MBBS UG CLASS on the topic antenatal/prenatal care from the PARK textbook chapter on maternal and child health

1. Antenatal Care
Dr Mamta G

2. Antenatal care (ANC)
• the care provided by skilled health-care professionals to pregnant women and
pregnant adolescent girls in order to ensure the best health conditions for both
mother and baby during pregnancy
• The components of ANC include:
• risk identification
• prevention and management of
pregnancy-related or concurrent diseases
• health education
• health promotion
• ANC reduces maternal and perinatal morbidity and mortality
• Ideally this care should begin soon after conception

3. Objectives of antenatal care
(1) To promote, protect and maintain the health of the
mother during pregnancy;
(2) To detect "high-risk" cases and give them special
attention
(3) To foresee complications and prevent them
(4) To remove anxiety and dread associated with
delivery
(5) To reduce maternal and infant mortality and
morbidity;
(6) To teach the mother elements of child care,
nutrition, personal hygiene, and environmental
sanitation;
(7) To sensitize the mother to the need for family
planning, including advice to cases seeking medical
termination of pregnancy; and
(8) To attend to the under-fives accompanying the
mother.

4. Health care services :
Antenatal visits
Ideally:
• once a month during the first 7 months
• twice a month, during the 8th month
• once a week till delivery, if everything is normal

6. • When not possible,
a minimum of 4 visits is the target:
• 1st visit - within 12 weeks, preferably as soon as the pregnancy is suspected, for
registration of pregnancy and first antenatal check-up.
• 2nd visit - between 14 and 26 weeks.
• 3rd visit - between 28 and 34 weeks. (to the PHC medical officer)
• 4th visit - between 36 weeks and term
• Advice to avail investigation facilities at the nearest PHC/CHC/FRU.
• Registration of pregnancy within 12 weeks -primary responsibility of the ANM.
• Village Health Nutrition Day -ensure early registration of pregnancy and
antenatal check-up.

7. Early pregnancy detection
1. It facilitates proper planning and allows for
adequate care to be provided for both mother and foetus.
2. Record the date of last menstrual period and calculate the expected date of
delivery.
3. The health status of the mother can be assessed and any medical illness that she
might be suffering from can be detected and record the baseline information on
blood pressure, weight, haemoglobin etc.
4. It helps in timely detection of complications at an early stage and to manage them
appropriately by referral as required.
5. It also helps to confirm if the pregnancy is wanted and if not, then refer the women
at the earliest to a 24 hours PHC or FRU that provides safe abortion services.
6. Early detection of pregnancy and provision of care from the initial stage facilitates a
good interpersonal relationship between the care giver and the pregnant woman.

8. • Estimation of number of pregnancies in a specified area and pregnancy
tracking
• In case the number of pregnancies registered is less than that of the
estimated pregnancies, ANM needs to track down the MISSED pregnancies
with the help of ASHAs and AWWs.
• Estimating the number of pregnancies will also help her judge whether she
has an adequate stock of the supplies required to provide routine

12. • The ANM should approach community leaders and
key people to ensure that the pregnant women are
registered and come for ANC.
• ASHA and link worker should visit every house in the
area and ensure that all pregnant women are
registered.
• Some women may be receiving ANC from the private
sector. Ensure that their names together with the
names of the facilities where they are registered are
mentioned in the antenatal register.
• The ANM must keep track of all pregnant women in
her area. In case a registered women does not turn-up
for her ANC check-up, ANM must follow her and
counsel her for the regular ANC check-up.

13. • An antenatal check-up after a missed appointment should include all the
components of the missed visit(s) as well as those that correspond to the
present visit.
• A policy decision has been taken for a name-based tracking system
whereby pregnant women and children can be tracked for their ANCs and
immunization along with a feedback system for the ANM, ASHA etc.
• This will also help in tracking and ensuring ANC/PNC for missed/left out
cases.

14. PREVENTIVE SERVICES FOR MOTHERS (ANTENATAL CHECK-UP)
The first visit
I. History-taking
During the first visit, a detailed history of the woman needs to be taken to :
(1) Confirm the pregnancy (first visit only):
(2) Identify whether there were complications during any previous pregnancy/confinement
(3) Identify any current medical/ surgical or obstetric condition(s)
(4) Record the date of 1st day of last menstrual period and calculate the expected date of
delivery by adding 9 months and 7 days to the 1st day of last menstrual period
(5) Record symptoms indicating complications, e.g. fever, persisting vomiting, abnormal
vaginal discharge or bleeding, palpitation, easy fatigability. breathlessness at rest or on mild
exertion, generalized swelling in the body, severe headache and blurring of vision, burning in
passing urine, decreased or absent foetal movements etc;
(6) History of any current systemic illness, e.g., hypertension, diabetes, heart disease,
tuberculosis, renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract infection,
STD. HIV/AIDS etc. Record family history of hypertension, diabetes. tuberculosis, and
thalassaemia. Family history of twins or congenital malformation
(7) History of drug allergies and habit forming drugs.

16. II. Physical examination
1. Pallor : Examine woman's conjunctiva, nails, tongue, oral mucosa and palms.
Pallor should be co-related with haemoglobin estimation.
2 . Pulse : The normal pulse rate is 60 to 90 beats per minute.
3. Respiratory rate : Normal respiratory rate is 18-20 breaths per minute.
4 . Oedema :
Oedema (swelling) which appears in the evening and disappears in the
morning after a full night's sleep, could be a normal manifestation of
pregnancy.
Any oedema of the face, hands, abdominal wall and vulva is abnormal.
Oedema can be suspected if a woman complains of abnormal tightening of any
rings on her fingers. She must be referred immediately for further
investigations.

17. 5. Blood pressure : Measure the woman's blood pressure at every visit. This is important to
rule out hypertensive disorders of pregnancy.
• Hypertension is diagnosed when two consecutive readings taken four hours or more apart
show the systolic blood pressure to be 140 mmHg or more and/or the diastolic blood
pressure to be 90 mmHg or more.
• High blood pressure during pregnancy may signify Pregnancy-Induced Hypertension (PIH)
and/or chronic hypertension. If the woman has high blood pressure, check her urine for
the presence of albumin.
• The presence of albumin ( +2) together with high blood pressure is sufficient to categorize
her as having pre-eclampsia. Refer her to the MO immediately. If the diastolic blood
pressure of the woman is above 110 mmHg, it is a danger sign that points towards
imminent eclampsia. The urine albumin should be estimated at the earliest. If it is strongly
positive, the woman should be referred to the FRU IMMEDIATELY.
• A woman with PIH, pre-eclampsia or imminent eclampsia requires hospitalization and
supervised treatment at a 24-hour PHC/FRU.

18. 6. Weight : A pregnant woman's weight should be taken at each visit. The weight taken during
the first visit; registration should be treated as the baseline weight.
Normally, a woman should gain 9-11 kg during her pregnancy.
Ideally after the first trimester, a pregnant woman gains around 2 kg every month. An inadequate
dietary intake can be suspected if the woman gains less than 2 kg per month. She needs to be
put on food supplementation with The help of the AWW
Low weight gain -Intrauterine Growth Retardation and low birth weight. Excessive weight gain
(more than 3 kg in a month) should raise suspicion of preeclampsia, twins (multiple pregnancy)
or diabetes. Take the woman's blood pressure and test her urine for proteinuria and sugar. If the
blood pressure is high and the urine is positive for protein or sugar, refer her to medical officer.
7. Breast examination : Observe the size and shape of the nipples for the presence of inverted or
flat nipples.

19. III. Abdominal examination
To monitor the progress of the pregnancy and
foetal growth.
1. Measurement of fundal height :
Enlargement of the uterus and the height of
the uterine fundus is
12 weeks - Uterine fundus just palpable per
abdomen.
20 weeks - Fundus flat at the lower border of
umbilicus.
36 weeks - Fundus felt at the level of
xiphisternum.

21. • The duration of pregnancy should always be expressed in terms of completed
weeks.
• In the first half of pregnancy the size of the uterus is of the greatest value in
confirming the calculated duration of pregnancy.
2. Foetal heart sounds : The foetal heart sounds can be heard after 6th month. The
rate varies between 120 to 140 per minute. They are usually best heard in the
midline; after the 28th week, their location may change because of the position and
lie of the foetus.
3. Foetal movements : Foetal movements can be felt by the examiner after 18- 22nd
week by gently palpating the abdomen.
4. Foetal parts : These can be felt about the 22nd week. After the 28th week, it is
possible to distinguish the head, back and limbs.
5. Multiple pregnancy : This must be suspected if the uterus is larger than the
estimated gestational age or palpation of multiple foetal parts.
6. Foetal lie and presentation : Relevant only after 32 weeks of pregnancy.
7. Inspection of abdominal scar or any other relevant abdominal findings

22. • IV. Assessment of gestation age
• Measurement of gestational age has changed over the time. As the dominant
effect of gestational age on survival and long-term impairment has become
apparent over the last 30 years, perinatal epidemiology has shifted from
measuring birth weight alone to focusing on gestational age.
• The most accurate "gold standard" for assessment is routine early ultrasound
assessment together with foetal measurements ideally in the first trimester.
Gestational age assessment based on the date of last menstrual period (LMP) was
previously the most widespread method used and remains the only available
method in many settings.
• Many countries now use "best obstetric estimate" , combining ultrasound and
LMP as an approach to estimate gestational age. It can have a large impact on the
number of preterm births reported.
• Any method using ultrasound requires skilled technicians, equipment and for
maximum accuracy, first trimester antenatal clinic attendance. These are not
common in low income settings, where majority of preterm births occur.
Alternative approaches to LMP in these settings include fundal height, clinical
assessment of the newborn after birth or birth weight as a surrogate.

24. • V. Laboratory investigations The following laboratory investigations
are carried out at the facilities indicated below :
• a . At the sub-centre : - Pregnancy detection test. - Haemoglobin
examination. - Urine test for presence of albumin and sugar. - Rapid
malaria test. b. At the PHC/CHC/FRU : - Blood group, including Rh
factor. – VDRL/RPR. - HIV testing. - Rapid malaria test (if unavailable at
SC). - Blood sugar testing. - HBsAg for hepatitis B infection.

25. Essential components of every antenatal check-up :
1. Take the patient's history.
2. Conduct a physical examination-measure the weight. blood
pressure and respiratory rate and check for pallor and
oedema.
3. Conduct abdominal palpation for foetal growth, foetal lie
and auscultation of foetal heart sound according to the stage
of pregnancy.
4. Carry out laboratory investigations, such as haemoglobin
estimation and urine tests for sugar and proteins.
Interventions and counselling
1. Iron and folic acid supplementation and medication as
needed.
2. Immunization against tetanus.
3. Group or individual instruction on nutrition, family
planning, self care, delivery and parenthood.
4. Home visiting by a female health worker/trained dai.
5. Referral services, where necessary.
6. Inform the woman about Janani Suraksha Yojana and other
incentives offered by the government.

26. RISK APPROACH
To identify "high risk" cases (as early as possible) from a large group of antenatal mothers and arrange for them skilled care,
while continuing to provide appropriate care for all mothers.
These cases comprise the following :
1. Elderly primi (30 years and over).
2. Short statured primi (140 cm and below).
3. Malpresentations, viz breech, transverse lie, etc.
4. Antepartum haemorrhage, threatened abortion.
5. Pre-eclampsia and eclampsia.
6. Anaemia.
7. Twins, hydramnios.
8. Previous still-birth, intrauterine death, manual removal of placenta.
9. Elderly grandmultiparas.
10. Prolonged pregnancy (14 days-after expected date of delivery).
11. History of previous caesarean or instrumental delivery.
12. Pregnancy associated . with general diseases, viz. cardiovascular disease, kidney disease, diabetes. tuberculosis, liver
disease, malaria, convulsions, asthma, HIV, RTI, STI, etc.
13. Treatment for infertility.
14. Three or more spontaneous consecutive abortions.

27. • The "risk approach'' is a managerial tool for improved MCH care. Its
purpose is to provide better services for all. but with special
attention to those who need them most.
• Inherent in this approach is maximum utilization of all resources,
including some human resources that are not conventionally
involved in such care - traditional birth attendants, community
health workers, women's groups, for example.

28. MAINTENANCE OF RECORDS
A Mother and Child Protection Card should be duly completed for
every woman registered.
It contains a registration number, identifying data, previous health
history and main health events etc.
The case record should be handed over to the woman.
She should be instructed to bring the record with her during all
subsequent check-ups/visits and also to carry it along with her at time
of delivery.
This card has been developed jointly by the Ministry of Health and
Family Welfare (MOHFW) and Ministry of Women and Child
Development (MOWCD) to ensure uniformity in record keeping.
This will also help the service provider to know the details of previous
ANCs/PNCs both for routine and emergency care.
The information contained in the card should also be recorded in the
antenatal register as per the Health Management Information System
(HMIS) format.

29. HOME VISITS
• Home visiting is the backbone of all MCH
services. at least one home visit by the Health
Worker Female or Public Health Nurse. More
visits are required if the delivery is planned at
home.
• The mother is generally relaxed at home.
• The home visit will win her confidence.
• The home visit will provide an opportunity to
observe the environmental and social
conditions at home and also an opportunity to
give prenatal advice.

30. Antenatal/ Prenatal advice
• The "talking points· pregnancy, child-birth,
family and child health care.
• (i) DIET : Reproduction costs energy. A
pregnancy in total duration consumes about
60,000 kcal, over and above normal metabolic
requirements. Lactation demands about 550
kcal a day.
• child survival is correlated with birth weight.
And birth weight is correlated to the weight gain
of the mother during pregnancy. On an average,
a normal healthy woman gains about 9-11 kg of
weight during pregnancy.

31. • If maternal stores of iron are poor (as may happen after repeated pregnancies), it is possible
that foetus may lay down insufficient iron stores. Such a baby may show a normal
haemoglobin at birth, but will lack the stores of iron necessary for rapid growth and increase
in blood volume and muscle mass in the first year of life.
• Stresses in the form of
malaria and other childhood
infections will make the
deficiency more acute, and
many infants become
severely anaemic during
early months of life.
• A balanced and adequate
diet is therefore, of utmost
importance during
pregnancy and lactation to
meet the increased needs of
the mother, and to prevent
·'nutritional stress".

32. (ii) PERSONAL HYGIENE :
(a) Persona/ cleanliness : The need to bathe every day and to wear clean
clothes should be explained. The hair should also be kept clean and tidy.
(b) Rest and sleep : 8 hours sleep, and at least 2 hours rest after mid-day meals
should be advised.
(c) Bowels: Constipation should be avoided by regular intake of green leafy
vegetables, fruits and extra fluids. Purgatives like castor oil should be avoided to
relieve constipation.
(d) Exercise: Light household work is advised, but manual physical labour
during late pregnancy may adversely affect the foetus.
(e) Smoking: nicotine has a vasoconstrictor influence in the uterus and induces
placental insufficiency. The adverse effects of smoking range from low birth-
weight to an increased risk of perinatal death.

33. (f) Alcohol : greater risk of pregnancy loss, and if they do not abort their children
may have various physical and mental problems. Heavy drinking has been
associated with a fetal syndrome (FAS) which includes intrauterine growth
retardation and developmental delay.
(g) Dental care: Advice should also be given about oral hygiene.
(h) Sexual intercourse: This should be restricted especially during the last trimester.

34. (iii) DRUGS :
Certain drugs taken by the mother during pregnancy may
affect the foetus adversely and cause foetal
malformations.
• thalidomide a hypnotic drug, which caused deformed
hands and feet of the babies born.
• LSD -cause chromosomal damage,
• streptomycin -8th nerve damage and deafness in the
foetus,
• iodide-containing preparations -congenital goitre in the
foetus.
• Corticosteroids -impair foetal growth,
• sex hormones -virilism,
• tetracyclines -affect the growth of bones and enamel
formation of teeth.
• Anaesthetic agents -depressant effect on the baby and
delay the onset of effective respiration.
• Later if the mother is breast-feeding, there are certain
drugs which are excreted in breast milk.

35. It was the 1950s. A German pharmaceutical
company was aggressively seeking approval for its
new star drug, Thalidomide. Europe approved it
first, followed closely by Australia.
A few years later it was noticed that 10,000 babies
were born without hands and feet because their
mothers had been prescribed Thalidomide.

36. (iv) RADIATION : Exposure to radiation is a positive danger to the developing foetus. The most
common source of radiation is abdominal X-ray. mortality rates from leukaemia and other neoplasms
were significantly greater among children exposed to intrauterine X-ray inaddition to congenital
malformations such as microcephaly. Furthermore, in all women of child-bearing age among whom
there is a possibility of pregnancy. Elective X-ray should be avoided in the two weeks preceeding the
menstrual period.
(v) WARNING SIGNS : The mother should be given clear-cut instructions that she should report
immediately in case of the following warning signals :
(a) swelling of the feet
(bl fits
(cl headache
(d) blurring of the vision
(el bleeding or discharge per vagina, and
(f) any other unusual symptoms.
(vi) CHILD CARE : Special classes are held for mothers attending antenatal clinics. Mother-craft
education consists of nutrition education, advice on hygiene and childrearing, cooking
demonstrations, family planning education, family budgeting, etc.

37. (3) Specific health protection
(i) ANAEMIA : about 50 to 60 per cent of women belonging to low socio-economic groups are
anaemic in the last trimester of pregnancy due to iron and folic acid deficiencies.
• Anaemia is associated with high incidence of premature births, postpartum haemorrhage,
puerperal sepsis and thromboembolic phenomena in the mother.
• The Government of India has initiated a programme in which 100 mg of elemental iron and
500 mcg of folic acid are being distributed daily for 100 days to pregnant women through
antenatal clinics, primary health centres and their subcentres.
(ii) OTHER NUTRITIONAL DEFICIENCIES : The mother should be protected against other
nutritional deficiencies that may occur, particularly protein, vitamin and mineral especially vit
A and iodine deficiency. In some MCH Centres fresh milk is supplied free of cost to all
expectant mothers; where this is not possible, skimmed milk should be given. Capsules of
vitamin A and D are also supplied free of cost.

39. (iii) ASYMTOMATIC BACTERIURIA (ASB): Urinary tract infection during pregnancy are associated
with risks to both mother and foetus including pyelonephritis, preterm birth, low birth weight
and increased perinatal mortality. The physiological changes during pregnancy makes a
pregnant woman more prone to urinary tract infection.
Midstream urine culture is the recommended method for diagnosis of ASB. The patient should
be appropriately treated for ASB.
(iv) GESTATIONAL DIABETES: Gestational diabetes is high blood sugar that develops during
pregnancy and usually disappears after giving birth. It is more common in the second half of
pregnancy. The woman develops increased risk of developing type 2 diabetes in the future.
The general symptoms are excessive thirst and hunger, frequent urination, drowsiness or
fatigue, dry itchy skin, blurring of vision, slow healing of wounds.
The second pregnancy may be associated with type 2 diabetes. Hyperglycaemia during
pregnancy can harm mother and the foetus, increasing risk of high blood pressure,
preeclampsia, miscarriage or stillbirth, birth defects and big baby (birth weight >4.5 kg).

40. (v) TOXEMIAS OF PREGNANCY = presence of albumin in urine and an increase in blood pressure .
Their early detection and management are indicated.
(vi) TETANUS : 2 doses of adsorbed tetanus toxoid should be given - the first dose at 16- 20 weeks
and the second dose at 20-24 weeks of pregnancy. No pregnant woman should be denied even
one dose of tetanus toxoid, if she is seen late in pregnancy.
For a woman who has been immunized earlier, one booster dose will be sufficient and will
provide necessary cover for subsequent pregnancies, during the next 5 years. It is advised not to
inject tetanus toxoid at every successive pregnancy because of the risk of hyperimmunization
and side-effects.

41. Pathological smile in woman with tetanus

42. (vii) Syphilis:
Pregnancies in women with primary and secondary syphilis often end in spontaneous
abortion, stillbirth, perinatal death or the birth of a child with congenital syphilis.
• Syphilitic infection in the pregnant woman is transmissible to the foetus. Neurological
damage with mental retardation is one of the most serious consequences of
congenital syphilis. When the mother is suffering from syphilis, infection of the foetus
is most likely to occur after the 6th month. And when the mother is suffering from
primary or secondary stages of syphilis.
• It is routine procedure in antenatal clinics to test blood for syphilis at the first visit.
• Congenital syphilis is easily preventable. Ten daily injections of procaine penicillin
(600,000 units) are almost always adequate.

43. (viii) GERMAN MEASLES (=Rubella)
When rubella was contracted* in the first 16 weeks of pregnancy, foetal death or death during the
first year of life occurred in 17 per cent of the pregnancies. Among survivors 15 per cent had major
defects. of which cataract, deafness and congenital heart diseases were the most common.
Currently vaccination of all school-aged children is done with rubella vaccine through routine
immunization schedule. Supplementing the community control of infection is the vaccination of all
women of childbearing age who are sero-negative.
Before vaccinating, it is advisable that pregnancy be ruled out and effective contraception be
maintained for 8 weeks after vaccination because of the possible risk to the foetus from the virus.

44. (ix) Rh STATUS : The foetal red cells may enter the maternal circulation during
labour, caesarean section, therapeutic abortion, external cephalic version, and
even spontaneously in the late pregnancy.
• The intrusion of these cells, if the mother is Rh-negative and the child is Rh-
positive, provokes an immune response in her so that she forms antibodies to
Rh which can cross the placenta and produce foetal haemolysis.
• In a pregnant woman, isoimmunization mainly occurs during labour, so that
the first child although Rh-positive, is unaffected except where the mother has
been already sensitized.
• In the second or subsequent pregnancies, if the child is Rh-positive, the
mother will react to the smallest intrusion of foetal cells by producing
antibodies to destroy foetal blood cells causing haemolytic disease in the
foetus. Clinically haemolytic disease takes the form of hydrops foetalis,
kernicterus and congenital haemolytic anaemia.

45. 1st pregnancy 2nd pregnancy

46. • If the woman is Rh-negative and the husband is Rh-
positive, Rh anti-D immunoglobulin should be
given at 28 weeks of gestation so that sensitization
during the first pregnancy can be prevented.
• If the baby is Rh-positive, the Rh anti D
immunoglobulin is given again within 72 hours of
delivery.
• It should also be given after abortion. Post
maturity should be avoided.
• The incidence of haemolytic disease due to Rh
factor in India is estimated to be approximately
one for every 400 to 500 live births.

47. (x) HIV INFECTION : HIV may pass from an infected mother
to her foetus, through the placenta or to her infant during
delivery or by breast-feeding. About one-third of the
children of HIV- positive mothers get infected through this
route. The risk of transmission is higher if the mother is
newly infected or if she has already developed AIDS.
Universal confidential voluntary screening of pregnant
women in high-prevalence areas may allow infected women
to choose therapeutic abortion, make an informed decision
on breast-feeding, or receive appropriate care.
(xi) HEPATITIS B INFECTION : Spread of infection can occur
from HBV carrier mothers to their babies. Most infections
appear to occur at birth. Vertical transmission can be
blocked by immediate post-delivery administration of B
immunoglobulin and hepatitis B vaccine.

48. (xii) PRENATAL GENETIC SCREENING :
screening for chromosomal abnormalities, congenital
structural anomalies, and haemoglobinopathies and
other conditions detectable by biochemical assay.
Universal genetic screening is generally not
recommended.
Typical examples are screening for trisomy 21 (Down's
syndrome) and severe neural tube defects.
Women aged 35 years and above, and those who already
have an afflicted child are at higher risk.
(4) Mental preparation
Mental preparation is as important as physical or
material preparation. Sufficient time and opportunity
must be given to the expectant mothers to have a free
and frank talk to remove her fears about confinement.
The "mothercraft" classes at the MCH Centres help a
great deal in achieving this objective.

49. (5) Family planning
The mother is psychologically more receptive to advice on family planning than at
other times. Educational and motivational efforts must be initiated during the
antenatal period. If the mother has had 2 or more children, she should be
motivated for puerperal sterilization. (All India Postpartum Programme service)
(6) Paediatric component: a paediatrician should pay attention to the under-fives
accompanying the mothers in ANC

50. • Homework- Go through the MCP card pdf
https://avpn.asia/wp-content/uploads/2020/04/India-MCP-Card-
English_01-05-2018.pdf
• Next class on- Intranatal and postnatal care