CHAPTER 22

Antenatal Care: Counseling and Advice

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ANTENATAL CARE

Systematic supervision (examination and advice) of a woman during pregnancy is called antenatal care. Antenatal care starts from the beginning of pregnancy and ends with the delivery.

Antenatal care is comprised of:

• Careful history-taking and examination.
• Advice given to pregnant woman.

Aim

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

Objectives �

• To screen the high-risk cases.
• To prevent or to detect and treat at the earliest any complications.
• To ensure continued medical surveillance and prophylaxis.
• To educate the mother about the physiology of pregnancy and labor.
• To alleviate the fear of the mother.
• To discuss with the couple the place, time and mode of delivery.
• To discuss about the care of newborns.
• To educate the couples about family planning methods.

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ANTENATAL CARE AND COUNSELING (AS PER GOVERNMENT OF INDIA GUIDELINES)

1. Iron Folic Acid (IFA) Supplementation

Prophylactic Dose

All pregnant women need to be given one tablet of IFA (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days, starting after the first trimester, at 14–16 weeks of gestation. This is the dose of IFA given to prevent anaemia (prophylactic dose). This dosage regimen is to be repeated for three months post-partum.

Therapeutic Dose

• If a woman is anaemic (haemoglobin less than 11 g/ dl) or has pallor, she needs two IFA tablets per day for three months. This means that a pregnant woman with anaemia needs to take at least 200 tablets of IFA. This is the dose of IFA needed to correct anaemia (therapeutic dose). This dosage regimen is to be repeated for three months post-partum in women with moderate to severe anaemia.
• The haemoglobin should be estimated again after a month. If the level has increased, continue with two tablets of IFA daily till it comes up to normal. If it does not rise in spite of the administration of two tablets of IFA daily and dietary measures, refer the woman for further investigations.

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2. Administration of TT Injection

3. Malaria Prophylaxis and Treatment

4. Nutrition and Rest

5. Breastfeeding

6. Sex During Pregnancy

7. Domestic Violence

8. Family Planning

9. Personal Hygiene

10. Preventing Urinary Tract Infections

11. Dental Care

12. Rest and Relaxation

13. Employment

14. Safety During Pregnancy

15. Clothing

16. Travel

Administration of TT Injection

• The administration of two doses of TT injection is an important step in the prevention of maternal and neonatal tetanus (tetanus of the newborn).
• The first dose of TT should be administered as soon as possible, preferably when the woman registers for ANC.
• The second dose is to be given one month after the first, preferably at least one month before the EDD. If the woman skips one antenatal visit, give the injection whenever she comes back for the next visit.

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• If the woman receives the first dose after 38 weeks of pregnancy, then the second dose may be given in the postnatal period, after a gap of four weeks. If the woman has been previously immunized with two doses during a previous pregnancy in the past three years, then give her only one dose as early as possible in this pregnancy.
• The dosage of TT injection to be given is 0.5 ml. Tetanus toxoid to be administered by deep intramuscular injection. It should be given in the upper arm, and not in the buttocks as this might injure the sciatic nerve.
• Inform the woman that there may be a slight swelling, pain and/or redness at the site of the injection for a day or two.

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Malaria Prophylaxis and Treatment

• No prophylaxis is recommended but insecticide-treated bed nets or Long-Lasting Insecticidal Nets (LLIN) should be given on a priority basis to pregnant women in malaria-endemic areas. These women should be counseled on how to use the LLINs.
• In non-endemic areas, all clinically suspected cases as per the National Vector-Borne Disease Control Programme (NVBDCP) guidelines should preferably be investigated for malaria with the help of microscopy or a Rapid Diagnostic Kit (RDK).

• In high malaria-endemic areas, pregnant women should be routinely tested for malaria at the first antenatal visit. Screen the woman for malaria every month by conducting the rapid diagnostic test even if she does not manifest any symptoms of malaria. If a pregnant woman shows symptoms of malaria at any time, she should be tested. If the result is positive, refer her to the PHC for treatment.

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Nutrition and Rest

• The woman should be advised to eat more than her normal diet throughout her pregnancy. Remember that a pregnant woman needs about 300 kcal extra per day, over and above her usual diet, and 500 kcal extra in the post-partum period. She should be told that she needs these extra calories in order to maintain her health as a mother and meet the needs of the growing fetus, and for successful lactation.
• Special categories of women who require additional nutrition during pregnancy have been identified. These include the following:

• Women who are underweight (less than 45 kg).
• Women who have an increased level of physical activity, above the usual levels, during pregnancy.
• Adolescent girls who are pregnant.
• Those who become pregnant within two years of the previous delivery.
• Those with multiple pregnancy.
• Women who are HIV positive.
• The woman’s food intake should be especially rich in proteins, iron, vitamin A, vitamin C, calcium and other essential micronutrients.

Breastfeeding

Pregnancy is the ideal time to counsel the mother on the benefits of breastfeeding her baby. Though breastfeeding is almost universal in India, the following key messages need to be given to the would-be mother.

Initiation of Breastfeeding

• Counsel the mother that breastfeeding should ideally be initiated immediately after birth, preferably within one hour, even if the birth has been by caesarean section.
• The sucking and rooting reflexes of the newborn, which are essential for the baby to successfully start breastfeeding, are the strongest immediately after delivery, making the process of initiation much easier for the mother and the baby.

• These reflexes gradually become weaker over the span of a few hours, thus making breastfeeding difficult later on.
• It is a common practice in India to delay the initiation of breastfeeding. It is a myth that colostrum (the first milk) is harmful to the baby and should be discarded and prelacteal feeds given instead. Prelacteal feeds may not be hygienic and can cause intestinal infections in the baby leading to diarrhoea.

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Advantages of Initiation of Early Breastfeeding

• The sucking and rooting reflexes in the newborn are the strongest immediately after delivery, making breastfeeding easier. Sucking helps in the release of oxytocin which helps in the contraction of the uterus and thus helps in preventing PPH.
• The newborn’s sucking helps to produce more breast milk.
• The baby receives colostrum, which is very rich in vitamin A and protective antibodies. This protects the baby from infections such as diarrhoea, tetanus and respiratory tract infections.

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Sex During Pregnancy

• It is safe to have sex throughout pregnancy, as long as the pregnancy is uncomplicated.
• Sex should be avoided during pregnancy if there is a risk of abortion (history of previous recurrent spontaneous abortions, or threatened abortion in the current pregnancy), a risk of pre-term delivery (history of previous pre-term labour), or a history of APH or PROM.
• Some women experience a decreased desire for sex during pregnancy. The husband should be informed that this is normal and the woman’s consent should be sought before engaging in sex..

Preventing Urinary Tract Infections

• Instruct women to inform their healthcare provider if blood or pain occurs with urination. Instruct about the following preventive measures:
• Use good hand-washing techniques before and after urinating; wipe the perineum from front to back.
• Use soft, absorbent toilet tissue preferably white and unscented as harsh, scented or printed toilet paper may cause irritation.
• Wear cotton underwear and avoid tight fitting underwear.

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• Advise the women to have at least eight glasses of liquid daily.
• Pregnant women should not limit fluid in an effort to reduce the frequency of urination and inform the women that if the urine looks dark they must increase their fluid intake.
• Educate the women not to ignore the urge for urination.
• Always urinate before going to bed at night.

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Dental Care

Dental care during pregnancy is especially important because nausea during pregnancy may lead to poor oral hygiene, allowing dental caries to develop.

Posture and Body Mechanics

Skeletal and musculature changes and hormonal changes (relaxin) in pregnancy may predispose the woman to backache and possible injury.

Employment

Employment usually has no adverse effects on pregnancy outcomes.

Safety During Pregnancy

• Strategies to improve safety are as follow:
• Changes in the body resulting from pregnancy include relaxation of joints, alteration to the center of gravity, faintness and discomforts. Problems with coordination and balance are common. So use of body mechanics is of prime importance.
• Avoid activities requiring coordination, balance and concentration.
• Take rest periods; reschedule daily activities to meet rest and relaxation needs.
• Avoid travel to high-altitude regions, which could jeopardize oxygen intake.
• Wear gloves when handling chemicals.
• Ensure adequate ventilation with clean air.

16. Immunization in Pregnancy

Antenatal Exercises

1. Deep breathing

Antenatal Exercises

2. Alternate Nostril Breathing

Antenatal Exercises

3. Abdominal breathing

Antenatal Exercises

4. Foot and leg exercise

Antenatal Exercises

5. Pelvic tilting exercise

Antenatal Exercises

6. Knee rolling Exercise

Antenatal Exercises

7. Hip-up drawing exercise

Antenatal Exercises

8. Tailor press exercise

Danger Signs During Pregnancy

Tests for Rupture of Membranes

Recognition of Ruptured Membranes

Nitrazine Test for pH

• Explain the procedure to the woman or couple.
• Wash hands.
• Use a cotton-tipped applicator impregnated with Nitrazine dye for determining pH.
• Sample containing amniotic fluid will be slightly alkaline whereas samples with urine and pus will be acidic.
• Dip the applicator deep into the vagina to pick up fluid.

Results

• Membranes probably intact: Identifies vaginal and most body fluids that are acidic:
• Yellow—pH 5.0
• Olive-yellow—pH 5.5
• Olive green—pH 6.0

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• Membranes probably ruptured: Identifies amniotic fluid that is alkaline:
• Blue-green—pH 6.5
• Blue-gray—pH 7.0
• Deep blue—pH 7.5

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Test for Ferning or Fern Pattern

• Explain the procedure to the woman or couple.
• Wash hands, apply sterile gloves, and obtain a specimen of fluid (usually during sterile speculum examination).
• Spread a drop of fluid from the vagina onto a clean glass slide with a sterile cotton-tipped applicator.
• Allow fluid to dry.
• Examine the slide under a microscope and observe for the appearance of ferning.

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RESPECTFUL CARE AND COMPASSIONATE �COMMUNICATION

�RECORDING AND REPORTING AS PER THE GOI GUIDELINES �

• A Mother and Child Protection Card should be duly completed for every registered women.
• 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 the time of delivery. (Fig. 9 Mother and Child Protection Card).

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Mother and Child Protection Card

HEALTH EDUCATION ON IFA

Iron Folic Acid Ecommendation

Introduction

Iron is one of the most essential minerals needed by our body. Iron is mainly present in the blood and muscles of body. Iron is needed for healthy blood.

Prevention of Anemia in Pregnancy

Contd...

Health Education on Calcium �and Vitamin D Supplementation

Adequate calcium intake during pregnancy and lactation has the potential to prevent pre-eclampsia, pre-term birth, neonatal mortality (NNM), improve maternal bone mineral content, breast milk concentration and bone development of neonates.

Protocol for Calcium Supplementation

• All pregnant and lactating women to be counselled about intake of calcium-rich foods.
• Oral swallowable calcium tablets to be taken twice a day (total 1g calcium/day) starting from 14 weeks of pregnancy up to six months post-partum.
• One calcium tablet should be taken with the morning/afternoon meal and the second tablet with the evening/night meal.
• It is not advisable to take both calcium tablets together as >800 mg calcium interferes with iron absorption. Calcium tablets should not be taken empty stomach since it causes gastritis.

Side Effects and Contraindications

• None, within the recommended limit (1 gm/d).
• A small proportion of women may experience mild gastritis so calcium tablets should be taken with meals.
• Excessive consumption of calcium (>3 gm/d) may increase the risk of urinary stones and Urinary Tract Infection (UTI)

Dietary Counseling for Calcium in Pregnancy and Lactation

• Counseling
• Improve Calcium and Vit D uptake by: Have one cup of curd every day.
• Must take green leafy vegetables.
• Drink one glass of milk every day.
• Take morning sunlight every day.
• Take one cup of ragi everyday
• Supplementation of calcium to all pregnant women after 1st trimester.
• Calcium supplementation leads to maternal and fetal wellbeing.

Health Education on Gestational Diabetes Mellitus

Testing for GDM

• Single-step testing using 75 g oral glucose and measuring plasma glucose 2 hours after ingestion:
• 75 g glucose is to be given orally after dissolving in approximately 300 ml water whether the pregnant woman comes in a fasting or non-fasting state, irrespective of the last meal. The intake of the solution has to be completed within 5 min.

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• A plasma standardised glucometer should be used to evaluate blood glucose 2 hours after the oral glucose load.
• If vomiting occurs within 30 min of oral glucose intake, the test has to be repeated the next day, if vomiting occurs after 30 minutes, the test continues.
• The threshold plasma glucose level of ≥140 mg/dL (more than or equal to 140) is taken as cut-off for diagnosis of GDM.

Glucose tolerance test with 75 gm oral glucose (WHO)

Health Education on Deworming in Pregnancy

Protocol for Deworming During Pregnancy

• Albendazole is the recommended drug of choice for deworming of pregnant women.
• Deworming should be done after the 1st trimester of pregnancy (preferably during the 2nd trimester).
• A single dose of 400 mg of albendazole is recommended

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Rh-Negative and Prophylactic Anti D

1. Sensitizing Events requiring Anti D Prophylaxis

HIGH RISK PREGNANCY

High-risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome-maternal or prenatal or both.

Screening of High-Risk Cases

• Maternal age Examination
• Reproductive history:
• Medical or surgical disorders:
• Family history

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Management of High –Risk Cases

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• Proper training of residents, nursing personnel and community health workers.
• Concentration of cases in specialized centers for management.
• Community participation, proper utilization of health-care manpower and financial resources where it is mostly needed.
• Availability of prenatal laboratory for necessary investigation.
• Availability of good pediatric service for neonates.
• Lastly, improvement of economic status and health awareness of the community.

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Folic Acid Therapy :

• Folic acid (4 mg/day) should be started in the pre-pregnant state and continued throughout the pregnancy. Early in pregnancy after the initial clinical examination, routine and special laboratory investigations should be undertaken.
• Advice should be given regarding diet, activities, rest and medicines. Minimum medicines should be taken during pregnancy, particularly in the early months.
• Blood transfusion should be given as prescribed by the doctor.
• 200 mg ferrous sulphate along with 1 mg folic acid should be administered to the client as prescribed

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Management of Labour

• It is evident that pre-planned caesarean section is necessary in a high-risk case.
• Some cases may need induction of labor after 37 to 38 completed weeks of gestation. Those cases that go into labor spontaneously or after induction need close monitoring during labor for the assessment of the progress of labor for any evidence of the fetal hypoxia.
• The conditions of the fetus can be assessed by:
• Fetal heart rate monitoring by stethoscope, fetoscope or doppler, continuous electronic monitoring.
• Passage of meconium in the liquor.
• Examination of fetal scalp blood for pH values.

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Referral Services

MATERNAL MENTAL HEALTH

EMOTIONAL RESPONSES THAT CAN CAUSE CONCERN IN PREGNANCY

ROLE OF DOULAS/ASHA

Primary Role

• Perform Urine Pregnancy Test.
• Ensure early registration and see to it that the first check-up is conducted within 12 weeks (first three months of pregnancy).
• Track every pregnancy by conducting at least four antenatal check-ups (including the first visit for registration).
• Administer two doses of TT injection.
• Provide at least 100 tablets of IFA.

Essential Role at Every Antenatal Check-up

• Take the patient’s history.
• Conduct a physical examination–measure the weight, blood pressure and respiratory rate and check for pallor and oedema.
• Conduct abdominal palpation for fetal growth, fetal lie and auscultation of Fetal Heart Sound (FHS) according to the stage of pregnancy.
• Carry out laboratory investigations

Desirable Role

• Determine the blood group, including the Rh factor.
• Conduct the Venereal Disease Research Laboratory (VDRL)/Rapid Plasma Reagin (RPR) test to rule out syphilis.
• Test the woman for Human Immuno deficiency Virus (HIV).
• Check the blood sugar.

Counseling

• Help the woman to plan and prepare for birth (birth preparedness/micro birth plan). This should include deciding on the place of delivery and the presence of an attendant at the time of the delivery.
• Advantages of institutional deliveries and risks involved in home deliveries.

PROCEDURE: URINARY PREGNANCY TEST

Definition

The Urine pregnancy test (UPT) is defined as an easy and rapid qualitative test used to detect human chorionic gonadotropin (HCG) hormone in the urine for early detection of pregnancy

Pre Procedural Preparations

Articles

Procedure

Procedure

Procedure

Post Procedural Responsibilities

WOMEN-CENTERED CARE

• Elements of Woman-Centered Care

The three key elements of woman-centered care:

• Choice: In its broadest sense, it means the ‘right and opportunity to select between options’. There should be no interference from others to a woman’s right to make choices about her body and health. The choice should be made after getting complete and accurate information and an opportunity to ask questions.
• Access to health-care services means the availability of services to a woman:
• As and when she needs them.
• Irrespective of her economic or marital status, age, educational or social background.
• Without delay because of administrative and logistic hurdles.
• Close to her home.

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• Quality: Quality of care under woman centered care means: Adequate time for counselling.
• Privacy and confidentiality maintained
• Using internationally recommended technologies.
• Following appropriate clinical standards and protocols for infection prevention, pain management, management of complications and other clinical components of care.
• Services tailored to a woman’s medical and personal needs.

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NURSING CARE PLAN FOR PREGNANT WOMAN

Nursing Assessment

• A detailed history of the woman needs to be taken to:
• Confirm the pregnancy.
• Identify whether there were complications during any previous pregnancy/confinement that may have a bearing on the present one.
• Identify any current medical/surgical or obstetric condition(s) that may complicate the present pregnancy.

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• Symptoms of discomfort such as nausea and vomiting, heartburn, constipation, increased frequency of urination, fever, persistent vomiting, abnormal vaginal discharge/itching, palpitations, easy fatigability breathlessness at rest/on mild exertion, generalized swelling of the body, puffiness of the face, severe headache and blurring of vision, passing smaller amounts of urine and burning sensation during micturition

Nursing Diagnosis

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• Anxiety related to deficient knowledge about prenatal visit throughout pregnancy as evidenced by womans’ questions and concerns.

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• Imbalanced nutrition: less than body requirements related to nausea and vomiting as evidenced by womans’ report and weight loss.

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• Fatigue related to hormonal changes in the first trimester as evidenced by womans’ complaints.

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• Fear related to deficient knowledge regarding the onset of labor and the process of labor related to inexperience, as evidenced by womans’ questions and statement of concerns.

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• Disturbed sleep patterns related to discomforts or insomnia in the third trimester, as evidenced by the womans’ report of inadequate rest.

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