The first visit

In FANC, the first ANC visit should occur in the first trimester, preferably before 16 weeks of gestation.

a) History

Personal history

• Name, Woreda, Kebele, house number, age, marital status, planned or unplanned pregnancy.
• Date of Last Menstrual Period (LMP); the certainty of dates (regularity of cycle, hormonal contraception used three months before LMP). Determination of the expected date of delivery (EDD) based on LMP and all other relevant information. Use the 280-day rule, (the LMP +280 days).
• Gravidity, parity, number of children alive and number of abortions.

Medical history

• Specific diseases and conditions: diabetes mellitus, renal, cardiac diseases, chronic hypertension, tuberculosis, past history of HIV-related illnesses and HAART, varicose veins, deep venous thrombosis, other specific conditions depending on what the service area perform (for example, hepatitis, malaria), other diseases (past or chronic) and allergies).
• Operations other than caesarian section.
• Current use of medicines (specify them).

Obstetric history

• Previous stillbirth or neonatal loss.
• History of three or more consecutive spontaneous abortion
• Birth weight of last baby < 2500 gm or > 4000 gm.
• Last pregnancy: hospital admission for hypertension or pre-eclampsia (eclampsia).
• Any unexpected event (pain, vaginal bleeding, others (specify them).

b) Physical Examination

• General appearance (look for signs of physical abuse).
• Vital signs: BP, PR, Temperature, RR, HEENT, severe anaemia, shortness of breath, pale complexion of fingernails, conjunctiva, buccal mucosa, the tip of the tongue.
• Check for oral hygiene and dental carries.
• Check for signs of jaundice, record weight and height to assess the mother's nutritional status.
• Perform breast examination.
• Abdomen -- measure uterine height (in centimetres).

c) Laboratory Tests

• Perform urine pregnancy test for HCG
• Perform HIV test depending on the mother's willingness. Also encourage testing of partner.

d) Implement the Following Interventions

• Supplementation of iron and folate to all pregnant women (one tablet of 60-mg elemental iron and 400 micrograms folate per day). To enhance the absorption of iron, instruct mothers to take iron when eating meat or vitamin-rich foods (fruits and vegetables). Avoid tea, coffee, and milk at the same time when taking iron; it interferes with the body's absorption of iron. Iron can also be taken between meals.
• Tetanus toxoid: give the first injection.
• In malaria endemic areas provide ITN.
• Perform HIV test and link to service providing centre positive pregnant women for PMTCT
• Refer clients that need specialised care based on diagnosis.

e) Advice, Questions and Answers, and Schedule the Next Appointment

• Provide advice on signs of pregnancy-related emergencies and how to deal with them including where she should go for assistance. This should be confirmed in writing in the antenatal card. Provide simple written instructions in the local language general information about pregnancy and delivery. When necessary, materials appropriate for an illiterate audience should be available, such as simple pictures and diagrams describing the advice given at each visit.
• Give advice on the birth plan, including transportation options to a health institution.
• Offer sufficient time for free communication and discussion with the mother.
• Advise the woman to bring her partner (or a family member or friend) to later ANC visits so that they can be involved in the discussion and can learn how to support the woman through her pregnancy.
• Discuss on the benefit of HIV testing, PMTCT, risk reduction support services including advice on safe sex.
• Provide HIV-posttest counselling according to Guideline for PMTCT of HIV in Ethiopia
• Advise women to stop the use of alcohol, tobacco smoking and chewing chat (if applies)
• Discuss on breast feeding options and advise on exclusive breast-feeding.
• Schedule appointment for the second visit at 24 - 26 weeks of gestation and state date/hour if possible.
• This should be written in the woman's appointment card and tell her to take note.

f) Maintain Complete Records

• Complete integrated client card.
• Complete appointment card.
• Enter information on registration book.

Note that in each visit, Vaccination against tetanus toxoid should be given during pregnancy. Consider also if the mother had taken other doses in her past life. It is proved that this toxoid vaccine has an only minimum interval for buster; there is no maximum interval limit. The protection is for both maternal and foetal benefit. As a service provider, you should seriously check for her vaccination status till she reaches the maximum level of protection (TT5). For further information, please, refer the schedule on EPI module.