Antenatal Care

Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for the mother and child. The primary aim of antenatal care is to achieve at the end of pregnancy a healthy mother and a healthy baby. Objectives:
The main objectives of antenatal care are to: 1. Promote ,protect and maintain the health of mother during pregnancy 2. Detect high risk cases and give them special attention 3. Foresee complications and prevent them 4. Remove anxiety and dread associated with delivery 5. Reduce maternal mortality and morbidity 6. Teach the mother the elements of child care, nutrition, personal hygiene, and environmental sanitation 7. Sensitize the mother to the need of family planning 8. Attend to the under fives accompanying the mother Antenatal visits: Ideally the mother should attend the antenatal clinic once a month during the first 7 months: twice a month during the next month: and therafter once a week, if everything is normal. a) The first visit, should include the following components: Health history Physical examination Laboratory examination:

i.
ii. iii. iv. v. vi. b)

Complete urine analysis Stool examination

Complete blood count including hemoglobin estimation Serological examination for HIV, Hepatitis B and veneral diseases(VDRL) Blood grouping and Rh determination Chest X-ray if needed

On subsequent visits: Physical examination (weight gain, blood pressure) Lab tests like urine examination and Hemoglobin estimation c) Iron and folic acid supplementation and medication as needed d) Immunization against Tetanus e) Instruction on nutrition, family planning and self care, delivery and parenthood f) Referral services if necessary Antenatal advice: Diet: On an average, a normal healthy woman gains about 12 Kg of weight during pregnancy. A balanced and adequate diet is of utmost importance during pregnancy and lactation. The mother needs about 300-500Cal/day extra during pregnancy and extra 550 Cal/day during lactation. Personal hygiene: Bathe daily and wear clean clothes Sleep 8 hrs at night, and a 2hrs rest after midday meal Avoid constipation by eating green leafy vegetables, fruits and extra fluids

 Do light household work, manual labor during late pregnancy should be avoided Avoid smoking , alcohol and drug intake (including medications for common illnesses) Maintain good oral hygiene Sexual intercourse should be restricted during last trimester especially last 6 weeks Drugs: The use of drugs/ medicines by the mother may adversely affect the growing fetus. Especially drugs like Thalidomide, Streptomycin, corticosteroids etc should be strictly avoided during pregnancy Radiation: Exposure to radiation is highly dangerous to the developing fetus. Warning signs: The mother should report immediately to the clinician in case of: Swelling of the feet Seizures/fits Headache Blurring of vision Bleeding/discharge per vagina Other unusual symptoms Child care: Mother craft education should include areas like nutrition, hygiene, childbearing, cooking demonstrations, family planning etc..

Schedule of visits during pregnancy The pregnant woman can consult the general practitioner as soon as possible following the first missed period and after an initial assessment can be seen by obstetrician between 8-14 weeks. Currently the trend is towards reducing the number of attendance's/ consultations, while at the same time establishing clearly defined objectives to be achieved at each visit. Booking Visit (8-14 weeks) This visit is to obtain a comprehensive history, establish the gestational age and identify maternal and fetal risk factors. Baseline investigations are performed. In most centres, women are offered a first trimester ultrasound scan for pregnancy dating, the exclusion of structural fetal abnormalities and measrement of the fetal nuchal translucency. The mid-trimester risk assessment visit (20-24weeks): The tests done in first trimester visit and at 16 weeks are reviewed with the woman. Also the clinician reviews the results of the ultrasound scan for fetal abnormality. Doppler ultrasound screening of the uterine arteries is suggested during this period to identify women at high risk of subsequent pre-eclampsia and intra-uterine growth restriction. Risk assessment is done based on the ultrasound scan and other findings and future management is planned accordingly. Antenatal visits in the second half of pregnancy Maternal health and fetal growth and well-being are assessed through these visits. The education of the woman regarding the rest of pregnancy and her delivery is done during this period. Also the clinician and the couple can discuss and decide on family planning aspects for the future. Antenatal education Parent craft classes are organized to discuss topics like breast feeding, pain management during the delivery etc. The common objectives of these formal educational sessions include the promotion of good health habits, allaying anxiety, increasing the feelings of control and

satisfaction with the pregnancy and delivery by the mother, preparation for the postnatal period, infant feeding, and subsequent contraception. The postdates visits - Induction of labour (41 -42 weeks) With accurate pregnancy dating, true postdate pregnancies are identified. At this visit a joint decision is taken as to whether an induction of labour is appropriate. This is current practice because of the reported association between postdates pregnancies and poor pregnancy outcome, particularly in order to prevent stillbirths due to the lack of an accurate, reliable test of fetoplacental reserve during those final few weeks of pregnancy. Induction of labour is usually performed by the 42nd week. If spontaneous labour does not occur by the 43rd week the likelihood of a Caesarean delivery is high, irrespective of the mode of onset labour.

Lesson 7: Personal Hygiene and Care During Pregnancy

7-1. GENERAL Your knowledge about personal hygiene and care of the pregnant patient will help to make her feel comfortable with her own body and less anxious about the effects of external substances on her developing fetus. Some modifications of certain activities may be required. This lesson will cover health concepts, which should be taught to the pregnant patient so that she may be able to enjoy her pregnancy to the fullest while still providing care for a healthy baby. 7-2. PERSONAL HYGIENE DURING PREGNANCY As a practical nurse, you have the opportunity to assist the expectant mother in attaining healthier patterns of living and to reinforce health-promoting behaviors. Skin care, hair care, breast care, dental care, bowel elimination, vaginal douching, and clothing are all important to the pregnant patient. a. Skin Care. The glands of the skin may be more active during pregnancy and the patient may tend to perspire more. Frequent baths or showers are recommended. (1) Baths can be therapeutic--relaxes tensed and tired muscles, helps counter insomnia, and makes the patient feel fresh and sweet smelling. (2) Baths may pose a physical maneuverability problem which increases the chance of falling late in the pregnancy; showers are recommended, but with caution when getting in and out and moving around in the shower. (3) The possibility of infecting the vaginal tract as a result of tub baths is considered highly unlikely. (4) Tub baths are contraindicated after rupture of the membranes. b. Hair Care. The hair tends to become oily more frequently during pregnancy due to overactivity of oil glands of the scalp and may require shampooing more frequently. The hair may grow faster during pregnancy and may require cutting more often. c. Breast Care. It is important to begin preparing the breast for breastfeeding during the prenatal period.

(1) A well-fitting support bra should be worn at all times. This will provide good support for the enlarging breasts. As the breasts enlarge, an increase in bra and cup size should be worn. (2) Pads may be worn inside the bra cups to absorb possible colostrum leakage from the nipples. The pads should be changed if they become wet from leakage. Prolonged moisture against the nipples may lead to tenderness and cracking once the newborn infant begins nursing. (3) The breasts should be washed daily (without soap) to remove dried colostrum and to prevent irritation to the nipples. Lanolin may be applied to the nipples to prevent evaporation of perspiration, thereby softening the skin. Wet tea bags may be placed on the nipples, as the tea will release tannic acid, which will toughen the skin. The nipples should be air dried or blow dried after washing to help toughen them, especially if the patient plans to breastfeed.

Brookside Note While many medications, including general anesthesia, should be avoided during pregnancy, local anesthesia (without epinephrine) is safe for needed dental work, such as replacement of the broken filling shown here. In our opinion, avoiding local anesthesia for necessary dental work is needlessly painful for the mother and or no benefit to the fetus. d. Dental Care. The patient must maintain normal, daily dental care. There is no documentation that supports increased dental cavities during pregnancy. (1) Minor dental work, such as fillings and simple extractions, may be done during pregnancy; however, patients are advised to avoid anesthetics. (2) Major dental work, to include all dental surgery, should be postponed until after the pregnancy because of the need to use anesthetics. Anesthetics may affect the developing fetus and the need to use analgesics may also affect the fetus. e. Bowel Elimination. (1) Patients who normally had no problems with bowel elimination habits will usually experience little or no change in the daily routine.

(2) Patients who have a tendency toward constipation become noticeably more irregular during pregnancy because of: (a) Decreased physical exertion. (b) Relaxation of bowel as a response to hormone. (c) Pressure on the bowel from the gravid uterus. (d) Constipating effect of iron supplements. (3) To prevent or to relieve constipation, you should encourage the patient to eat a diet high in fiber, maintain an adequate fluid intake, and to exercise--especially walking. f. Vaginal Douching. Explain to the patient that normal vaginal secretions are usually intensified during pregnancy due to increased circulation and hormone. (1) Vaginal douching should only be done with a physician's order for treatment of a specific condition. There is potential for introduction of infection and development of an air embolism. (2) Vaginal douching should never be done after a rupture or even suspected rupture of the membrane. (3) Feminine hygiene deodorant sprays should not be used due to increased chance of perineal irritation, cystitis, and urethritis. Undesirable odors can be controlled with daily use of soap and water. (4) If a douche is ordered, it should be done slowly using a gravity bag. Bulb syringe and "squeeze" operated pre-packaged douches should be avoided, as they are capable of producing too much force. (a) Douche while sitting on a toilet to decrease the risk of injury by falling. (b) The tip is not to be inserted deeper than 3 inches. (c) The bag should not be higher than 2 feet above the level of the vagina. The bag higher than 2 feet above will increase the force of pressure. g. Clothing. During pregnancy, the clothes should be given the same or perhaps even a little more attention than at other times. (1) The clothes should be lightweight, nonconstrictive, adjustable, absorbent, and enhance the sense of well-being of the patient. (2) No constrictive round garters or girdles should be used due to interference in the blood's circulation from the legs. (3) The shoes should be comfortable and well-fitting, easy to apply, especially in the last trimester when it is difficult to bend over to tie or buckle. They should also have a good solid base of support (broad heel) to avoid tottering, which may lead to a fall.