ANTENATAL CARE

Prof. K.Punithalakshmi

Principal

JIET College of Nursing, Jodhpur

What is Antenatal care?

• Antenatal care (ANC) is the health care of pregnant women in the months and weeks before the birth of their babies. The care is aimed at detecting those problems already present or those that can develop in the pregnant woman and her unborn child.
• ANC has a further role of improving the general health of the woman.

Definition

• Systematic supervision (examination and 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.
• Actually prenatal care is the care in continuum that starts before pregnancy and ends at delivery and the postpartum period.

• Antenatal care comprises of:

• Careful history taking and examinations (general and obstetrical)

• Advice given to the pregnant woman

​

AIMS

• The aims are:

(1) To screen the ‘high risk’ cases.

(2) To prevent or to detect and treat at the earliest any complications.

(3) To ensure continued risk assessment and to provide ongoing primary preventive health care.

(4) To educate the mother about the physiology of pregnancy and labor by demonstrations, charts and diagrams (mother craft classes), so that fear is removed and psychology is improved.

(5)To discuss with the couple about the place, time and mode of delivery, provisionally and care of the newborn.

(6) To motivate the couple about the need of family planning and also appropriate advice to couple seeking medical termination of pregnancy.

​

​

OBJECTIVE

• The objective is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.

The criteria of a normal pregnancy are—delivery of a single baby in good condition at term (between 38–42), with fetal weight of 2.5 kg or more and with no maternal complication.

What can antenatal care achieve?

• • Improve maternal health
• • Improve the health and survival of the baby
• • Provide the pregnant woman with information on: −
• Warning signs during pregnancy and how to respond
• Bad habits such as drinking alcohol and smoking
• Nutrition
• Contraception
• Feeding her infant
• HIV

Terminology

• Gravida is no: of pregnancy.
• Para is no: of delivery
• A nullipara is one who has never completed a pregnancy to the stage of viability. She may or may not have aborted previously.
• A nulligravida is one who is not now and never has been pregnant.
• A primipara is one who has delivered one viable child. Parity is not increased even if the fetuses are many (twins, triplets).

• A primigravida is one who is pregnant for the first time.
• A multigravida is one who has previously been pregnant. She may have aborted or have delivered a viable baby.
• Multipara is one who has completed two or more pregnancies to the stage of viability or more.
• Parturient is a women in labor.
• Puerpera is a woman who has just given birth.

​

​

Models of Antenatal Care Provision

• Traditional ANC model(s)
• Began two hundred years ago and instituted programs and interventions that were traditionally thought to benefit the mother and her fetus
• Activities were not scientifically tested as to their effectiveness or benefit

​

• Followed a visit pattern of 4 weeks until 28^th week; then every 2 weeks until 36^th week and a weekly visit with many interventions at each visit
• Led up to 14 visits and cost incurred for many investigations that were not necessarily warranted
• It has recently been suggested that the traditional ANC practice be replaced by new models of focused ANC programs

​

Models of ANC – Continued

• Focused ANC- also called “new” or “WHO” models
• Followed large randomized multicenter trials between the traditional and focused ANC programs that identified evidence based interventions and visit patterns that benefited mothers and their fetus and were cost effective as well

​

• Suggested four routine visits only at different gestations with a few evidence based diagnostic and intervention modalities performed at each visit
• Visits were at 16,28,32 and 36 weeks
• Additional visits were individualized on an individual basis

​

Initial visit- History

• Present pregnancy
• Accurate dating of gestational age
• Any symptoms – minor or major complaints
• Fetal movement perception
• ANC details – investigations and interventions if the mother is referred from other facilities
• Presence of any of the danger signs

• Past obstetric history
• Details of any obstetric complications in previous pregnancies
• Family history
• Any familial medical conditions
• Family history of congenital anomalies; multifetal gestations and hypertensive disorders of pregnancy
• Personal history
• History of medical illnesses
• History of smoking, alcohol intake and habitual drugs use

​

• Vital signs and anthropometry (weight and height)
• Detailed physical exam for medical or surgical illnesses
• Abdominal exam
• Fundal height by symphysis-fundal height measurement by the tape method
• Fetal heart auscultation after 10^th week by doppler or 20^th week by fetal heart stethoscope
• Fetal presentation after the 28^th week but malpresentations abnormal after the 34^th week

​

• Fetal presentation is found by palpation
• Fundal Grip
• Lateral Grip
• Pelvic Grip
• Pawlik Grip

​

• Pelvic examination
• For uterine size measurement if gestation is less than 12^th week
• Early evidence of pregnancy on physical exam- cervical softening; Chadwick’s sign, Von-Fernwald’s sign and Hegar’s sign

​

Subsequent visits – Activities

• History
• Follow up on previous complaints
• Any new complaints since last visits
• Development of any of the danger symptoms
• Fetal movements history

• Physical examination
• Brief detailed exam including the vital signs, anthropometry and general examination
• Adequacy of weight gain since last visit
• Adequacy of fundal growth since last visit
• Presence of fetal heart beat
• Presence of other findings such as generalized edema

​

​

Diagnostic work-up during antenatal care

ANTENATAL ADVICE

• PRINCIPLES:

(1) To counsel the women 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 the psychology and to remove the fear of the unknown by counseling the woman.

​

DIET: The diet during pregnancy should be adequate to provide—

1. good maternal health

(b) optimum fetal growth

(c) the strength and vitality required during labor and

(d) successful lactation.

During pregnancy, there is increased calorie requirement due to increased growth of the maternal tissues, fetus, placenta and increased basal metabolic rate.

• The increased calorie requirement is to the extent of 300 over the non pregnancy state during second half of pregnancy. Generally, the diet in pregnancy should be with woman’s choice as regard the quantity and the type.

• Woman with normal BMI should eat adequately so as to gain the optimum weight (11 kg). Overweight women with BMI between 26–29 should limit weight gain to 7 kg and obese women (BMI > 29) should gain less weight. Excessive weight gain increases antepartum and intrapartum complications including fetal macrosomia.

Supplementary nutritional therapy

• As there is a negative iron balance during pregnancy and the dietetic iron is not enough to meet the daily requirement especially in the second half of the pregnancy.
• Thus, supplementary iron therapy is needed for all pregnant mothers from 16 weeks onwards.

• Above 10 gm% of hemoglobin, 1 tablet of ferrous sulfate containing 60 mg of elemental iron is enough. The dose should be proportionately increased with lower hemoglobin level to 2–3 tablets a day.
• 3 tablets provide 180mg of absorbable iron. As the essential vitamins are either lacking in the foods or are destroyed during cooking, supplementary vitamins are to be given daily from 20th week onwards.

​

Antenatal Hygiene

• ANTENATAL HYGIENE: In otherwise uncomplicated cases, the following advices are to be given. Rest and sleep: The patient may continue her usual activities throughout pregnancy. However, excessive and strenuous work should be avoided especially in the first trimester and the last 4 weeks.

• Recreational exercise (prenatal exercise class) are permitted as long as she feels comfortable. There is individual variation of the amount of sleep required. However, on an average, the patient should be in bed for about 10 hours (8 hours at night and 2 hours at noon) especially in the last 6 weeks. In late pregnancy lateral posture is more 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 hemorrhoids due to hard stool.

• Bathing: The patient should take daily bath
• Clothing, shoes and belt: The patient should wear loose but comfortable garments. High heel shoes should better be avoided in advanced pregnancy when the center of balance alters.
• 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 especially 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.
• Air travel is contraindicated in cases with placenta previa, pre-eclampsia, severe anemia and sickle cell disease. Prolonged sitting in a car or Flights should be avoided due to the risk of venous stasis and thrombo embolism. 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 mal development or growth restriction

​

• IMMUNIZATION: Fortunately, most of life-threatening epidemics are rare. In the developing countries immunization in pregnancy is a routine for tetanus; others are given when epidemic occurs or traveling to an endemic zone or for traveling 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.
• In unprotected women, 0.5 mL tetanus toxoid is given intramuscularly at 6 weeks interval for 2 such, the first one to be given between 16–24 weeks. Women who are immunized in the past, a booster dose of 0.5 mL IM is given in the last trimester.

​

• 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 to 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.

​

• She is advised to come to hospital for consideration of admission in the following circumstances:

• Painful uterine contractions at interval of about 10 minutes or earlier and continued for at least an hour—suggestive of onset of labor.

• Sudden gush of watery fluid per vaginam—suggestive of premature rupture of the membranes.

• Active vaginal bleeding, however slight it may be.

Health Teaching during the First Trimester

• Physiological changes during pregnancy
• Weight gain
• Fresh air and sunshine
• Rest and sleep
• Diet
• Daily activities
• Exercises and relaxation
• Hygiene

​

• Teeth
• Bladder and bowel
• Sexual counseling
• Smoking
• Medications
• Infection
• Irradiation
• Occupational and environmental hazards
• Travel
• Follow up
• Minor discomforts
• Signs of Potential Complications

​

Do’s & Don'ts

• Exercise should be simple, mild exercise avoid lifting heavy weights
• A tooth can be extracted during pregnancy, but local analgesia is recommended
• Catheter and enema should be avoided.
• Smoking may lead to ptyalism, nervousness and hyper emesis and make pregnant woman at increased risk of chest infections and thrombo-embolic disorders

​

​

Cont…

• Pregnant woman should avoid contact with infectious diseases especially rubella or (German measles) because it has deleterious effects on the fetus
• Pregnant woman should avoid exposure to x-ray or irradiation because of possible teratogenic effects on the fetus such as birth defects or childhood leukemia

THANK YOU

​