1. ANTENATAL CARE

2. ANTENATAL CARE
• Antenatal care is the medical supervision of women
during pregnancy, from the time of conception until the
labor.
• During antenatal period, maternal as well as fetal
monitoring is done on a regular basis.
• Early diagnosis during pregnancy can prevent
maternal ill-health, injury, maternal mortality, fetal
death, infant mortality and morbidity.
.

3. AIMS:
•The main aim of antenatal care is to promote maternal
health and help in normal fetal development.
The objectives of antenatal care are:
• Assess the health status of the mother and fetus.
• Promote and maintain health status of the mother during
the antenatal period.
• Screen the high-risk pregnancy; and prevent and treat
any untoward complications.

4. • Orient mother with physiology of pregnancy and
labor. Remove anxiety and fear associated with
pregnancy.
• Reduces maternal and infant morbidity and mortality.
• Discuss with the couple about time, place and mode of
delivery.
• Motivate the couple about need of family planning

5. For a normal pregnancy, generally 5 check ups are advised at
10th week, 18th week, 24th week, 30th and 36th week
Antenatal assessment
• Assessment of maternal and fetal well being is done during
antenatal period is done through history taking, physical
examination and abdominal examination of mother.

6. FIRST VISIT
History and physical examination
During the first visit, a detailed history is taken from the mother.
It includes the following-
1.General information:Name, Address,Date,Age, Gravida and
parity,L.M.P and E.D.D
2.Period of gestation

7. 3.History of present pregnancy
Last menstrual period dates - calculate Expected Day of Delivery
(EDD)
• cycle regularity
• history of recent oral contraceptive pill use
•early ultrasound assessment of gestational age
•Booking visit - gestational age, first trimester blood pressure
measurements, screening serology (blood group, Rh and RBC
antibodies, rubella immunity, hepatitis B, syphilis, and HIV status)

8. • Naegele's rule
• Naegele's rule is a standard way of calculating the due date for a
pregnancy when assuming a gestational age of 280 days at childbirth.
• The rule estimates the expected date of delivery (EDD) by adding a
year, subtracting three months, and adding seven days to the origin of
gestational age.
• The Naegele's formula is a simple arithmetic method for calculating the
EDD (estimated date of delivery) based on the LMP (last menstrual
period).
• To the date of the first day of the LMP (e.g. 22nd June 2008): add seven
days (i.e 29th) subtract 3 months (i.e March)

9. Obstetrical History-
•Number of pregnancies
•Date and year of pregnancies
•Pregnancy / special labor
•Mode of delivery
•Sex and health status of events the baby
•Problems in labour and pregnancy

10. Menstrual history-
Menstrual history is taken from the mother stating her age at
menarche; frequency, duration and amount of menstrual blood flow
and any dysfunctional uterine bleeding. LMP is also noted, which
helps in telling the expected date of delivery.

11. Family history-
• Family history tells about any genetic disease in the family, or any
racial characteristics.
• Certain diseases which run in the families, should be noted such
as, hypertension, diabetes, tuberculosis, multiple pregnancies etc.
Past medical and surgical history-
Any history of past medical diseases or previous surgeries as to be
noted.

12. Personal history-
•About adequate Nutrition,morning sickness,weight gain
•Rest and sleep
•Activity ad exercises
•Any history of tobacco chewing,smoking or alcohol habits
•Use of any contraceptive methods,intrauterine devices.
•Sexual history:Any intercourse during pregnancy
•Elimination:Frequency of micturation,constipation

13. Previous gynaecological problems:
• STIs,
• endometritis,
• infertility,
• surgery,
• PCOD

14. PHYSICAL EXAMINATION
Physical examination is done during early antenatal period to find out any
abnormalities or diseases.
The physical examination is carried out systematically, in an organized
manner.
Height- It is taken as soon as the mother comes for her first antenatal check
up. If she is short statured, there are chances of small pelvis.
Weight- Each time, weight must be taken from the same weighing machine.

15. General build- It is noted whether woman is obese, average or thin.
Eyes- Inspect for anemia from the conjuctiva and jaundice from the
sclera.
Ears- Look for ear ache, any discharge, tinnitus etc.
Oral cavity- It is to be inspected for gossitis, stomatitis etc.
Neck- It is checked for thyroid and lymph nodes.
Breasts- To be examined for flat, inverted or cracked nipples

16. Vital signs-
• Pulse is checked. In respiration, breathing pattern, rhythm, rate and
wheezing etc are noticed.
• Blood pressure reading provides baseline data for comparison in whole
pregnancy. Adequate blood pressure is needed to maintain placental
perfusion.
• Lower extremities- Legs are examined for edema. Oedema is caused by
the pressure of the gravid uterus on the iliac veins of the lower extremities,
leading to increased venous pressure. Varicosities are also observed.
• Blood tests are also performed to check for Hemoglobin, ABO and Rh
factor. eOn first visit of mother, history should be taken from the mother as
mentioned before.

17. • An important thing, which is to be mentioned here is-
Antenatal Examination-
Before performing the obstetric examination of the mother, she should
be asked to evacuate the bladder. After making her lie in dorsal
position, she is made to flex her knees. Examination is performed by
fully exposing the abdomen and the examiner stands on the right side
of the mother.

18. 1) Inspection-
• The size and shape of the uterus is assessed.
• An examiner can so observe fetal movements.
• In multiparous woman, one may note pendulous domen, in which the
uterus sags forward.
• Skin condition and presence of any scar noted.
• Linea nigra may be seen.

19. 2) Palpation-
• Before doing palpations, examiner must make her hands warm and
finger pads should be used for examination, instead of fingertips.
•At first, height the uterus is noted by placing the ulnar border of the left
hand on the upper order of the fundus.
•The distance is measured between the fundal border and the symphysis
pubis and is termed as SFH (symphysis fundal height).
• Leopold manoeveuvres is used to determine the fetal lie, presentation,
position according to Leopold, there are four maoeveuvres.

20. First manoeveuvre
(Fundal palpation)-
 It is done by facing the mother.
 Both hands are placed on the woman's
fundus and fingers are curved around
the top of the fundus.
 Palpation is done for the fetal parts.
 The round, hard and movable head
suggests of fetal head, whereas broad,
soft and irregular mass suggests of
breech.
 If nothing like this is palpated, it is
suggestive of a transverse lie.

21. Second manoeveuvre (Lateral
palpation)-
 Examiner continues facing the
mother.
 Both hands are placed on the
uterus, between the symphysis
pubis and the uterine fundus.
 Gently pressure is put, pushing
the fetus to the other side.
 With pressure on one side, the
other side is palpated.

22.  A smooth, curved and resistant feel
suggests fetal back.
 If there is a feeling of irregular
mass, which moves when pressed,
it suggests of the fetal limbs.
Another method to locate the fetal
back is by walking the fingertips of
both hands over the abdomen.

23. Third manoeveuvre (Pawlik's
manoeveuvre)
- Keep facing the woman's head and
make her to bend the knees, so that
abdomen is relaxed.
- The portion of lower abdomen is held
by the examiner with her hands and is
pressed into the abdomen to feel the
presenting part.
- If presenting part is not engaged, a
movable mass is felt.
- In case, engagement has occurred,
there is no movable mass felt by
examiner.

24. Fourth manoeveuvre (Pelvic
palpation)-
• Examiner should face woman's feet
and knees of the woman are bent.
• Hands are placed on the sides of the
uterus, just below the umblical level
and grasped snugly, held close
together, pointing downwards &
inwards.

25. • The attitude of head is determined
by noting the position of sincipital
and occipital poles.
• Keep the hands moving towards
the pelvic inlet.
• If the hands divulge away,it shows
the presenting part is engaged.
• Incase the hands are converging,it
is suggestive of non-engagement
of the head.

26. • A hard mass with distinctive round, smooth surface felt, then head is
presenting part.
• - Sinciput will be felt on the opposite side from the back and higher than the
occiput - indicates well flexed head.
• If the prominences - Sinciput & occiput at the same level - indicates deflexed
head.
• * If bulk of head felt on the same side as back - indicates extended head.

27. Auscultation-
With the use of pinard's fetal stethoscope, examiner can hear the heart
sounds of the fetus.
It is placed on the mother's abdomen, at right angles to it over the fetal
back. Ear is placed in firm contact with the fetoscope, without touching it.
The fetoscope is moved to the point of maximum intensity of the sound and
F.H.S is heard.
Generally, it is heard below the umblicus in cephalic presentation and
around the umbilicus in breech presentation.
F.H.S depends upon the position of the back of the fetus.
Leopold's maneuver Fundal Grip(First maneuver) Lateral Grip(Second
maneuver) Pawlik's Grip (Third maneuver) Pelvic Grip (Fourth maneuver)

30. SCREENING AND ASSESSMENT FOR HIGH RISK
A pregnancy, which is at risk for serious complications, is
considered to be a high-risk pregnancy.
All pregnancies should be evaluated to determine whether
there are or will be risk factors.
Classifying a pregnancy as high risk helps ensure that it
receives extra attention.
Screening options are available to provide a risk assessment
for specific birth defects during pregnancy and involve no risk
of miscarriage
The most common reason for referral is risk of preterm
delivery, often associated with premature rupture of the
membranes.

31. A major benefit of screening and assessment of high-risk
mothers is,
- If the problem or any complicating factor is detected early, there
are better chances for a mother to deliver a healthy baby.
Not only the baby, but if the problem is assessed in early pregnancy,
the outcome of the mother is also very good.

32. The high-risk cases are-
• Obstetrical history revealing-
Previous stillbirth
Previous neonatal death
Previous premature infant
• History of recurrent abortions
Fetal blood transfusion for hemolytic diseases
• Medical history of mother revealing-
Maternal illness Chronic hypertension Abnormal PAP test Insulin dependent
diabetes Renal disease Rh-isoimmunization
• Maternal physical risk factors- Incompetent cervix Uterine malformations

33. Risk factors in current pregnancy-
• Moderate to severe preeclampsia
• Polyhydramnios or oligohydramnios
• Placenta previa
• Multiple pregnancies
• Abruptio placenta

34. • Abnormal fetal position
• Vaginal bleeding
• Malpresentation
• Excess or decreased liquor
• Small for date gestation
• Changed fetal pattern
• Lower Hb, less than 10y/dl
• Poor weight gain
• B.P. Systolic, more th Proteinuria, glycosuria than 155mm of Hg/
vaginal infection

35. Pregnancy at risk require
• * Antenatal care at hospital.
• * Referral at proper time.
• Identification of High Risk Pregnanc

36. RISK APPROACH AND SCREENING OF CASES
In the early pregnancy, the things that are taken into account are-
• Blood tests including haemoglobin, ABO and Rh grouping, blood sugar
levels.
• Excessive weight gain of the mother due to fluid retention.
• Falling weight also poses a risk, as there can be intrauterine growth
retardation.
• Pre-existing hypertension or pregnancy-induced hypertension causes a
risk for mothers as well as fetuses.
• Excess amount or decreased amount of amniotic fluid is another risk
factor.
• Other approaches, which should be followed for high-risk cases, are:

37. Maternal serum alpha-feto protein (MSAFP)-
•In alpha feto protein, test of maternal serum and amniotic fluid is
done. It is done, if the woman is having risk of having a baby with a
neural tube defect or other congenital defects.
• If AFP level is high, it indicates a fetal pathology; and if the level is
low, it is suggestive of Down syndrome.
•In certain cases the MSAFP level is increased, such as multiple
pregnancy, calculation of wrong gestational age, open neural tube
defects, renal anomalies etc.
•Time of performing test- 15-18 weeks.

38. Chorionic villus sampling-
• In this the sample of chorionic villi is taken
under the guidance of ultrasound.
• Few villi can be collected from chorion
frondosum, transcervically (catheter is
introduced through cervix), or
transabdominally (insertion of needle into
the maternal abdomen, through the uterine
wall and into the placental tissue).
• Diagnosis is obtained by 24 hours.
• The positive thing about this test is that
results are obtained early, and if termination
is required, it can be done in first trimester
only.

39. Chorionic villus sampling-
•This test is also associated with fetal loss, limb deformities, vaginal
bleeding etc.
• Apart from a risk of miscarriage, there is a risk of infection and
amniotic fluid leak.
•The resulting amniotic fluid leak can develop into a condition known
as oligohydramnios which is low amniotic fluid level.
Time of performing test- after 10 weeks.

40. Cordocentesis-
•In this, fetal blood sample is taken in pregnancy,
to check for any chromosomal abnormality or
blood affecting disorder.
•A needle is inserted through the maternal
abdomen under the guidance of ultrasound, to
puncture the umbilical vein and collect 0.5 to 2
ml of fetal blood.
•This test may lead to preterm labor, abortion or
intra uterine death of the fetus.
•Time of performing test- after 18 weeks.

41. Triple test-
• This test includes the combination of three tests- maternal serum alph
afeto protein, hCG and unconjugated oestriol.
•This test tells about the presence of Down's syndrome.
•If the pregnancy is affected, MSAFP and oestriol is low and hCG is
high.
•Time of performing test- 16-18 weeks.

42. Amniocentesis-
In this there is the aspiration of
amniotic fluid via the
transabdominal insertion of a fine
needle into the amniotic cavity.

43. PROCEDURE-
• Before the actual procedure, a local anesthetic may be given to relieve the pain
when inserting the needle used to withdraw the fluid.
•A needle is inserted through the mother's abdominal wall through the wall of the
uterus into the amniotic sac.
•With the aid of ultrasound-guidance, needle is guided towards an area of ​​the
sac that is away from the fetus and extracts approximately 20ml of amniotic fluid
for testing.
•Amniotic fluid has cells that have been shed by the developing fetus.
• The cells are checked for the number and size of chromosomes (karyotype) to
see if there are any problems that put the baby at risk for certain conditions.
• After the amniotic fluid is extracted, the fetal cells are separated from it, The
cells are grown in a culture medium, then fixed and stained. Under a
microscope the chromosomes are examined for abnormalities.

44. • The most common abnormalities detected are chromosomal disorders
such as Down syndrome, Edward syndrome [Trisomy 18] and Turner
syndrome; neural tube defects such as spina bifida and anencephaly.
The test can identify several hundred genetic disorders.
• Amniocentesis can also reveal whether the mother or baby is RH-
negative, and whether the baby's lungs are mature enough for him to
be born if immediate termination is required. Amniocentesis doesn't
detect every kind of abnormality, however - for example, it can't tell
whether the baby has a cleft lip or palate.

45. Amniocentesis is done during pregnancy when:
• We want to confirm indications of Down's syndrome and certain other
defects. a woman previously having a chromosomal affected pregnancy
or genetic disorder.
• Abnormalities detected by ultrasound examination indicating an increased
risk of a chromosome abnormality.
• Either of the parent is having genetic disorder or family history of birth
defects.
• Recommended for women older than 35 years.
• A woman requests it because she is concerned that her baby may have a
chromosome abnormality.

46. Risks associated with amniocentesis-
• Maternal or fetal hemorrhaging- Bleeding following amniocentesis should
always be investigated.
•Infection- Infection can occur after amniocentesis which can lead to severe
complications.
•Fetal injury- There is a risk of injury to the fetus resulting from contact with
the needle used for amniocentesis.
Miscarriage- There are chances of miscarriage, but the rate is quite
less. Many fetuses with severe genetic defects miscarry naturally during the
first trimester.
Time of performing test- After 14-16 weeks.

47. Amniocentesis in late pregnancy-
Amniocentesis can also be done in third trimester, mainly to see whether
baby’s lungs are developed. The developing fetus makes many substances
that can be found and measured in amniotic fluid. The amounts of these
substances show how mature the lungs are and if the baby will be able to
breathe without help if delivered early.

48. The confirmation of lung maturation is done to minimize the chances of respiratory distress
syndrome of the baby. In this test, specifically we are looking for
• Lecithin: Sphingomyelin ratio and identification of phosphatidyl glycerol.
• Fetal movement count- In the later pregnancy, fetal well-being is assessed by having
the fetal movement count.
• In Cardif 'count 10' formula, the patient is told to count the 10 fetal movements,
starting from a particular time. She should report to the physician, if she feels less than
10 movements in 12 hours, on two consecutive days.
• In Daily fetal movement count (DFMC), mother is told to count the fetal movements
for one hour, three times a day (say, morning, afternoon and evening). Later, the total
count is multiplied by 4, which gives DFMC. Mother should report if she feels less than
10 movements in 12 hours.

49. MODALITIES OF DIAGNOSIS; INVASIVE AND NON INVASIVE
For the prenatal screening and diagnosis, various invasive and non-invasive
methods are used.
Non-Invasive methods
• Examination of the woman's uterus from outside the body.
• Ultrasound detection.
• Listening to the fetal heart sound (FHS).
• External fetal monitoring, often known as a non-stress test.

50. Invasive methods
Chorionic villus sampling- CVS involves getting a sample of the
chorionic villus and testing it.
Amniocentesis- It is done in second trimester, by obtaining amniotic
fluid from aniotic sac. Cells from the fetus will be floating in this fluid,and
can be separated and tested.
Fetoscopy- These involve putting a probe into a women's uterus to
observe with ultrasonic guidance to sample blood or tissue from the
embryo or fetus.
MSAFP- Maternal serum alpha feto protein

51. Ultrasonics
• Ultrasound scan is currently considered to be a safe, non-invasive,
accurate and cost-effective investigation in the fetus.
• An ultrasound scan involves transmitting high frequency sound waves
through the uterus.
•These bounce off the baby and the returning echoes are translated by
a computer into an image on a screen that reveals the baby's position
and movements.

52. • Hard tissues such as bone reflect the biggest echoes and are white
in the image, and soft tissues appear gray and speckled.
•Fluids (such as the amniotic fluid that the baby lies in) do not reflect
any echoes so appear black.
•It is the contrast between these different shades of white, gray and
black that allows the sonographer to interpret the images
A full bladder is often required for the procedure when abdominal
scanning is done in early pregnancy.

53. Uses of ultrasound-
1) Check viability of the fetus- The heartbeat of the fetus can be checked by
ultrasound.
2) Check the number of pregnancies- It tells whether the mother is pregnant
with one baby or more usually before 14 weeks, ultrasound scanning is
used to check whether the fetus is alive and whether it is alone or one of
twins or triplets.
3) Detects an ectopic pregnancy- Abnormality such as that of ectopic
pregnancy can be detected, where the embryo implants outside of the
womb, usually in the Fallopian tube.

54. Doppler umbilical velocimetry –
Doppler ultrasonography measures the velocity at which RBC's in uterine
and fetal vessels travel. This is helpful to determine the vascular resistance
present in women with diabetes or hypertension of pregnancy and whether
resultant placental insufficiency is occurring.
Placental grading - It is based particularly on the amount of calcium
deposits in the placenta. Placenta can be graded as 0 (12-24 weeks), 1 (30-
32 weeks), 2 (36 weeks) or 3 (38 weeks).

55. Amniotic fluid volume assessment –
• If fetus becomes stressed in utero with dectrease in amniotic fluid,
it puts fetus at risk of umbilical cord compression and interferes
with nutrition. For less than 20 weeks, the uterus is divided along
the midpoint (linea nigra) into two vertical line halves. The vertical
diameter of the largest pocket of amniotic fluid present on each
side is measured in cms. Amniotic Fluid Index (AFI) is sum of the
two. After 20 weeks, the uterus is divided into four parts and a sum
of four is taken. Average AFI: 12-15 cm (28-40 weeks); 5-6
(oligohydramnios), 20-24 (polyhydramnios).

56. Detect cause of vaginal bleeding-
Ultrasound helps in finding out the cause of any bleeding the mother may be
having. In case of vaginal bleeding, viability of the fetus is also assessed by
ultrasound. A visible heartbeat could be seen and detectable by pulsed
Doppler ultrasound for about 6 weeks and is usually clearly depictable by 7
weeks.
Find out accurately date of pregnancy-
Exact date of pregnancy can also be found out by measuring the baby. In
patients with uncertain last menstrual periods, such measurements must be
made as early as possible in pregnancy to arrive at a correct dating for the
patient.

57. The measurements made are:
a) The Crown-rump length (CRL)
This measurement can be made between 7 to 13 weeks and gives very accurate
estimation of the gestational age.
b) The Biparietal diameter (BPD)
The diameter between the 2 sides of the head. This is measured after 13 weeks-
increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Fetus at 9 weeks
c) The Femur length (FL)
Measures the longest bone in the body and reflects the longitudinal growth o= e
fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14
weeks to about 7.8 cm at term.
d) The Abdominal circumference (AC)
The single most important measurement to make in late pregnancy. It reflects ore of
fetal size and weight rather than age

58. • Assess the risk of Down's syndrome-
• Presence of Down's syndrome can be detected by measuring fluid at the
back of the baby's neck at 11-14 weeks (what's called the nuchal
translucency scan).
• Some major abnormalities can also be detected at this stage. At 11 to 14
weeks, measurement of the thickness of the skin at the back of the neck
(known as nuchal translucency measurement) can be used to calculate the
risk of the fetus having a chromosome abnormality.
• Find out why a blood screening test was abnormal. Assist in performing
diagnostic tests- Certain tests to assess fetal well being, such as CVS or
amniocentesis, are performed safely with the help of ultrasound, by showing
the position of the baby and placenta.
•

59. • Development of fetus- From 18 weeks onwards, it is possible to
examine the fetus in more detail. Most organ systems can be
examined to ensure that the fetus appears to be developing
normally. The spine, skull, brain, heart, lungs, kidneys, arms and
legs can all be seen.
• • Diagnose certain abnormalities- Such as spina bifida. Many
structural abnormalities in the fetus can be reliably diagnosed by an
ultrasound scan, and these can usually be made before 20 weeks.