11.1 Antenatal Care (ANC/FANC), Risk Assessment & Health Promotion

11.1 Antenatal Care (ANC/FANC), Risk Assessment & Health Promotion

Quick Answer: Antenatal care (ANC) provides timely screening, preventive therapy, and education to ensure optimal maternal and perinatal outcomes. Ghana's services grew from focused, risk-based antenatal care, and WHO (2016) recommends at least eight contacts starting before 12 weeks. Core clinical duties at booking include GTPAL obstetric profiling, Naegele's rule for EDD determination (LMP + 7 days - 3 months + 1 year), symphysis-fundal height measurement (cm matching weeks between 20–36 weeks), Leopold's maneuvers, essential screening (Hb, ABO/Rh, HIV, VDRL/RPR, HBsAg, sickling, urinalysis), malaria chemoprophylaxis with IPTp-SP under directly observed therapy (DOT), Td immunization, and Birth Preparedness and Complication Readiness (BP/CR) planning.

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Core Objectives of Antenatal Care

Antenatal care represents a foundational pillar of maternal and newborn health services in Ghana. Rather than treating pregnancy as an illness, modern obstetric nursing conceptualizes ANC as a proactive, comprehensive health promotion and surveillance framework.

The primary clinical objectives of antenatal care are:

• Health Promotion & Disease Prevention: Provide evidence-based interventions including micronutrient supplementation, tetanus prophylaxis, and malaria chemoprophylaxis to avert preventable morbidity;
• Early Screening & Risk Stratification: Detect pre-existing chronic conditions (such as cardiac disease, chronic hypertension, diabetes) and pregnancy-induced complications (such as gestational diabetes, preeclampsia, multiple gestation) before decompensation occurs;
• Fetal Surveillance: Monitor intrauterine growth, gestational age concordance, and fetal viability across each trimester;
• Birth Preparedness & Complication Readiness (BP/CR): Empower the woman, partner, and family to formulate realistic delivery plans, arrange emergency logistics, and identify skilled delivery providers;
• Client & Family Education: Counsel on optimal maternal nutrition, danger signs of pregnancy, breastfeeding preparation, family planning spacing, and newborn care.

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Antenatal Care Delivery Models: GHS FANC vs. WHO 2016 8-Contact Model

Historically, pregnant women were subjected to rigid, routine monthly visits that often delivered superficial care without targeted interventions. The Ghana Health Service (GHS) adopted the Focused Antenatal Care (FANC) model, which recognized that every pregnancy is at risk and emphasized quality, goal-oriented visits over mere frequency. WHO's 2016 antenatal care model recommends a minimum of eight contacts to reduce perinatal deaths and improve women's experience of care; check which schedule your current national guideline and facility use.

[!NOTE] Under the WHO model, the term contact is deliberately preferred over "visit," implying an active, supportive, two-way therapeutic engagement between the pregnant woman and the healthcare team rather than a passive clinic appointment.

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The Comprehensive Booking Visit (Initial Assessment)

The initial antenatal booking visit is the most exhaustive clinical encounter in pregnancy and should ideally take place within the first trimester (< 12 weeks). The midwife establishes a baseline record against which all future assessments are benchmarked.

Obstetric History & Terminology: The GTPAL System

Accurate documentation of reproductive history provides immediate insight into obstetric risk. While historical records utilized Gravidity (total pregnancies) and Parity (pregnancies carried to viability, typically 28 weeks in Ghana), the five-digit GTPAL system provides superior clinical granularity:

• G (Gravidity): Total number of pregnancies, regardless of outcome (including current pregnancy, miscarriages, and ectopics);
• T (Term Deliveries): Number of births carried to 37 completed weeks of gestation or beyond;
• P (Preterm Deliveries): Number of births delivered between 28 weeks (viability in Ghana) and 36 completed weeks + 6 days;
• A (Abortions / Miscarriages): Number of pregnancies ending prior to 28 weeks gestation (spontaneous or induced, including ectopic and molar pregnancies);
• L (Living Children): Total number of children currently living.

Clinical Example: A woman is currently pregnant. She has a history of one singleton delivery at 39 weeks (alive), twin delivery at 33 weeks (both alive), and one spontaneous miscarriage at 10 weeks. Her score is G4 T1 P1 A1 L3 (Twins count as one pregnancy and one preterm birth event, but contribute 2 to living children).

Calculating Estimated Date of Delivery (EDD): Naegele's Rule

Accurate dating is paramount for assessing fetal growth and timing interventions. When the woman has a regular 28-day menstrual cycle and accurately recalls her Last Normal Menstrual Period (LMP), the Estimated Date of Delivery is calculated using Naegele's Rule:

EDD = First Day of LMP + 7 Days - 3 Months + 1 Year

Alternative operational shortcut: If LMP falls in January, February, or March, add 7 days and add 9 months within the same calendar year. For LMP in April through December, add 7 days, subtract 3 months, and advance to the next calendar year.

Exam Calculation Example:

• LMP: May 14, 2025
• Add 7 days: May 21, 2025
• Subtract 3 months: February 21, 2025
• Add 1 year: February 21, 2026 (EDD)

Caveat: Naegele's rule assumes an exact 28-day cycle with ovulation occurring on day 14. If the client has a 35-day cycle, ovulation occurred 7 days later; therefore, 7 days must be added to the calculated EDD (LMP + 14 days - 3 months + 1 year). Where cycle history is uncertain or irregular, early first-trimester crown-rump length (CRL) ultrasound represents the gold standard for gestational dating.

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Clinical Obstetric Examination

Symphysis-Fundal Height (SFH) Measurement

Abdominal examination commences with measuring the fundal height using a non-elastic tape measure. The midwife identifies the upper border of the pubic symphysis with one hand and places the tape zero-mark there, extending the tape along the longitudinal axis of the uterus over the abdominal curvature to the uppermost superior border of the uterine fundus.

• Landmark Corroboration:
  • 12 Weeks: Fundus is palpable just above the superior border of the pubic symphysis;
  • 16 Weeks: Fundus rests midpoint between the pubic symphysis and the umbilicus;
  • 20–22 Weeks: Fundus reaches the level of the umbilicus;
  • 36 Weeks: Fundus reaches the level of the xiphisternum (highest point of elevation);
  • 38–40 Weeks: Fundus frequently descends slightly ("lightening") as the fetal head engages into the maternal pelvic brim.
• McDonald's Rule: Between 20 and 36 weeks, the symphysis-fundal height in centimeters corresponds directly to the gestational age in weeks (within a normal tolerance of ± 2 cm).
• Clinical Discrepancies:
  • SFH > 2 cm greater than expected: Multiple gestation, polyhydramnios, macrosomia, uterine fibroids, molar pregnancy, or incorrect dates.
  • SFH > 2 cm smaller than expected: Intrauterine fetal growth restriction (IUGR), oligohydramnios, transverse lie, intrauterine fetal demise, or incorrect dates.

Leopold's Four Maneuvers

Leopold's maneuvers are a systematic, four-step palpation method performed with the client in a semi-recumbent position with knees slightly flexed to relax abdominal musculature, bladder emptied, and examiner standing on the client's right side.

[!IMPORTANT] Exam Alert: Examiner Orientation in Leopold's Maneuvers Licensure questions frequently test examiner orientation: The nurse faces the client's face/head for the first three maneuvers (Fundal, Lateral, Pawlik's) and turns to face the client's feet only during the Fourth Maneuver (Second Pelvic Grip).

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Essential Antenatal Laboratory Investigations

At the booking visit, a standard panel of routine laboratory investigations is carried out:

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Preventive Interventions in Pregnancy (Ghana National Guidelines)

1. Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp-SP)

Malaria in pregnancy causes severe maternal anemia, placental sequestration, intrauterine growth restriction, low birth weight, and abortion. In Ghana, an endemic transmission zone, the national policy mandates Intermittent Preventive Treatment using Sulfadoxine-Pyrimethamine (IPTp-SP / Fansidar).

• Administration Protocol: Administered under strict Directly Observed Therapy (DOT) where the midwife observes the pregnant woman swallow the tablets in the clinic with potable water;
• Timing: Initiated at the start of the second trimester (from the 16th week of gestation or upon confirmation of quickening);
• Dosing Frequency: Administered at each scheduled antenatal contact with an interval of at least 4 weeks (1 month) between doses;
• Minimum Standard: Every pregnant woman must receive a minimum of 3 doses (IPTp3), though monthly dosing continues up to the time of delivery;
• Absolute Contraindications: Known allergy to sulfonamides/sulfur drugs, and women with HIV who are already receiving daily Cotrimoxazole (Septrin) prophylaxis (to prevent fatal sulfa toxicity and Stevens-Johnson syndrome).

2. Tetanus-Diphtheria (Td) Toxoid Immunization

Tetanus neonatorum is completely preventable via maternal active immunization. The Ghana Health Service utilizes Tetanus-Diphtheria (Td) toxoid to eliminate maternal and neonatal tetanus.

3. Routine Micronutrient Supplementation

• Iron: Elemental iron 60 mg daily to meet expanding maternal blood volume and fetal erythropoiesis;
• Folic Acid: 400 mcg (0.4 mg) daily to prevent neural tube defects (anencephaly, spina bifida) and megaloblastic anemia. Women with pre-existing sickle cell disease or previous neural tube defect pregnancies require high-dose folic acid (5 mg daily).

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Birth Preparedness and Complication Readiness (BP/CR)

Every pregnancy carries an unpredictable risk of sudden acute obstetric complications. The midwife must actively facilitate a documented Birth Preparedness and Complication Readiness Plan with each client and her family, detailing:

1. Designated Skilled Attendant & Facility: Identifying an accredited health facility equipped with emergency obstetric care;
2. Emergency Transport Logistics: Designating a dependable driver/vehicle and emergency contact numbers;
3. Dedicated Emergency Funds: Establishing cash or community health insurance savings for emergency drugs, supplies, or blood products;
4. Identified Blood Donors: Pre-identifying two compatible, pre-screened blood donors willing to donate on demand;
5. Clean Delivery Kit: Procuring necessary maternity items (cord ties, sterile blades, mackintosh, pads, baby clothes);
6. Designated Support Person / Decision Maker: Appointing a trusted family companion to accompany the mother and make decisions if she is incapacitated.

[!CAUTION] Clinical Pearl: Major Danger Signs in Pregnancy Nurses and midwives must educate pregnant women to report to an emergency facility immediately—without waiting for their next scheduled appointment—upon experiencing any of the following obstetric danger signs:

• Vaginal bleeding (threatened miscarriage, placenta previa, abruptio placentae);
• Severe, persistent frontal headache or blurred vision/flashes (preeclampsia);
• Severe epigastric or right upper quadrant abdominal pain (impending eclampsia/HELLP);
• Sudden edema of the face, eyelids, and hands;
• Reduced or absent fetal movements (fetal compromise or demise);
• Sudden gush or continuous leaking of watery fluid from the vagina (premature rupture of membranes);
• High fever with chills/rigors (severe malaria, pyelonephritis, chorioamnionitis);
• Foul-smelling vaginal discharge or severe persistent vomiting leading to dehydration.