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INTRODUCTION –
Every Year there are an estimated 200 million pregnancies in the world. Each of these pregnancies
is at risk for an adverse outcome for the woman and her infant.
While risk can not be totally eliminated, they can be reduced through effective, and acceptable
maternity care.
To be most effective, health care should begin early in pregnancy and continue at regular intervals.
MEANING-
Systematic supervision (examination&advice) of a woman during pregnancy is called antenatal
(Prenatal) care. The supervision should be regular and periodic in nature according to the need of
the individual.
DEFINITION-
1. Antenatal care refers to the care that is given to an expected mother from time
of conception is confirmed until the beginning of labor.
2. Planned examination and observation for the woman from conception until
the beginning of labor.
1. To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
2. Prevention, early detection,and treatment of pregnancy-related complications as Pre-
eclampsia, eclampsia,andhemorrhage.
3. Prevention, early detection and treatment of medical disorders as anemia and diabetes.
4. Detection of early malpresentation, malposition’s,and disproportion that may influence the
decision of labor.
5. Instruct the pregnant woman about hygiene, diet and warning symptoms.
6. Laboratory studies of parameters may affect the fetus as blood group, Rh typing,
toxoplasmosis,and syphilis.
Delivery of a single baby in good condition at term ( 38 – 42 weeks), with a fetus weight of
2.5 kg or more and with no maternal complication.
OBJECTIVES –
1. To assess the health status of the mother and fetus.
2. To assess the fetal gestational age and to obtain baseline investigation.
3. To screen out the “at risk” pregnancy and to formulate the plan of subsequent
management.
HISTORY TAKING –
1. Vital statistics
a) General Examination of the Mother name, age, gravida, parity, expected date of
delivery.
b) Period of gestation
Gravida denotes a pregnant state both present and past irrespective of the
period of gestation.
Parity denotes the state of previous pregnancy beyond the period of
viability.
c) Duration of marriage- This is relevant to note the fertility or fecundity. A
pregnancy long after marriage without taking any method of contraception is
called low fecundity and soon after marriage is called high fecundity. A woman
with low fecundity is unlikely to conceive frequently.
d) Religion
e) Occupation – It is helpful to interpret symptoms of fatigue due to excess
physical workor stress occupation hazard. Such women should be informed to
reduce such activities.
f) Occupation of husband-
To access the socioeconomic condition of the patient,
To anticipate the complications likely to be associated with low social
status such as anaemia, pre-eclampsia, prematurity etc.
To give reasonable and realistic antenatal advice during family planning
guidance.
g) Period of gestation- The duration of pregnancy is to be expressed in terms of
completed weeks, a fraction a week of more than 3 days is to be considered as
completed week. In the early pregnancy it is calculated from the first day of last
normal menstrual period(LNMP) and in later month of pregnancy it is
calculated from the expected date of delivery.
2. Complaints
Elaboration of the chief complaints as regard their onset, duration, severity, use of
medications and progress.
Calculation of EDD
6. Menstrual History
Age at menarche, frequency, duration and amount of flow, premenstrual symptoms,
dysfunctional uterine bleeding.
Calculation of the expected date of delivery(EDD)- This is done according to Naegele’s
formula by adding 9 calendar month and seven days to the first day of the last menstrual
period. Alternatively, one can count back 3 calendar months from the first day of last
period and then add 7 days to get the expected date of delivery.
9. Family History
Family History of diabetes, hypertension, tuberculosis, multiple pregnancy, non-hereditary
disease if any or twinning, congenital anomaly of fetus is to be inquired.
10. Personal History
About the nutrition, morning sickness, weight gain.
Rest and sleep 8 hours during night and 2 hours during day time.
Activity and exercise.
Habits such as alcoholism, smoking, tobacco chewing.
Marital, any consanguineous marriage and duration of marriage.
Contraception such as pills or intra uterine devices.
Drugs during pregnancy
Sexual history- any intercourse during pregnancy.
Elimination- Frequency of micturition, Constipation.
PHYSICAL EXAMINATION-
Objectives-
To assess-
Fetal well being.
Lie , presentation, position and number of fetuses.
Anaemia, pre-eclampsia, amniotic fluid volume and fetal growth.
To organize specialist antenatal clinics for patients with problems like cardiac disease
and diabetes.
To select, time for ultrasonography amniocentesis or chorionic villous biopsy when
indicated.
History Collection
Appearance of any new complaints, quickening, lightening, examination.
Weight, pallor, oedema of legs, BP monitoring Abdominal examination.
1st trimester: Height of the fundus
2nd trimester: External ballotment, fetal movements, palpation of the fetal parts, fundal height
3rd trimester: Identify lie, presentation, position, growth pattern, engagement, girth of the
abdomen, fundal height.
Uncover the patient’s abdomen from the xiphisternum to the public hairline, ensuring
adequate exposure while allowing for patient modesty. Abdominal wall relaxation is maximized
by the patient resting her arms alongside her abdomen, rather than behind her head. The
patient’s legs may also be slightly flexed at the hips to aid relaxation.
Inspection: The presence of an abdominal mass arising from the pelvis consistent with
pregnancy, scars, pigmentation or other skin lesions are noted. Fetal movements may be observed.
FHR monitoring: A Normal fetal heart rate is 110-160 beats per minute. The fetal heart is best
heard over the fetal back, particularly when listening with a pinard stethoscope.
Vaginal Examination:
Vaginal examination in the early weeks of pregnancy helps
To establish the diagnosis of pregnancy
To decide whether the pregnancy is uterine or extra uterine.
To ascertain whether there there are any tumors or abnormalities in the genital tract
complicating pregnancy.
In the later weeks and particularly near team, it helps in the diagnosis of the presentation and
position of the fetus and in assessing the pelvis. The risk of infection by a careless vaginal
examination is always present: hence the examination should be with all antiseptic solution.
The fetus – in - Utero
1. Lie: The lie refers to the relation of the long axis of the fetus to the long axis of the uterus
or maternal spine. The lie may be longitudinal(99%), it may be transverse or oblique.
2. Presentation: The part of the fetus which occupies the lower pole of the uterus. The
presentation may be cephalic(96%), podalic(3%), shoulder and other (0.5%).
3. Presenting Part: The part of the presentation which overlies the external os. Thus in
cephalic presentation the presenting part is vertex(commonest), brow or face, depending
upon the degree of flexion of the head.
4. Attitude: The relation of the different part of the fetus to one another. The common
attitude is flexion.
5. Denominator: It is an arbitrary bony fixed point which comes in relation with the various
quadrants of the maternal pelvis. The following are the denominator of the different
presentation occiput in the vertex, mentum in the face, frontal eminence in brow, sacrum
in breech and acromian in shoulder.
6. Position: It is the relation of the denominator to the different quadrants of the pelvis. The
pelvis is divided into equal segments of 45 degree to place the denominator in each
segment. Thus there are 8 positions with each presenting part. The situation of the fetus in
the pelvis, determined and described by the relation of the given arbitrary point in the
coronal plane of the maternal pelvis(Maternal Index).
Cephalic Presentation
Vertex presentation (Point of direction: Lambdoid, occipital, posterior, smaller or
triangular fontanelle; commonly occiput)(95%).
Left occipitoanterior (LOA)(Left ileo-pectineal eminence)(60%).
Left occipitoposterior(LOP)(Left sacroiliac symphisis)(3%).
Left Occipitotransverse(LOT)
Right Occipitoanterior (ROA) (Right ileo-pectinal eminence)(6%).
Right occipitoposterior(ROP)(Right sacroiliac symphisis)(30%).
Right occipitotransverse(ROT)
Bregma presentation (Point of direction : bregmatic, frontal or larger fontanelle)
Face presentation (Point of direction : chin) (0.5%)
Left mentoanterior (LMA)
Left mentoposterior (LMP)
Left mentotransverse (LMT)
Right mentoanterior (RMA)
Right mentoposterior (RMP)
Right mentotransverse (RMT)
Brow presentation (point of direction : nose root)
Left frontoanterior (LFA)
Left frontoposterior (LFP)
Left frontotraverse (LFT)
Right frontoanterior (RFA)
Right frontoposterior (RFP)
Right frontotransverse (RFT)
Pelvic presentation (breech) (4%)
Complete breech presentation (25-30-%, especially in multiparae): feet crossed and
thighs flexed on abdomen; buttocks and feet against the outlet (point of direction:
sacrum)
Left sacroanterior (LSA)
Left sacroposterior (LSP)
Left sacrotransverse (LST)
Right sacroanterior (RSA)
Right sacroposterior (RSP)
Right sacrotransverse (RST)
Incomplete breech presentation(30-35%): same designations as above
Buttocks variety(70%)
Incomplete variety with procidentia: one or more little parts(footling, knees)
precede the buttocks
Shoulder presentation(point of direction: acromion)(<0.5%)
Left sacpulanterior (LScA)
Left scapuloposterior (LScP)
Right scapuloanterior (RScA)
Right scapuloposterior (RScP)
ANTENATAL ADVICE:
Principles:
Antenatal Hygiene: In otherwise uncomplicated cases, the following advises are to be given.
Rest and Sleep: The patient may continue her usual activities throughout pregnancy.
However, excessive and strenous work should be avoided specially in the first trimester and
the last 4 weeks. Recreational exercise are permitted as long as she feels comfortable.
Bowel: Constipation is common. It may cause backache and abdominal discomfort.
Regular bowel movement may be facilitated by regulation of diet taking plenty of fluids,
vegetables and milk or prescribing stool softners at bed time. There may be rectal bleeding,
painful fissures or haemorrhoids due to hard stool.
Bathing: The patient should take daily bath but be careful against slipping in the bathroom
due to imbalance.
Clothing, shoes and belt: The patient should wear loose but comfortable garments. High
heel shoes should better be avoided in advanced pregnancy when the centre of balance
alters. Constricting belt should be avoided.
Dental care: Good dental and oral hygiene should be maintained. The dentist should be
consulted, if necessary. This will facilitate extraction or filling of the caries tooth, if
required, comfortably in the 2nd trimester.
Care of the breasts: Breast engorgement may cause discomfort during late pregnancy. A
well fitting brassiere can give relief.
Coitus: Generally coitus is not restricted during pregnancy. Release of prostaglandins and
oxytocin with coitus may cause uterine contractions. Women with increased risk of
miscarriage or preterm labor should avoid coitus if they feel such increased uterine activity.
Travel: Travel by vehicles having jerks are better to be avoided specially in first trimester
and the last 6 weeks. The long journey is preferably be limited to the second trimester. Rail
route is preferable to bus route. Travel in pressurized aircraft is safe upto 36 weeks. Air
travel is contraindicated in case with placenta praevia, pre-eclampsia, severe anaemia and
sickle cell disease. Prolonged sitting in a car or aeroplane should be avoided due to the risk
of venous stasis and thromboembolism. Seat belt should be under the abdomen.
Smoking and alcohol: In view of the fact that smoking is injurious to health, it is better to
stop smoking not only during pregnancy but even thereafter. Heavy smokers have smaller
babies and there is also more chance of abortion. Similarly alcohol consumption is to be
drastically curtailed or avoided, so as to prevent fetal maldevelopment or growth restriction.
IMMUNISATION:
Fortunately most of the life threatening epidemics are rare. In the developing countries
immunization in pregnancy is a routine for tetanus; others are given when epidemic occurs
or travelling to an endemic zone or for travelling overseas.
Live virus vaccines (rubella, measles, mumps, yellow fever) are contraindicated. Rabies,
Hepatitis A and B vaccines, toxoids can be given as in nonpregnant state.
Tetanus: Immunization against tetanus not only protects the mother but also the neonates.
Drugs: Almost all the drugs given to mother will cross the placenta to reach the fetus.
Possibility of pregnancy should be kept in mind while prescribing drugs to any woman of
reproductive age.
GENERAL ADVICE:
The patient should be persuaded to attend for antenatal check up positively on the
schedule date of visit. She is instructed to report the physician even at an early date if some
untoward symptoms arise such as intense headache, disturbed sleep with restlessness,
urinary troubles, epigastric pain, vomiting and scanty urination.
High risk pregnancy is one in which mother, fetus and new born is or will be at increased risk for
modality and morbidities due to problems and complication during pregnancy.
The risk approach strategy is expected to have far-reaching effects on the whole organization of
MCH/FP services and lead to improvements in both the coverage and quality of health care, at all
levels, particularly at primary health care level. Inherent in this approach maximum utilization of
all resources including some human resources that are not conventionally involved in such care
like traditional birth attendants, community health workers, women’s group.
Purpose
To provide better services for all, but with special attention to those who need the most.
A high-risk pregnancy is one in which some condition puts the mother, the developing fetus or
both at higher-than-normal risk for complications during or after the pregnancy and birth.
Maternal risk is defined as the probability of dying or experiencing serious injury as a result of
pregnancy or child birth. The risk of developing problem and complications varies. Some are
at risk than other depend upon various risk factors. These are discussed as under:-
A) Biophysical Assessment
1. Ultrasonography
2. Radiology in Obstetrics
3. Magnetic Resonance Imaging
B) Biochemical Assessment
1. Amniocentesis
2. Alpha-fetoprotien (AFP)
3. Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis
4. Chrionic Villus Sampling
5. Maternal Blood Assessments
6. Placental Biopsy
7.
C) Electronic Monitoring
1. Nonstress test
2. Contraction Stress Tests/ Oxytocin Challenge test
3. Daily Fetal Movement Count (DFMC) or Kick Counts.
ABSTRACTS-
1. A questionnaire study of mothers' views of the antenatal care provided in Belfast showed
general satisfaction. Retrospective examination of their charts, however, showed in some cases
that insufficient attention was paid to the medical and obstetric history in the selection of the
type of care made by the women and their doctors. Some women with high-risk factors were
booked for shared care and some patients at low risk were booked for total hospital care. The
reasons for this are unclear. The mothers felt that continuity of care and communication at
the health center were better than at the hospital. Analysis of the number of hospital
attendances showed that shared care patients appeared to be making an excessive number of
visits to the hospital. Many total hospital care patients also admitted that they were attending
their general practitioners. There appeared to be marked duplication of effort as a result of
poor communication between patient, general practitioner and hospital. Alternative ideas for
care are suggested a more integrated system for sharing antenatal care, and the development
of general practitioner units within the specialist obstetric hospital. (McKenzie-Mcharg, 2014)
2. Both the under 18 conception and birth rates are falling. However, despite this, the United
Kingdom has a high rate of teenage pregnancy compared to similar countries in Western
Europe. Young mothers and their babies have poorer access to maternity care and experience
worse obstetric outcomes than older mothers. It is likely that the risks associated with teenage
pregnancy reflect a significant interplay between the socio-demographic status of many of
these teenagers, their nutritional status and their uptake of antenatal care. This review looks at
the complications associated with teenage pregnancy and how the implementation of
specialized antenatal care aims to improve outcomes. (Whitworth, 2017)
3. Within the continuum of reproductive health care, antenatal care (ANC) provides a platform
for important healthcare functions, including health promotion, screening and diagnosis, and
disease prevention. It has been established that, by implementing timely and appropriate
evidence-based practices, ANC can save lives. Endorsed, by the UN Secretary-General, this is
a comprehensive WHO guideline on routine ANC for pregnant women and adolescent girls.
It aims to complement existing WHO guidelines on the management of specific pregnancy-
related complications. The guidance aims to capture the complex nature of the issues
surrounding ANC health care practices and delivery and to prioritize person-centered health
and well-being, not only the prevention of death and morbidity, in accordance with a human
rights-based approach. "To achieve the Every Woman Every Child vision and the Global
Strategy for Women's Children's and Adolescents' Health, we need innovative, evidence-
based approaches to antenatal care. I welcome these guidelines, which aim to put women at
the center of care, enhancing their experience of pregnancy and ensuring that babies have the
best possible start in life." Ban Ki-moon, UN Secretary-General (WHO, 2013)
4. Early and frequent antenatal care attendance during pregnancy is important to identify and
mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at
childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care
attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit
from its preventive and curative services. This study assesses the timing of adult and
adolescent pregnant women's first antenatal care visit and identifies factors influencing early
and late attendance. The study was conducted in the Ulanga and Kilombero rural
Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory
studies informed the design of a structured questionnaire. A total of 440 women who
attended antenatal care participated in exit interviews. Socio-demographic, social, perception-
and service-related factors were analyzed for associations with the timing of antenatal care
initiation using regression analysis. The majority of pregnant women initiated antenatal care
attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group
compared to other ethnic groups such as the Pogoro, Mhehe, Mindoand others, perceived
the poor quality of care, late recognition of pregnancy and not being supported by the
husband or partner were identified as factors associated with a later antenatal care enrolment
(p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated
with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started
antenatal care no later than adult pregnant women despite being more likely to be single.
Factors including poor quality of care, lack of awareness about the health benefit of antenatal
care, late recognition of pregnancy, and social and economic factors may influence the timing
of antenatal care. Community-based interventions are needed that involve men and need to
be combined with interventions that target improving the quality, content,and outreach of
antenatal care services to enhance early antenatal care enrolment among pregnant women.
(Gross, 2012)
BIBLIOGRAPHY-
1. Bhaskar Nima. Midwifery & Obstetrical Nursing: Administration of Midwife and Obstetrical
Nursing. 2nd ed. Bangalore: EMMESS Medical Publishers, 2015.P- 130 – 40
2. Dutta DC. Text Book of Obstetrics including Perinatology and Contraception: Antenatal care,
Pre-Conceptional Counselling,and Care.In:Konar Hiralal editor.7th ed.London.New Central
Book Agency (P ) Ltd:2011.P.106-18