL SUPPLEMENTATION (DRUGS)

• Daily oral Iron and Folic acid supplementation with 60 mg elemental iron from 12 weeks onward and
400microgram folic acid in 1st trimester is recommended for pregnant woman to prevent anaemia,
puerperal sepsis, low birth weight and preterm birth.
• Daily calcium supplementation(1.5- 2 gm oral elemental calcium) after 1st trimester is recommended for

16
 pregnant mother to reduce the risk of preeclampsia.
• As most of the pregnant mother is Vit. D deficient, so Calcium along with Vit. D is recommended for
pregnant women.

Foot Note:
Vitamin A, Zinc, multiple micronutrients ( other than iron, folic acid, Calcium &Vit D ) are not
recommended for pregnant woman to improve maternal and perinatal outcome

PREVENTIVE MEASURES
• At upazila and above level, asymptomatic bacteriuria is managed following urine R/M/E &/or C/S and
appropriate antibiotics are given for 7 days to prevent preterm labour.
• Regarding immunization, live attenuated virus vaccines (Rubella,Measles, Mumps,Varicella, yellow fever)
are contraindicated in pregnancy period.
• Rabies, Hepatitis A and B vaccines, tetanus, toxoids can be given during pregnancy.
• Tetanus: During pregnancy this vaccine is given to the mother to prevent maternal and neonatal
tetanus. In first pregnancy two doses are required. First dose of tetanus is to be given between 20 -32
weeks and second dose is to be given 4 weeks after the 1st dose (2nd dose should be given at least 4
weeks before delivery).
• If any pregnant mother has completed the 5 doses before pregnancy she doesn't need any TT
immunization. If she has taken 2 injection of TT in school or previous pregnancy (within 3 years) - she has
to take only one injection during her current pregnancy.
• Single dose of antihelminthic (Tab.Albendazole) can be given after 1st trimester (12weeks)
• WHO recommends a package of interventions for preventing and controlling malaria including use of
insecticide- treated nets, appropriate case management with prompt & effective treatment.

INTERVENTIONS FOR COMMON PHYSIOLOGICAL SYMPTOMS

Problem Management
Nausea and vomiting • Assurance
Most pregnant women experience • Advice to take dry toast or biscuit before rising from bed, avoid
nausea and vomiting especially in fatty or fried food, to take small frequent feed along with 3
early morning and getting out of main meals.
bed between 4th-14th weeks.
• If these measures fail, anti-emetics (selective) can help.
• If severe, to be referred to secondary hospitals
Tiredness • Advice for adequate rest (at least 2 hrs at day time and 8 hrs at
It is a symptom of early night)
pregnancy but could also be a • Avoidance of strenuous work
sign of anaemia in later
• Take nutritious food
pregnancy.

17
Problem Management
Heartburn( hyper acidity) • Take frequent small feed
It is also a common problem of • Avoidance of fatty, spicy food
pregnancy.
• Avoidance of smoking, Tobacco, gul, shadapata etc
• Using high pillow to sleep may help.
• If these measures fail, antacid preparations can help.

Constipation • Advice to take plenty of fluid and vegetables, warm milk, husks
Constipation is quite common • If these measures fail, Milk of magnesia (laxative) can help.
during pregnancy.
• Take vegetable and fruit
• Advice oral calcium therapy and vitamin B complex(1 tab twice
Leg Cramps(Pain in leg) daily)
It is usually due to deficiency of
calcium. • Improvement of posture (erect, not to bend)
• Avoid lifting heavy weight, adequate rest with elevation of the
Backache legs and flex the hips may help.
Varying degree of backache may • If these measures fail, an occasional dose of Paracetamol is
appear for the first time during helpful.
pregnancy usually in the later
months. • Adequate rest
• Avoidance of prolonged standing/sitting
Varicose vein (Swelling of • Putting the legs up
leg veins ) • Elastic crape bandage is often advised. These usually disappear
Swelling of vein of legs may after delivery.
appear or aggravate during
pregnancy usually in later
months. • No treatment is required if it is physiological oedema.
• Oedema subsides on rest with slight elevation of limbs.
Leg oedema (Ankle swelling) • Diuretics should not be prescribed.
Excessive fluid retention as
evidenced by marked gain in
weight (pre-eclampsia has to be
excluded in women with ankle
edema associated with high
blood pressure). In case of UTI
• Advise to drink plenty of water
Frequency of micturition • Treat with Cap. Amoxicillin 500 mg 8 hourly for 5-10 days
During early and late pregnancy • If symptoms persists refer to appropriate facilities to examine
frequent micturition is normal. But the routine microscopic & culture examination of urine
if it appears between 12-36
weeks it may be a feature of
urinary tract infection.

18
 Problem Management
Anal piles (Hemorrhoids) • Advice to take plenty of fluid and vegetables, warm milk, husks
Anal piles or Hemorrhoids may etc.
cause annoying complications • Sometime need use of laxative to keep the bowel soft and
like bleeding and pain and may helpful to avoid haemorrhoids.
get prolapsed during pregnancy
• Never use enema.

Vaginal discharge
Normal vaginal discharge is • Assurance and personal cleanliness is usually necessary.
usually increased during • If there is infection, itching, pain in lower abdomen, pus or
pregnancy. bloody discharge, refer these cases to secondary facilities.

ANTENATAL ADVICE

• She should take adequate rest (2 hours in day time and 8 hours at night). She should avoid heavy physical
activity and lifting heavy objects.
• Regular exercise (30 min/day) of low impact and as a part of daily activities.
• The patient should take daily bath & pass urine frequently to avoid urine infection.
• She should take plenty of fluid and green vegetables for bowel clearance. Constipation should be
avoided.
• The patient should wear loose but comfortable garments. High heel shoes should be avoided.
• Good dental and oral hygiene should be maintained.
• Extraction or filling of the caries tooth, if required, can be done in the second trimester.
• A well-fitting brassiere can give relief of breast engorgement during late pregnancy.
• Generally, coitus is not restricted during pregnancy. Women with increased risk of miscarriage or preterm
labour should avoid coitus if she feels tightness of uterus.
• Travel by vehicles having jerks is better to be avoided, especially in first trimester and the last 6 weeks.
• The long journey is preferably to be limited to the second trimester.
• Rail route is preferable to bus route.
• Travel in pressurized aircraft is safe up to 36 weeks.
• Smoking & exposure to second hand smoke should be avoided. Heavy smokers have smaller babies and
there is also more chance of abortion and abruptio placentae in late pregnancy.
• Lowering caffeine intake during pregnancy is recommended to decrease the risk of pregnancy loss and
low birth weight.
• Birth planning is required to facilitate safe delivery and to avoid unnecessary delay in referring the
patient in case of a complication during labour.

19
Birth Planning:

Issue Option

Where will you deliver? Hospital/Home

Who will conduct your delivery? Trained/untrained birth attendant

Where will you go if there is any UHC/DH/MCWC/Medical College Hospital/Private

complication during pregnancy/ Clinic/NGO Clinic
delivery/after delivery?

What type & transport will you Ambulance/Rickshaw/Van Board/ Bullock

use in case of emergency to cart/boat/Train
reach the hospital?

Have you saved some money to Saving small amount of money throughout pregnancy is
bear the expenses of emergency good enough for meeting the expenses of delivery.
if needed?

• Birth spacing at least 2 years.

Trimester Specific Counselling:
Discuss importance of good Nutrition, Adequate weight gain, Iron , Folic Acid. Tablet Calcium, Regular ANC,TT,
Rest and Exercise
First Trimester
• Discuss pregnancy date and EDD
• Discuss first trimester changes and minor problems
• Discuss need to avoid alcohol, drugs, cigarettes shada pata and jorda
• Environmental dangers -arsenic well water, lead poisoning from gasoline substances and unsafe foods
• STD/HIV counseling for prevention and early treatment

20
• Educate about danger signs.
• Do birth planning
• Concept of Family Planning

Second Trimester
• Review second trimester changes
• Review nutritional history
• Repeat the danger signs of pregnancy
• Failure to gain weight < 1kg/month (after the first trimester)-refer
• Describe the importance and components of birth planning
• Concept of Family Planning
Third Trimester
• Finalizing Birth Planning
• Discuss normal third trimester changes
• Explain normal signs of true and false labour
• Explain danger signs of labour
• Explain safe delivery
• Explain importance of Postnatal Visit
• Postnatal danger signs
• Importance of Family Planning
• Explain colostrum and exclusive breastfeeding

ANTENATAL COUNSELLING

Family planning counselling during Antenatal care

• Family planning counselling during pregnancy should start from the beginning of the ANC but more
emphasis should be given in the third trimester of pregnancy.
• Birth spacing at least 2 years.
• Information on when to start a method after delivery will vary depending whether a woman is breast
feeding or not.
• Postpartum family planning is an important issue.
• If the woman chooses female sterilization; can be performed immediately postpartum after vaginal
delivery if no sign of infection (ideally within 7 days, or delay for 6 weeks).
• If the woman chooses an intrauterine device (IUD), implanon; can be inserted immediately postpartum if
no sign of infection (up to 48 hours, or delay 4 weeks)

General Advice
• The patient should be persuaded to attend for antenatal check-up positively on schedule date of visit.
• She is instructed to report to the physician even at an early date if some unwanted symptoms arise
• She is advised to come to hospital for admission in the following circumstances:
p Painful uterine contractions at interval of about 10 min. or earlier
p Sudden gush of watery fluid per vagina
p Active vaginal bleeding

21
 WHO Recommendations 2016

A. Nutritional intervention

Type of
Care option Recommendation
Recommendation

Dietary A 1.1: Counseling about healthy eating and keeping Recommended

interventions physically active during pregnancy is recommended for
pregnant women to stay healthy and to prevent excessive
weight gain during pregnancy.
A 1.2: In undernourished populations, nutrition education on Context-specific
increasing daily energy and protein intake is recommended recommendation
for pregnant women to reduce the risk of low-birth-weight
neonates.
A 1.3: In undernourished populations, balanced energy and Context-specific
protein dietary supplementation is recommended for recommendation
pregnant women to reduce the risk of stillbirths and
small-for-gestational-age neonates
A 1.4: In undernourished populations, high-protein Not recommended
supplementation is not recommended for pregnant women
to improve maternal and perinatal outcomes

Iron and folic A 2.1: Daily oral iron and folic acid supplementation with 30 Recommended
acid mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic
supplements acidis recommended for pregnant women to prevent
maternal anaemia, puerperal sepsis, low birth weight, and
preterm birth.
A 2.2: Intermittent oral iron and folic acid supplementation Context-specific
with 120 mg of elemental iron and 2800 µg (2.8 mg) of folic recommendation
acid once weekly is recommended for pregnant women to
improve maternal and neonatal outcomes if daily iron is not
acceptable due to side-effects, and in populations with an
anaemia prevalence among pregnant women of less than
20%.
A 3: In populations with low dietary calcium intake, daily
Calcium calcium supplementation (1.5–2.0 g oral elemental calcium) is Context-specific
supplements recommended for pregnant women to reduce the risk of recommendation
pre-eclampsia.
A 4: Vitamin A supplementation is only recommended for
Vitamin A pregnant women in areas where vitamin A deficiency is a severe Context-specific
supplements public health problem,to prevent night blindness. recommendation
A 5: Zinc supplementation for pregnant women is only
Zinc recommended in the context of rigorous research. Context-specific
supplements recommendation
(research)

22
 Type of
Care option Recommendation
Recommendation

Multiple A 6: Multiple micronutrient supplementation is not Not recommended

micronutrient recommended for pregnant women to improve maternal and
supplements perinatal outcomes.
Vitamin B6 A 7: Vitamin B6 (pyridoxine) supplementation is not Not recommended
(pyridoxine) recommended for pregnant women to improve maternal and
supplements perinatal outcomes.
Vitamin E and A 8: Vitamin E and C supplementation is not recommended Not recommended
C supplements for pregnant women to improve maternal and perinatal
outcomes
Vitamin D A 9: Vitamin D supplementation is not recommended for Not recommended
supplements pregnant women to improve maternal and perinatal
outcomes.
Restricting A 10: For pregnant women with high daily caffeine intake
caffeine intake (more than 300 mg per day),lowering daily caffeine intake
during pregnancy is recommended to reduce the risk of
pregnancy loss and low-birth-weight neonates.

B. Maternal and Fetal Assessment

B.1 Maternal Assessment

Type of
Care option Recommendation
Recommendation

Anaemia B 1.1 Full blood count testing is the recommended method for Context-specific
diagnosing anaemia in pregnancy. In settings where full blood recommendation
count testing is not available, on-site haemoglobin testing with a
haemoglobinometer is recommended over the use of the
haemoglobin colour scale as the method for diagnosing
anaemia in pregnancy.
Asymptomatic B.1.2 Midstream urine culture is the recommended method Context-specific
bacteriuria (ASB) for diagnosing asymptomatic bacteriuria (ASB) in pregnancy. recommendation
In settings where urine culture is not available, on-site
midstream urine Gram-staining is recommended over the use
of dipstick tests as the method for diagnosing ASB in
pregnancy.
Intimate partner B.1.3. Clinical enquiry about the possibility of intimate partner Context-specific
violence (IPV) violence (IPV) should be strongly considered at antenatal care recommendation
visits when assessing conditions that may be caused or
complicated by IPV in order to improve clinical diagnosis and
subsequent care, where there is capacity to provide a
supportive response (including referral where appropriate)
and where the WHO minimum requirements are met.

23
 Type of
Care option Recommendation
Recommendation
Gestational B.1.4 Hyperglycaemia first detected at any time during Recommended
diabetes mellitus pregnancy should be classified as either gestational diabetes
(GDM) mellitus (GDM) or diabetes mellitus in pregnancy, according
to WHO criteria.
Tobacco use B.1.5. Health-care providers should ask all pregnant women Recommended
about their tobacco use (past and present) and exposure to
second-hand smoke as early as possible in the pregnancy and
at every antenatal care visit.
Substance use B.1.6. Health-care providers should ask all pregnant women Recommended
about their use of alcohol and other substances (past and
present) as early as possible in the pregnancy and at every
antenatal care visit.
Human B.1.7. In high-prevalence settings, provider-initiated testing Recommended
immuno-deficien and counseling (PITC) for HIV should be considered a routine
cy virus (HIV) and component of the package of care for pregnant women in all
syphilis antenatal care settings. In low-prevalence settings, PITC can
be considered for pregnant women in antenatal care settings
as a key component of the effort to eliminate mother-to-child
transmission of HIV, and to integrate HIV testing with syphilis,
viral or other key tests, as relevant to the setting, and to
strengthen the underlying maternal and child health systems.
B.1.8. In settings where the tuberculosis (TB) prevalence in the
general population is 100/100 000 population or higher,
Tuberculosis (TB) systematic screening for active TB should be considered for Context-specific
pregnant women as part of antenatal care. recommendation

24
B.2 Fetal Assessment

Type of
Care option Recommendation
Recommendation

Daily fetal B.2.1 Daily fetal movement counting, such as with “count-to-ten” Context-specific
movement kick charts, is only recommended in the context of rigorous recommendation
counting research. (research)
Symphysis-fundal B.2.2 Replacing abdominal palpation with symphysis-fundal Context-specific
height (SFH) height (SFH) measurement for the assessment of fetal growth is recommendation
measurement not recommended to improve perinatal outcomes. A change
from what is usually practiced (abdominal palpation or SFH
measurement) in a particular setting is not recommended.
B.2.3 Routine antenatal cardiotocography is not recommended
Antenatal cardio- for pregnant women to improve maternal and perinatal Not recommended
tocography outcomes.
B.2.4 One ultrasound scan before 24 weeks of gestation (early
Ultrasound scan ultrasound) is recommended for pregnant women to estimate Recommended
gestational age, improve detection of fetal anomalies and
multiple pregnancies, reduce induction of labour for post-term
pregnancy, and improve a woman’s pregnancy experience.
B.2.5 Routine Doppler ultrasound examination is not
recommended for pregnant women to improve maternal and
Doppler ultrasound perinatal outcomes. Not recommended
of fetal blood
vessels

C. Preventive measures
Type of
Care option Recommendation
Recommendation

Antibiotics for C.1 A seven-day antibiotic regimen is recommended for all Recommended
asymptomatic pregnant women with asymptomatic bacteriuria (ASB) to
bacteriuria (ASB) prevent persistent bacteriuria, preterm birth and low birth
weight
Antibiotic
prophylaxis to C.2: Antibiotic prophylaxis is only recommended to prevent Context-specific
prevent recurrent recurrent urinary tract infections in pregnant women in the recommendation
urinary tract context of rigorous research. (research)
infections
Antenatal anti-D C.3: Antenatal prophylaxis with anti-D immunoglobulin in Context-specific
immunoglobulin non-sensitized Rh-negative pregnant women at 28 and 34 weeks recommendation
administration of gestation to prevent RhDalloimmunization is only (research)
recommended in the context of rigorous research.
C.4: In endemic areas,preventive anthelminthic treatment is Context-specific
recommended for pregnant women after the first trimester as recommendation
part of worm infection reduction programme. (research)
C.5: Tetanus toxoid vaccination is recommended for all pregnant Recommended
women, depending on previous tetanus vaccination exposure, to
prevent neonatal mortality from tetanus.

25
 Type of
Care option Recommendation
Recommendation

Recommendations integrated from other WHO guidelines that are relevant to ANC

Malaria C.6: In malaria-endemic areas in Africa, intermittent preventive Context-specific

prevention: treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommendation
intermittent recommended for all pregnant women. Dosing should start in
preventive the second trimester, and doses should be given at least one
treatment in month apart, with the objective of ensuring that at least three
pregnancy (IPTp) doses are received.

C.7: Oral pre-exposure prophylaxis (PrEP) containing

Pre-exposure tenofovirdisoproxilfumarate (TDF) should be offered as an Context-specific
prophylaxis (PrEP) additional prevention choice for pregnant women at substantial recommendation
for HIV prevention risk of HIV infection as part of combination prevention
approaches.

D. Interventions for common physiological symptoms

Type of
Care option Recommendation
Recommendation

Nausea and D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are Recommended
vomiting recommended for the relief of nausea in early pregnancy, based on
a woman’s preferences and available options.
Heartburn D.2: Advice on diet and lifestyle is recommended to prevent and Recommended
relieve heartburn in pregnancy. Antacid preparations can be
offered to women with troublesome symptoms that are not
relieved by lifestyle modification.
Leg cramps D. 3: Magnesium, calcium or non-pharmacological treatment Recommended
options can be used for the relief of leg cramps in pregnancy, based
on a woman’s preferences and available options.
D.4: Regular exercise throughout pregnancy is recommended to
Low back and prevent low back and pelvic pain. There are a number of different Recommended
pelvic pain treatment options that can be used, such as physiotherapy,
support belts and acupuncture, based on a woman’s preferences
and available options.
D.5: Wheat bread or other fibre supplements can be used to relieve
Constipation constipation in pregnancy if the condition fails to respond to Recommended
dietary modification, based on a woman’s preferences and
available options.
D.6: Non-pharmacological options, such as compression stockings,
Varicose veins leg elevation and water immersion, can be used for the Recommended
and oedema management of varicose veins and oedema in pregnancy, based
on a woman’s preferences and available options.

26
 Health systems interventions
to improve the utilization
and quality of ANC

There is a multitude of interventions that can be employed to improve the utilization and quality of ANC
depending on the context and setting. For this purposes, WHO has considered the following interventions:
1. Women-held case notes (home-based records)
2. Midwife-led continuity of care models
3. Group ANC
4. Community-based interventions to improve communication and support
5. Task shifting
6. Recruitment and retention of staff
7. ANC contact schedules.

1. Women-held case notes

• Women are given their own case notes to carry during pregnancy.
• Case notes may be held in paper (e.g. card, journal, handbook) or electronic formats (e.g. memory
stick),
• Women are expected to take them along to all health visits.
• If women then move, or are referred from one facility to another, and in the case of complications
where immediate access to medical records is not always possible, the practice of women-held case
notes may improve the availability of women’s medical records
• In addition, the practice may facilitate more accurate estimation of gestational age, which is integral
to evidence-based decision-making, due to improved continuity of fetal growth records
• Women-held case notes might also be an effective tool to improve health awareness and
client–provider communication

Additional facts
• In our country perspective, it will be better if possible to keep one copy of case note in the facility.
• Give the patient a hard covered file for the case notes to keep it intact or together.

Evidence indicates that women who carry their case notes are more likely to feel control of their
pregnancy experiences but have no effect on perinatal mortality.

2. Midwife-led continuity of care (MLCC) models

Midwives are the primary providers of care in many ANC settings.
In MLCC models, a known and trusted midwife (caseload midwifery), or small group of known midwives (team

27
midwifery), supports a woman throughout the antenatal, intrapartum and postnatal period, to facilitate a
healthy pregnancy and childbirth, and healthy parenting practices.

The MLCC model includes

• continuity of care;
• monitoring the physical, psychological, spiritual and social well-being of the woman and family
throughout the childbearing cycle;
• providing the woman with individualized education, counselling and ANC; attendance during labour,
birth and the immediate postpartum period by a known midwife; ongoing support during the postnatal
period;
• identifying, referring and coordinating care for women who require obstetric or other specialist attention.
Thus, the MLCC model exists within a multidisciplinary network in which consultation and referral to other
care providers occurs when necessary. The MLCC model is usually aimed at providing care to healthy women
with uncomplicated pregnancies.

Evidence suggests that MLCC slightly increase the chance of vaginal birth and reduce caesarean
sections and instrumental vaginal delivery rate. It may also reduce the risk of preterm birth and
perinatal mortality.

3. Group Antenatal care

Group antenatal care provided by qualified health-care professionals may be offered as an alternative to
individual antenatal care for pregnant women.
In Group Antenatal care model, the first visit for all pregnant women is an individual visit. Then at subsequent
visits, they are integrated into a group ANC session, with facilitated educational activities and peer support.
The usual pregnancy health assessment, held in a private examination area should be individualized.
The group ANC may be associated with lower health-care provider costs due to increased staff productivity
and efficiency; e.g. health-care providers do not need to repeat advice to each woman individually.

For the group ANC care model

• Health-care facilities need to be seeing sufficient numbers of pregnant women, as allocation to groups is
ideally performed according to gestational age.
• Health-care providers need to have appropriate facilities to deal with group sessions, including access to
large, well ventilated rooms or sheltered spaces with adequate seating.
• Group ANC may take longer than individual ANC, and this may pose practical problems for some women
in terms of work and childcare.
• Health-care providers should be able to offer a variety of time slots for group sessions (morning,
afternoon, evening) and should consider making individual care available as well.
• However, training and supervising health-care providers to conduct group based counselling and
participatory discussions are also associated with cost.

The evidence suggest that the effects of group ANC when compared with individual ANC ,there is
little or no effect on maternal , foetal and neonatal outcome but it may provide higher woman
satisfaction scores.

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4. Community-based interventions to improve communication and support
4.1. Facilitated participatory learning and action (PLA) cycles with women’s groups
The implementation of community mobilization through facilitated participatory learning and action (PLA)
cycles with women’s groups is recommended to improve maternal and newborn health, particularly in rural
settings with low access to health services. Participatory women’s groups represent an opportunity for
women to discuss their needs during pregnancy, including barriers to reaching care, and to increase support
to pregnant women.
The intervention consisted of
• Involving women (pregnant and non-pregnant) in PLA cycles facilitated by trained facilitators, with the
aim of identifying, prioritizing and addressing problems women face around pregnancy, childbirth and
after birth, and empowering women to seek care and choose healthy pregnancy and newborn care.
• Meetings were usually held on a monthly basis and specific activities were prioritized according to the
local context and conditions.
• Coverage of women’s group meetings ranged from one group per hundreds to one group per thousand
people in the population among included trials, with the proportion of pregnant women attending
groups ranging from 2% to 51%.

The evidence suggests that participatory women’s groups (PWGs) may reduce maternal and
perinatal mortality. PWGs may have little or no effect on ANC coverage of four visits but increase ANC
coverage of at least one visits.

4.2: Community mobilization and antenatal home visits

Packages of interventions that include household and community mobilization and antenatal home visits are
recommended to improve antenatal care utilization and perinatal health outcomes, particularly in rural
settings with low access to health services.
• The antenatal home visits by lay health workers during pregnancy may improve ANC utilization health
outcomes.
• Antenatal home visits may be helpful in ensuring continuity of care across the antenatal intrapartum and
postnatal periods and in promoting other healthy behaviour.
• The focus of antenatal home visits to promote maternal health education, ANC attendance , tetanus
toxoid vaccinations and iron and folic acid supplements, and birth and newborn-care preparedness.
• Stakeholders need to be clear that antenatal home visits by lay health worker is not to replace ANC visits.
• Health-care providers need initial and ongoing training in communication with women and their
partners, group facilitation, in the convening of public meetings and in other methods of communication.
• Information for women and community members should be provided in languages and formats
accessible to them and ensure reliable supplies of appropriate information materials.
• Programme planners should be aware of the potential for additional costs associated with home visits
and community mobilization initiatives, including the potential need for extra staff and travel expenses.

When considering the use of antenatal home visits, women’s groups, partner involvement or
community mobilization, programme planners need to ensure that these can be implemented in a
way that respects and facilitates women’s needs for privacy as well as their choices and their
autonomy in decision-making.

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The evidence indicates that antenatal home visits probably have little or no effect on maternal mortality but
may reduce perinatal mortality. Antenatal home visits may have little or no effect on ANC coverage of at least
four visits.
5: Task shifting components of antenatal care delivery
Task shifting the promotion of health-related behaviours for maternal and newborn health to a broad range
of cadres, including lay health workers, auxiliary nurses, nurses, midwives and doctors is recommended.
• Task shifting has an important role to play in allowing flexibility in health-care delivery in low-resource
settings, i.e. lay providers who are trained and supervised can independently conduct safe and effective
HIV testing using rapid tests
• Policy-makers need to work towards midwife-led care for all women.
• Lay health workers need to be recognized and integrated into the system, and not be working alone, i.e.
task shifting needs to occur within a team approach.
• The mandate of all health workers involved in task shifting programme’s needs to be clear.

6: Recruitment and retention of staff in rural and remote areas

Policy-makers should consider educational, regulatory, financial, personal and professional support
interventions to recruit and retain qualified health workers in rural and remote areas.
Strong recommendations on recruitment and staff retention from the above guideline include the following.
• Use targeted admission policies to enrol students with a rural background in education programmes for
various health disciplines and/or establish a health-care professional school outside of major cities.
• Revise undergraduate and postgraduate curricula to include rural health topics and clinical rotations in
rural areas so as to enhance the competencies of health-care professionals working in rural areas.
• Improve living conditions for health workers and their families and invest in infrastructure and services
(sanitation, electricity, telecommunications, schools, etc.).
• Provide a good and safe working environment, including appropriate equipment and supplies,
supportive supervision and mentoring.
• Identify and implement appropriate outreach activities to facilitate cooperation between health workers
from better-served areas and those in underserved areas, and, where feasible, use tele-health to provide
additional support.
• Develop and support career development programmes and provide senior posts in rural areas so that
health workers can move up the career path as a result of experience, education and training, without
necessarily leaving rural areas.
• Support the development of professional networks, rural health-care professional associations, rural
health journals, etc., to improve the morale and status of rural providers and reduce feelings of
professional isolation.
• Adopt public recognition measures such as rural health days, awards and titles at local, national and
international levels to lift the profile of working in rural areas.

This recommendation has been adapted and integrated for the ANC guideline from the 2010 WHO
publication Increasing access to health workers in remote and rural areas through improved
retention: global policy recommendations (2012)

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7: Antenatal care contact schedules
Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and
improve women’s experience of care.
• The four-visit focused ANC (FANC) model does not offer women adequate contact with health-care
practitioners and is no longer recommended.
• The FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks,
the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation. Thereafter, women are
advised to return to ANC at 41 weeks of gestation or sooner if they experience danger signs.
• Evidence shows that the FANC model, which was developed in the 1990s, is probably associated with
more perinatal deaths than models that comprise at least eight ANC visits.
• Evidence suggests that more ANC visits, irrespective of the resource setting, is probably associated with
greater maternal satisfaction than less ANC visits.

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D. Interventions for common physiological symptoms

Type of
Care option Recommendation
Recommendation

Woman-held E.1: It is recommended that each pregnant woman carries her own Context-specific
case notes case notes during pregnancy to improve continuity, quality of care recommendation
and her pregnancy experience.
Midwife-led E.2: Midwife-led continuity-of-care models, in which a known Context-specific
continuity of care midwife or small group of known midwives supports a woman recommendation
throughout the antenatal, intrapartum and postnatal continuum,
are recommended for pregnant women in settings with well
functioning midwifery programmes.
E.3: Group antenatal care provided by qualified health-care
Group antenatal professionals may be offered as an alternative to individual Context-specific
care antenatal care for pregnant women in the context of rigorous recommendation
research, depending on a woman’s preferences and provided that (research)
the infrastructure and resources for delivery of group antenatal
care are available.
E.4.1: The implementation of community mobilization through
Community- facilitated participatory learning and action (PLA) cycles with Context-specific
based women’s groups is recommended to improve maternal and recommendation
interventions to newborn health, particularly in rural settings with low access to
improve health services. Participatory women’s groups represent an
communication opportunity for women to discuss their needs during pregnancy,
and support including barriers to reaching care, and to increase support to
pregnant women.
E.4.2: Packages of interventions that include household and
community mobilization and antenatal home visits are Context-specific
recommended to improve antenatal care utilization and perinatal recommendation
health outcomes, particularly in rural settings with low access to
health services.

References:
1. WHO recommendations on antenatal care for a positive pregnancy experience. WHO Library
Cataloguing-in-Publication Data. ISBN 978 92 4 154991 2; World Health Organization 2016.
2. Every Mother Every Newborn, UNICEF, Bangladesh, 2018.
3. Pocket book of Hospital Care for Mothers; Guidelines for management of common Maternal Conditions.
WHO, ISBN 988-92-9022-498 3; WHO 2017.
4. Emergency Obstetric and Neonatal Care Protocol (EmONC); WHO, UNICEF- 2018.

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