Antenatal care in detail

1. Antenatal Care

2. What is Antenatal care
• Periodic and regular supervision including
examination and advice of a woman during
pregnancy is called Antenatal care.
• The supervision should be of a regular and
periodic nature in accordance with the need
of the individual.

3. Aims
The aims are-
• To screen the high risk cases
• To prevent or detect or treat at the earliest
any complication
• To ensure continued medical surveillance and
prophylaxis
• To educate the mother about the physiology
of pregnancy and labour by demonstrations,
charts and diagrams so that fear is removed
and psychology is improved

4. Aims (cont’d)
• To discuss with the couple about the place,
time and mode of the delivery, provisionally
and care of the newborn
• To motivate the couple about the need of
family planning
• To advice the mother about breast-feeding,
post-natal care and immunization

5. Objectives
To ensure a normal pregnancy with
delivery of a healthy baby from a
healthy mother

6. Criteria of normal
pregnancy
Delivery of a single baby in good
condition at term with no maternal
complication

7. Services
As per WHO recommendation at least 4 visit-
• 1st visit around 16 weeks
• 2nd visit between 24-28 weeks
• 3rd visit at 32 weeks
• 4th visit at 36 weeks

8. Services (cont’d)
Generally-
• At interval of 4 weeks up to 28 weeks
• At interval of 2 weeks up to 36 weeks
• At weekly interval up to EDD

9. Antenatal care comprises of-
• Careful history taking and examination and
investigation
• Advice given to the pregnant woman

10. • Gravida denotes a pregnant state both
present and past, irrespective of the period of
gestation.
• Parity denotes a state of previous pregnancy
beyond the period of viability
• Gravida and para refer to pregnancies and
not to babies. As such, a woman who delivers
twins in first
• pregnancy is still a gravida one and para one.

12. THE FIRST VISIT
• History taking
• Examination
• Investigation

13. History taking
1. Particulars of the patient
2. Chief complaints with duration
3. Past history
4. Obstetric history
5. Menstrual history
6. Family history
7. Drug History
8. History of immunization
9. Socio-economic history
10.Contraceptive history
11.History of allergy

14. Particulars of the patient
1. Name
2. Age
3. Address
4. Marital status
5. Date of Admission
6. Date of Examination

15. Chief complaints with duration
1. Period of amenorrhea
2. Nausea & vomiting, vertigo
3. Increased frequency of micturition
4. Constipation
5. Heaviness of breast
6. Rise of temperature
7. Edema
8. Pain in the abdomen
9. Backache
10. Vaginal bleeding

16. Past history
1. HTN
2. DM
3. BA
4. Renal Disease
5. Psychiatric illness
6. IHD
7. Any previous operation

17. Obstetrical History
• Duration of marriage
• Gravida
• Para
• ALC

18. Menstrual History
Age of menarche
Menstrual period
Menstrual cycle
LMP
EDD

19. Family history
a) HTN
b) DM
c) Multiple pregnancy

20. Drug History
Antihypertensive
Hypoglycemic
Antidepressant
Corticosteroid
Anticoagulant

21. Physical examination
General examination
Abdominal examination

22. General examination
• Appearance
• Height of patient
• Weight of patient
• Anemia
• Jaundice
• Edema
• Cyanosis
• Clubbing
• Koilonychia

23. General examination (cont’d)
• Temperature
• Pulse
• BP
• RR
• Breast
• Heart sound
• Lungs

24. Abdominal examination
Inspection
Palpation
percussion
Auscultation

25. Inspection
Shape of the uterus
Striae
scar mark

26. Palpation
• Assessment of fundal height
• Lie
• Abdominal girth
• Fundal grip
• Lateral grip
• First pelvic grip
• Second pelvic grip

27. Auscultation
Normal FHR is 120-160 b/m
Causes of fetal tachycardia (>160 b/m)
Causes of fetal bradycardia (<120 b/m)

28. Causes of fetal tachycardia
(>160 b/m)
1. Maternal high fever
2. Fetal distress
3. Maternal tachycardia

29. Causes of fetal bradycardia
(<120 b/m)
1. Fetal distress
2. Fetal cardiac conduction defect

30. Investigation
• CBC
• Blood grouping & Rh typing
• Urine R/E
• RBS
• VDRL
• HBS Ag
• HIV1 &2
• Ultrasound

31. Ultrasound
early pregnancy (preferably at 10-13 weeks) to:
• Determine gestational age
• Detect multiple pregnancies
• Help with later screening for Down's syndrome

32. Ultrasound (cont’d)
At 11-14 weeks:
offer nuchal translucency screening for Down's
syndrome, with other tests if available.
At 18-20 weeks:
offer screening with ultrasound for congenital
anomalies.
At 36 weeks:
for fetal maturity, placenta praevia.

33. In subsequent visit
• Patient complaints
• General examination
• Gestational age to be calculated
• Identification of problem
• Fetal movement
• SFH measurement
• Health education
• Prophylaxis & treatment of anemia
• Developing individualized birth plan

34. Second visit (24-28 weeks)
SFH measurement
To detect Multiple pregnancy

36. • Three-agent Tdap vaccine—tetanus toxoid,
reduced diphtheria toxoid, and acellular pertussis (Centers
for Disease Control and Prevention,2013a) maternal
antipertussis antibodies are relatively short-lived, and Tdap
administration before pregnancy—or even in the first half of
the current pregnancy—is not likely to provide a high level of
newborn antibody protection. The
• Advisory Committee on Immunization Practices, therefore,
has recommended that a dose of Tdap
• be given to women during each pregnancy, optimally
between 27 and 36 weeks’ gestation to
• maximize passive antibody transfer to the fetus

37. Third visit (32 weeks)
Screen for-
1. Preeclampsia
2. Multiple pregnancy
3. anemia
4. IUGR

38. Fourth visit (36 weeks)
• Identification of fetal
1. Lie
2. Presentation
3. Position
• Update birth plan

39. Antenatal advice
Principles:
1. To impress the patient about the importance of
regular check up
2. To maintain or improve the health status of the
woman to the optimum till delivery by judicious
advice regarding diet, drugs and hygiene
3. To improve and tone up the psychology and to
remove the fear of pregnancy by talking
sympathetically to the patient and explaining the
principle changes and events likely to occur
during pregnancy

40. Antenatal advice (cont’d)
• Diet
• Rest & sleep
• Bowel
• Personal cleanliness
• Clothing, shoes & belt
• Dental care
• Care of breast
• Coitus
• Travelling
• Smoking & alcohol
• Immunization
• Drug
• Mental preparation
• Exercise
• Child care
• Birth plan
• Warning sign
• Family planning
Following advices are to be given:

41. Diet
Diet should be:
1. nutritious
2. balanced
3. light
4. easily digestible
5. rich in protein, mineral and vitamin
6. with woman’s choice

42. DDA of a woman during pregnancy (2nd half)
Food element pregnancy
Kilocalories 2500
Protein 60 gm.
Iron 40 mg
Folic acid 400 mg
Calcium 1000 mg
Vitamin A 6000 I.U.

43. Rest and sleep
• 8 hour sleep at night
• At least 2 hour sleep after mid-day
meal
• Hard strenuous work should be
avoided in first trimester and last 4
weeks

44. Bowel
• Regular bowel movement may be facilitated
by regulation of diet, taking plenty fluid,
vegetable and milk
Coitus
Should be avoided in
• 1st trimester
• last 6 weeks

45. Travelling
Should be avoided in
• 1st trimester
• last 6 weeks
Air travelling is contraindicated in
• Placenta previa
• Preeclampsia
• Severe anemia

46. Immunization
Indicated-
• TT
• HAV
• HBV
• Rabies
Contraindicated-
• Live virus vaccine (rubella measles, mumps,
varicella)

47. Warning sign
1. Headache
2. Blurring of vision
3. Convulsion
4. Vaginal bleeding
5. Fever

48. Preconceptional care
 Preconceptional care is the one step ahead of
antenatal care.
 When a couple is seen and counseled about
pregnancy, its course and outcome before the
time of actual conception, is called
Preconceptional care.
 Objective: to ensure that, a woman enters
pregnancy with an optimal state of health
which would be safe both to herself and the
fetus.

49. Preconceptional care includes:
 Identification of high risk factor
 Basal level health status including BP recording
 Rubella & Hepatitis immunization
 Folic acid supplementation
 Maternal health is optimized preconceptionally
such as overweight, anemia
 Patient with medical disease like hypertension,
diabetes are stabilized in an optimal state by
intervention

50. Preconceptional care includes: (cont’d)
 Drugs used before pregnancy are verified and
changed if required to prevent any adverse effect of
the fetus; e.g., warfarin is replaced with heparin, oral
anti-diabetic drug with insulin
 Advise to stop smoking, alcohol and drug abuse
 Proper counseling to those with history of recurrent
foetal loss or family history of congenital
abnormalities
 Counseling regarding health care cost
 Find out supporting or helping people to help the
mother and care of the new born