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Optimal antenatal care and delivery

Every pregnant woman should have antenatal care (ANC) under the supervision of a skilled health worker, and in a well-equipped facility. Skilled ANC providers include Midwives and Obstetricians, often working together as a team.

Ideally, care should begin pre-conceptually. This is an opportunity to review issues that may adversely affect the pregnancy, and take remedial measures. Pre-conceptual Folic Acid should be commenced and continued until 12 weeks of the pregnancy.

All women should make efforts to commence ANC at about 12 weeks of pregnancy. A full medical evaluation is done, and routine screening tests are requested. The tests include screening for HIV and Hepatitis, Syphilis, urine checks, blood group and level of haemoglobin. An ultrasound scan is also done, confirming the duration of the pregnancy and giving an estimated date of delivery. This scan also provides an opportunity to screen for some fetal abnormalities. Additional tests may be offered depending on specific circumstances.

Education and counselling are integral components of this first visit. Couples are advised on danger signs, educated on healthy habits and preventive measures for certain illnesses like malaria. Individual medical profiles guide nutritional supplements, immunisations and preventive medications. An ANC card is then offered, and each couple should keep a copy of this. If the 12 week visit is skipped, opportunities are missed to optimise and plan subsequent care.

Screening for chromosomal abnormalities such as Downs Syndrome is not universally available, and is expensive. Couples must make the choice about having such tests, as they must contend with implications of positive results. A detailed ultrasound scan should be offered at around 18 – 22 weeks, aiming to exclude fetal developmental defects. Detailed scans are not universally available as well, and should only be done by specially trained caregivers.

Subsequent ANC visits must be individualised to be cost-effective. The WHO recommends further visits at 20 – 24 weeks, 28 – 32 weeks and at 36 weeks. At each of these visits, maternal health must be re-assessed and fetal growth monitored. If complications such as raised blood pressure (pre-eclampsia) or poor fetal growth are detected, specific measures must be put in place. These may include more frequent ANC visits, fetal growth scans, and specific decisions on the timing and mode of delivery.

Birth plans should be made and agreed during the antenatal period. This includes selecting the facility, desired birth positions, pain relief, birth partner etc. It is worthwhile making a pre-delivery visit to the chosen facility to get familiarised with the layout and the staff.

Every delivery should be supervised by a skilled birth attendant. This must be in facilities well equipped to handle complications of delivery, or capable of timely referral to more equipped facilities. Putting such measures in place dramatically decreases the number of women suffering serious complications or dying during pregnancy and labor.

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