Structured antenatal care (ANC) is one of the most evidence-backed interventions in obstetrics. In India, effective implementation of a standardised ANC protocol remains the single greatest lever for reducing the maternal mortality ratio (MMR) — currently 97 per 100,000 live births nationally but ranging from 30 in Kerala to over 200 in some high-burden states. This guide consolidates the FOGSI standard of care with MoHFW's Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) framework into a practical, visit-by-visit reference for busy OB-GYN practitioners.
1. Recommended ANC Visit Schedule
The WHO's 2016 ANC guidelines recommend a minimum of 8 contacts for a positive pregnancy experience. India's MoHFW mandates at least 4 (in line with its earlier focused ANC model), but FOGSI-aligned urban practice targets 8–10 visits for low-risk singleton pregnancies. The schedule below reflects tertiary and secondary care standards.
| Visit | Gestational Age | Key Objectives | Investigations Due |
|---|---|---|---|
| Booking Visit | As early as possible; ideally < 12 weeks | History, baseline examination, EDD confirmation, high-risk stratification, counselling, registrations (MCP card, PMSMA) | CBC, blood group & Rh, RBS/FBS, urine R/M, VDRL, HIV, HBsAg, urine culture; NT scan + serum markers (11–13+6 w); TSH (high-risk) |
| Visit 2 | 16 weeks | Review booking investigations, anaemia management, TT-1, counsel on diet and minor ailments | Repeat Hb if anaemic at booking; mid-trimester anomaly scan booked (18–22 w) |
| Visit 3 | 20 weeks | Anomaly scan review, fetal growth assessment, uterine size, quickening | Level II (TIFFA) anomaly scan; urine for protein if BP elevated |
| Visit 4 | 24 weeks | Glucose challenge test, anaemia review, preeclampsia risk assessment, TT-2 | 75 g OGTT (GDM screen); CBC; urine protein; fetal growth scan if indicated |
| Visit 5 | 28 weeks | Review OGTT results, repeat blood group in Rh-negative (anti-D if indicated), fetal movement counselling | CBC; HbA1c if GDM diagnosed; anti-D at 28 w if Rh-negative & unsensitised |
| Visit 6 | 32 weeks | Fetal presentation, growth, anaemia review, preterm risk assessment, hospital admission plan | Fetal growth scan (if small-for-dates or high-risk); repeat CBC; urine R/M |
| Visit 7 | 36 weeks | Confirm presentation, birth plan counselling, breastfeeding preparation, GBS screen (if institutional protocol), postpartum contraception discussion | Vaginal/rectal GBS swab (institutional protocol); NST/BPP if high-risk; repeat Hb |
| Visit 8 | 38 weeks | Confirm engagement, cervical assessment (if indicated), review birth plan, discuss IOL indications | NST; amniotic fluid index (AFI) if post-dates risk; CTG if high-risk |
| Visit 9 | 40 weeks | Post-dates management, IOL discussion, fetal wellbeing assessment | NST; AFI; CTG; IOL at 40+10 per ACOG/FOGSI if unfavourable cervix |
2. Investigations by Trimester
First Trimester (Up to 13+6 Weeks)
- Complete Blood Count (CBC): Establish baseline Hb, MCV (differentiates iron deficiency from thalassaemia trait), platelet count. Hb below 11 g/dL = anaemia; below 7 g/dL = severe anaemia requiring urgent intervention.
- Blood Grouping and Rh typing: Mandatory. Rh-negative women need partner testing and indirect Coombs test (ICT) at booking and 28 weeks.
- Random/fasting blood glucose: Screen for pre-gestational diabetes. FBS ≥ 126 mg/dL or RBS ≥ 200 mg/dL on two occasions = overt DM in pregnancy.
- Urine routine and microscopy: Asymptomatic bacteriuria (ABU) is present in 2–10% of pregnant women and significantly increases preterm birth risk if untreated. Urine culture on MSU if dipstick positive for nitrites/leucocytes.
- VDRL/RPR: Congenital syphilis is preventable. Treat with benzathine penicillin G immediately on confirmation; notify and test partner.
- HIV (ICTC counselling): Pre-test counselling mandatory. PPTCT protocol: enrol reactive mothers in ART immediately; aim for viral load suppression before delivery.
- HBsAg: HBsAg-positive mothers require neonatal HBV vaccination within 12 hours of birth + HBIG (where available).
- TSH: Offer to all; mandatory in women with goitre, prior thyroid disease, family history of thyroid disorder, or from iodine-deficient regions. Subclinical hypothyroidism (TSH 2.5–10 mU/L) is treated in pregnancy.
- First Trimester Combined Screen (FTCS): NT measurement + serum PAPP-A + free beta-hCG between 11+0 and 13+6 weeks. Detection rate for trisomy 21 approximately 90% with 5% false-positive rate. Offer cell-free fetal DNA (cfDNA/NIPT) to high-risk women (age ≥ 35, high-risk FTCS, previous aneuploidy).
- Dating ultrasound: CRL measurement before 14 weeks is the gold standard for EDD assignment. Never override a first-trimester date with a late-trimester scan.
Second Trimester (14–27+6 Weeks)
- Level II (TIFFA) Anomaly Scan at 18–22 weeks: Targeted imaging of fetal anatomy. Document all four cardiac chambers, outflow tracts, spine, kidneys, bladder, lips, palate, and limbs. Placental location must be documented — recheck at 32 weeks if low-lying or praevia suspected.
- 75 g OGTT (GDM screen) at 24–28 weeks: Indian women have a high baseline risk of GDM (prevalence 10–15%). DIPSI (single-step, non-fasting 75 g OGTT, 2h glucose ≥ 140 mg/dL = GDM) is widely used in Indian practice. IADPSG criteria (fasting ≥ 92, 1h ≥ 180, 2h ≥ 153 mg/dL on a formal fasted OGTT) are used in higher-resource settings.
- Repeat CBC at 24–28 weeks: Re-evaluate Hb; adjust iron therapy. Mid-trimester Hb below 10.5 g/dL warrants parenteral iron in poorly tolerant or non-compliant patients.
- Cervical length measurement (transvaginal ultrasound): Offer to women with prior preterm birth or short cervix at 18–24 weeks. CL below 25 mm at 24 weeks = high preterm risk; consider progesterone (vaginal micronised 200 mg/night) and referral to MFM.
- Maternal serum AFP / Quad Screen (15–20 weeks): Where FTCS was not performed, or as an additional screen. Elevated AFP warrants detailed scan for neural tube defects and abdominal wall defects.
Third Trimester (28 Weeks to Term)
- Repeat CBC at 28 and 36 weeks: Physiological haemodilution is maximal at 32–34 weeks. Ensure Hb is above 11 g/dL before anticipated delivery.
- Fetal growth scan at 28–32 weeks (selective or universal per protocol): Customised fetal growth charts (Intergrowth-21 or Indian population-derived) preferred. Plot EFW and HC/AC ratio. Umbilical artery Doppler if SGA or IUGR suspected.
- Anti-D at 28 weeks (Rh-negative, unsensitised): 300 mcg IM. Repeat ICT at 28 weeks before administration. Post-delivery anti-D within 72 hours if baby is Rh-positive.
- Non-stress test (NST) and amniotic fluid index (AFI): Twice weekly from 36 weeks in high-risk pregnancies (GDM, PIH, IUGR, post-dates). Reactive NST: two accelerations of ≥ 15 bpm for ≥ 15 seconds in 20 minutes.
- GBS culture (vagino-rectal swab) at 35–37 weeks: While not universally adopted in all Indian centres, is recommended by FOGSI for prevention of early-onset neonatal GBS disease. Positive: intrapartum IV penicillin G from active labour onset.
- Coagulation screen (PT, aPTT, fibrinogen): Indicated in PIH, ICP (obstetric cholestasis), HELLP syndrome risk, or planned regional anaesthesia with thrombocytopenia.
- Liver function tests (LFT) and bile acids: In women presenting with pruritus, especially palms and soles. Elevated serum bile acids (≥ 10 μmol/L) confirm intrahepatic cholestasis of pregnancy (ICP); ≥ 40 μmol/L = severe ICP, deliver by 37 weeks.
3. Supplementation Protocol
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400 mcg/day from pre-conception through 12 weeks for all women. 5 mg/day for women with a previous NTD-affected pregnancy, maternal epilepsy on valproate/carbamazepine, or malabsorption syndromes. Continue at 400 mcg/day throughout pregnancy for general maternal wellbeing.
Iron
Start at 14 weeks. Dosing by Hb:
- Non-anaemic (Hb ≥ 11 g/dL): 60 mg elemental iron daily (standard IFA tablet).
- Mild-moderate anaemia (Hb 7–11 g/dL): 120 mg elemental iron daily, re-check Hb in 4 weeks. Once Hb normalises, reduce to 60 mg maintenance.
- Severe anaemia (Hb below 7 g/dL): Admit, investigate cause (iron deficiency, B12/folate deficiency, haemolytic, thalassaemia), parenteral iron (ferric carboxymaltose or iron sucrose IV preferred over oral in severe cases). Blood transfusion if symptomatic or Hb below 6 g/dL with haemodynamic compromise.
- Parenteral iron (IV iron sucrose / ferric carboxymaltose): Use when oral iron is not tolerated, Hb response is inadequate after 4 weeks of oral therapy, or third-trimester anaemia leaves insufficient time for oral correction before delivery.
Counsel patients to take iron tablets on an empty stomach with citrus juice (Vitamin C enhances absorption). Avoid with tea, coffee, or dairy within 1 hour. Stool darkening and constipation are expected side effects.
Calcium
500–1000 mg elemental calcium per day from 20 weeks (or earlier in high PIH-risk patients). WHO recommends 1.5–2 g/day for women with low baseline dietary calcium intake — relevant for much of the Indian population. Do not co-administer calcium and iron within 2 hours; they compete for absorption.
Vitamin D
400–600 IU/day of Vitamin D3 throughout pregnancy. Check serum 25-OH Vitamin D in women at high risk (dark skin, limited sun exposure, vegetarians, prior deficiency). Severe deficiency (below 20 nmol/L): supplemental doses of 1000–2000 IU/day under supervision. Vitamin D deficiency is associated with GDM, preeclampsia, preterm birth, and neonatal hypocalcaemia.
Aspirin (Pre-eclampsia Prophylaxis)
Low-dose aspirin 75–150 mg at night, starting before 16 weeks, is recommended for women with high preeclampsia risk (≥ 1 high-risk factor: previous preeclampsia, chronic hypertension, pre-gestational DM, renal disease, autoimmune disease, multiple pregnancy) or ≥ 3 moderate-risk factors. Continue until 36 weeks or delivery. Evidence base: ASPRE trial, NICE guidelines, FOGSI position statement.
4. Vaccination in Pregnancy
Tetanus Toxoid (TT) / Td
Two doses of TT or Td under the National Immunisation Schedule: TT-1 at first contact (ideally before 12 weeks), TT-2 four weeks after TT-1. In subsequent pregnancies where the last dose was given within 3 years, a single booster (TT-Booster) is sufficient. Document dose and batch number in the MCP card.
Influenza Vaccine
Annual inactivated influenza vaccine is safe and recommended in all trimesters. Influenza in pregnancy carries significant risk of preterm birth, maternal pneumonia, and ICU admission. Administer ideally in the first or second trimester before influenza season peaks (October–February in India).
COVID-19 Vaccination
FOGSI recommends COVID-19 vaccination for all pregnant women. Current evidence supports the safety of approved vaccines (including mRNA platforms) in pregnancy; risk of severe COVID-19 outweighs theoretical vaccine risks. Counsel on benefits including maternal protection and possible transplacental antibody transfer to the neonate.
Contraindicated in Pregnancy
Live attenuated vaccines are contraindicated: MMR, varicella, yellow fever (unless unavoidable travel risk), oral polio vaccine. Inadvertent MMR administration in early pregnancy is not an indication for termination but should be documented.
5. Identifying High-Risk Pregnancies
Early and accurate risk stratification is the most critical function of the booking visit. High-risk cases must be identified by 12 weeks to allow timely referral, co-management with MFM or relevant specialists, and institution of preventive interventions.
- Age below 18 or above 35 years
- Grand multiparity (parity ≥ 4) — increased risk of placenta praevia, PPH, anaemia
- Previous adverse outcomes: stillbirth, neonatal death, recurrent miscarriage (≥ 2), prior preterm birth (below 34 weeks)
- Prior caesarean or uterine surgery (myomectomy, metroplasty) — scar integrity risk
- Pre-existing medical conditions: chronic hypertension, pre-gestational DM, thyroid disease (hypo/hyperthyroid), cardiac disease (structural, arrhythmia), renal disease (CrCl below 60 or proteinuria), epilepsy, SLE/APS/other autoimmune disease, haemoglobinopathy (thalassaemia trait, sickle cell disease)
- BMI above 35 (obesity class II/III) or below 18.5 (undernutrition)
- Multiple gestation (twin, triplet)
- Uterine anomaly (bicornuate, septate, unicornuate uterus)
- Unexplained severe anaemia (Hb below 7 g/dL) at booking
- High-risk FTCS (risk ≥ 1:100 for trisomy 21, 18, or 13)
- Substance use, domestic violence, inadequate social support
- Previous cervical incompetence or short cervix (CL below 25 mm)
6. Counselling Checklist — Visit by Visit
Structured counselling at each visit is as important as the physical examination. The following checklist is a minimum standard; adapt to the patient's literacy, language, and specific concerns.
Foundation Counselling
- Confirm pregnancy, explain EDD, and the trimester framework
- Importance of regular ANC visits and not missing appointments
- MCP card purpose; PMSMA and JSSK entitlements
- Nutrition: balanced diet, adequate protein, iron-rich foods (green leafy vegetables, jaggery, legumes), calcium sources, hydration
- Start IFA and folic acid immediately; explain expected side effects
- Rest and physical activity: avoid heavy lifting; light walking is safe and beneficial
- Sexual activity: generally safe in low-risk pregnancy unless otherwise contraindicated
- Substance avoidance: tobacco, alcohol, paan, nicotine, and unsupervised medications are all harmful
- Pre-test HIV counselling; explain PPTCT protocol
- Danger signs — teach all six danger signs (see Section 8) and establish what to do if they occur
- Register for institutional delivery; discuss birth preparedness plan
Mid-Pregnancy Counselling
- Review anomaly scan findings with the patient — explain what was assessed and what the results mean
- Fetal movement: quickening expected around 18–22 weeks; reassure if not yet felt
- Counsel on fetal kick counts from 28 weeks (10 kicks in 2 hours; decreased movement = contact provider)
- Discuss GDM screening at 24–28 weeks — explain dietary implications if diagnosed
- Reinforce danger signs and birth plan registration
- Influenza vaccination if not yet given
Third Trimester Preparation
- Fetal kick count monitoring: formal Cardiff method or simplified 10-kicks-in-2-hours rule from 28 weeks
- Pre-eclampsia warning signs: sudden oedema (face/hands), headache, visual disturbance, epigastric pain — seek care immediately
- Signs of preterm labour: regular painful contractions before 37 weeks, watery vaginal discharge (PROM), pelvic pressure — go to hospital immediately
- Breastfeeding preparation: colostrum, early initiation, exclusive breastfeeding for 6 months
- Anti-D: counsel Rh-negative women; administer at 28 weeks
- Birth preparedness: confirm hospital name, route, funds, blood donors (O-negative if possible), transport plan
- Postpartum contraception: discuss options early so an informed decision is made before delivery
Birth and Postpartum Planning
- Fetal presentation: document vertex/breech; offer ECV for persistent breech at 36 weeks in eligible women
- Finalise birth plan: mode of delivery, pain relief options (epidural availability), presence of support person
- Discuss signs of labour: regular contractions every 5 minutes lasting 60 seconds, bloody show, rupture of membranes — when to go to hospital
- Post-dates plan: IOL offered from 40+10 days; explain why (stillbirth risk increases beyond 41 weeks)
- Newborn care: eye care (erythromycin), Vitamin K injection, BCG, OPV-0, Hep B-0 at birth
- Kangaroo Mother Care (KMC) for low birth weight infants: explain benefits
- Postpartum danger signs: heavy bleeding, fever, wound discharge, mood changes
- Remind of postpartum visit at 6 weeks
7. Documentation Requirements
Comprehensive, contemporaneous documentation protects both the patient and the practitioner. The following records are mandatory at each visit:
- MCP (Maternal Child Protection) card: Filled and updated at every visit. Blood pressure, weight, urine findings, fundal height, fetal heart rate (FHR), presentation, oedema, and investigations must be recorded.
- Case notes / clinic file: Detailed notes including any deviation from routine, patient complaints, counselling given, investigations ordered and reviewed, plan of management, and next visit date.
- Consent documentation: Informed consent for HIV testing, genetic testing (FTCS, cfDNA), and any invasive procedure (amniocentesis, chorionic villus sampling) must be documented in writing.
- High-risk referral documentation: Any referral must include a detailed referral note with clinical summary, investigations, reason for referral, and contact details.
- Drug prescription records: Document every prescription — IFA, calcium, aspirin, progesterone — with dose, duration, and patient's understanding of side effects.
- PMSMA registration: Government-registered facilities must upload beneficiary data to the Mother and Child Tracking System (MCTS/RCH portal) for programme monitoring.
8. Counselling Patients on Warning Signs
The MoHFW's six danger signs framework provides a simple, teachable set of indicators that every pregnant woman and her family should know. Teach these at booking and reinforce at every subsequent visit. Use visual aids in the patient's primary language.
Six Danger Signs Every Patient Must Know
- Vaginal bleeding — at any stage of pregnancy, any amount beyond normal spotting. Do not wait; go to hospital immediately.
- Severe headache or visual disturbance — flashing lights, blurred vision, or seeing spots, especially with facial swelling. Could indicate preeclampsia.
- High fever (above 38°C) — may indicate UTI, malaria, typhoid, or intrauterine infection.
- Severe abdominal pain — persistent, worsening, or with rigidity. Rule out placental abruption, appendicitis, or uterine rupture.
- Decreased or absent fetal movement after 28 weeks. Ten or fewer kicks in 12 hours requires immediate assessment.
- Convulsions (fits) — eclampsia or other neurological emergency. Call ambulance immediately; do not leave the patient alone.
In addition to the six danger signs, counsel specifically on:
- Rupture of membranes (water breaking): Any watery discharge soaking a pad, especially before 37 weeks, should prompt immediate hospitalisation. PPROM carries infection and cord prolapse risk. Do not apply anything intravaginally or delay travel.
- Signs of preterm labour: Regular uterine contractions before 37 weeks — even if not painful — with or without cervical change.
- Swelling of face and hands suddenly: Distinguish from the normal ankle oedema of late pregnancy. Sudden facial or hand oedema with headache = hypertensive emergency until proven otherwise.
- Difficulty breathing, chest pain, or one-sided leg swelling: Pulmonary embolism risk is elevated in pregnancy; do not dismiss these symptoms.
Teach the danger signs using the "FAST" method combined with a laminated card the patient can take home. Ask the patient to repeat back at least three signs at the end of the booking visit. Documentation of danger-sign counselling in the case notes is mandatory — medicolegally and programmatically.
9. Antenatal Care and the Aayi Platform
For OB-GYN practitioners looking to improve ANC compliance and patient engagement, the Aayi platform for doctors offers a structured tool to bridge the gap between clinic visits. Patients can receive trimester-specific educational content, track symptoms and fetal movements, and escalate concerns directly — reducing avoidable emergency visits while keeping the doctor informed. Practices can configure push reminders for upcoming visits and investigations, improving attendance at critical milestones such as the 24-week GDM screen and 36-week birth preparedness session.
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Explore Aayi for Doctors →10. Frequently Asked Questions (Clinical Reference)
How many ANC visits are recommended in India per FOGSI/MoHFW guidelines?
MoHFW mandates a minimum of 4 visits (FANC model). FOGSI-aligned urban practice targets 8–10 visits for low-risk singleton pregnancies. High-risk patients require more frequent review — at minimum monthly until 28 weeks, fortnightly to 36 weeks, and weekly thereafter.
What investigations are mandatory at the booking visit?
CBC, blood group and Rh typing, random or fasting blood glucose, urine routine and microscopy, VDRL/RPR, HIV (with counselling), HBsAg, and urine culture if UTI is suspected. First-trimester combined screen (NT + serum markers) between 11 and 13+6 weeks is strongly recommended. TSH should be checked in high-risk groups or per local protocol.
What are the high-risk flags to identify early in pregnancy?
Age below 18 or above 35, grand multiparity, prior adverse obstetric outcomes, previous uterine surgery, pre-existing medical conditions (DM, HTN, thyroid, cardiac, renal, autoimmune, haemoglobinopathy), BMI above 35 or below 18.5, multiple pregnancy, uterine anomalies, high-risk FTCS, and significant social risk factors. All high-risk cases must be documented, marked on the MCP card, and co-managed with appropriate specialists.
Which vaccines are recommended during pregnancy in India?
TT-1 and TT-2 (or Td) under the national schedule; single booster if last dose within 3 years. Annual inactivated influenza vaccine in all trimesters. COVID-19 vaccination as per current FOGSI recommendations. Live attenuated vaccines (MMR, varicella) are contraindicated.
What is the iron, folic acid, and calcium supplementation protocol for pregnancy in India?
Folic acid 400 mcg/day from pre-conception through 12 weeks (5 mg/day for NTD risk groups). Iron: 60 mg elemental iron/day from 14 weeks in non-anaemic women; 120 mg/day for Hb below 11 g/dL; parenteral iron for severe anaemia or oral intolerance. Calcium 500–1000 mg/day from 20 weeks; up to 1.5–2 g/day in low-calcium-intake populations. Vitamin D 400–600 IU/day throughout pregnancy.
Summary Reference Card
| Gestational Age | Must-Do Investigations | Supplements | Key Counselling |
|---|---|---|---|
| Booking (<12 w) | CBC, group+Rh, RBS, urine R/M, VDRL, HIV, HBsAg, TSH; NT scan | Folic acid 400 mcg/day; start IFA | Danger signs, MCP card, diet, substance avoidance |
| 16 weeks | Repeat Hb if anaemic; review booking results | IFA + folic acid; TT-2 if due | Diet, anaemia management, minor ailments |
| 18–22 weeks | Level II anomaly scan (TIFFA) | IFA + calcium from 20 w | Placental site, fetal movement (quickening) |
| 24–28 weeks | 75 g OGTT; CBC; urine protein | Adjust iron dose per OGTT/Hb; influenza vaccine | GDM diet, fetal kick counting from 28 w |
| 28 weeks | ICT; anti-D if Rh-negative; CBC | Anti-D 300 mcg if Rh-neg unsensitised | Preterm signs, birth preparedness, postpartum contraception |
| 32 weeks | Fetal growth scan (selective); CBC; urine R/M | Calcium + iron maintenance | Preeclampsia warning signs, hospital plan |
| 36 weeks | GBS swab; NST/BPP (high-risk); repeat Hb | Aspirin continue to 36 w; all supplements | Birth plan finalise, breastfeeding prep, newborn vaccination |
| 38–40 weeks | NST; AFI; CTG (high-risk) | Maintain iron + calcium | Post-dates IOL plan, labour signs, when to go to hospital |
Closing Note from Dr. Sai Sudha
The evidence is unambiguous: structured, comprehensive antenatal care reduces maternal and perinatal mortality. In India's diverse healthcare landscape — from tertiary referral centres in metros to community health centres in rural districts — the principles remain constant even when resources vary. Every OB-GYN's first obligation is to identify who is high risk, document it clearly, and ensure those patients receive the additional monitoring they need.
The challenge in busy outpatient settings is time. A structured checklist approach — such as the one outlined in this protocol — reduces cognitive load and ensures that no critical investigation or counselling point is missed, even on a day when you see 40 patients before noon. Build the checklist into your practice workflow, train your nursing and paramedical staff to initiate it, and use digital tools where available to support patient compliance between visits.
Antenatal care is not a series of bureaucratic checkboxes. It is the systematic application of evidence to protect two lives — every time, for every patient.