Ante natal care

By

Naveen Sharma

j.N . Medical college

Belgaum , india
 Antenatal care ideally consists of
 
* Pre-conception counselling
* Assessment of risk factors (including maternal health)
* Ongoing assessment of fetal well-being
* Ongoing assessment of complications
* Education about normal discomforts of pregnancy, emotional aspects
(including post-natal depression), local antenatal classes, reducing risk of
SIDS, parenting issues (including child-proofing the house and coping with
crying infants)
* Discussion of birthing care options
 Examination at first check up
 MCH care card is filled up with all data
 Complaints:
Amenorrhea ; Nausea with or without vomiting(morning sickness) Urinary
frequency and urgency; Pain slightly in the breast
 History of present pregnancy:
 Obstetrics history:
 Contraceptive history;
 Menstrual history;
first day of LMP
EDD ;(by naegele’s formula)
(for IVF pregnancy date of lmp is 14 day prior to date of embroy transfer.)
pattern of menses preceding this, as irregular cycles or OCP withdrawal bleeds
will make dating the pregnancy unreliable. ( If doubt exists then an ultrasound can
be performed - the earlier the scan the more accurate it is for dating the conceptus
 Past medical/surgical history
 Diet history ,
 drug history ;( Vitamin A>2500 I.U.
daily (>2 capsules) may cause birth
defects
 immunization history
 Family history (HTN, DM,TB,twins )
 General physical
examination;
 Ht :( if ,<140 cm in short stature
primi ,her birth passage comes smaller
to deliver 3kg baby)
 Wt.
 Pallor:
In lower palpebral
conjunctiva,
dorsum of tongue,
nail bed
 Jaundice:
Bulbar conjunctiva,
Hard palate,
Under surface of
tongue,
Skin
 Oedema of leg
Causes
1. Physiological
2. Pre Eclampsia
3. Anaemia
4. Hypoproteinemia
5. Cardiac Failure
6. Nephrotic
syndrome
 Examination of neck:
Thyroid enlargement
Lymph node
Neck veins
 Pulse,
 BP,
 Temp,
 Respiratory Rate
 Breast Examination
Mandatory
Note the nipple (cracked or
depressed ) and skin condition of
areola

Breast changes (valuable in

primigravida)
Enlarment with vascular
engorgement
Montgomery’s tubercles are
prominent
Thick yelloish secretion (by12 wks)
 Obstertrical Examination
Inspection:
Presence of incisional scars
Linea nigra (by 20th week )
Striae Gravidae
Presence of Herniation
Position of umbilicus
Palpation:
Fundal height(Fundus of uterus just
palpable above pubic smphysis at 12
weeks)

pelvic examination :
to exclude any pelvic pathology
 Investigation
Confirmation of prenancy ;
agglutination inhibition test:
direct agglutination test:
by detecting hCG in serum or urine.
(by 8 to 11days after conception ) .Not
reliable after 12 wks
Examination of blood;
hb,abo and rh grouping ,
blood glucose
VDRL,
. Examination of urine :
for protein , sugar, and puscells,(if >5
/high power field, urine culture and
sensitivity is done)
Cervical cytology study by papanicolaou
stain
 Special investigation
 Serological test for rubella,

hepatitis B , HIV
 USG (in 1st trimester)

to detect early pregnancy(by

gestational sac early by 29 to 35
days ) ,accurate dating (by CRL
between 7 and 12
weeks),number of fetuses, gross
fetal anomaly
Triple test (MSAFP, E3 and hcg) at
15-18 wks if suspecting downs
syndrome, neural tube defect )
 At Subsequent visit
Generally check up is done
at interval of 4 wks up to
28 wks; at interval of 2
week up to 36 wks and
weekly till the expected
date of delivery.
Minimum 3 visit
1st at 20 wks or as soon as
pregnancy is known
2nd at 32 wks
3rd at 36 wks.
Maternal wt.
Expected to gain wt. 1.5 kg every 4
week
To gain 11 kg wt. throughout
pregnancy for 3kg wt. baby
Maternal wt. is key to foetal wt. gain
and assessment of foetal growth
Anemia is checked
BP is carefully checked,after she lies
on bed. (diastolic pressure>90, or
increase of >20 from first visit is
significant)
Oedema in feet and ankle is checked.
 High risk cases
 Elderly primi (30 yrs and above )
 Short statured primi (140 cm and below )
 Malpresentation,viz breech, transeverse lie.
 Antepartum haemorrhage,threatened abortion
 Pre-eclampsia and eclampsia
 Anaemia
 Twins , hydramnios
 Previous still-birth,intrauterine death,manual removal of placenta
 Elderly grandmultiparas
 Prolonged pregnancy(14 days after edd )
 h/o previous caesarean or intrumental delivery
 Pregnancy associated with general disease,cvd,DM,TB
 Obstetrics examination
Preparatory Procedures

1. Instruct woman to empty her bladder first

Rationale:

The full bladder may be mistakenly a part of the fetus

2 . Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal
muscles. Place a small pillow under the head for comfort
Rationale:

This easily exposes the body part to be examined.

3. Drape the client properly.
Rationale:

This promotes privacy.

4. Explain procedure to the patient.
Rationale:

This make the client knowledgeable and establishes rapport between the her and the nurse.
5. Warm hands by rubbing together.
Rationale:

Cold hands can stimulate uterine contractions. 6. Use the palm for palpation not the fingers.
6. Use the palm for palpation not the fingers.
Rationale:

Doing so clearly verifies the accuracy of the procedure

 Fundal ht. (to
corroborate normal
foetal growth.)
 Ulnar border of left
hand is placed on
upper most level of
fundus
First manaeuver:Fundal Grip

 Purpose:
1. To determine fetal part lying in the
fundus.
2. To determine presentation.
• Procedure:
 Using both hands, feel for the fetal

part lying in the fundus.

 FINDING….

 Head is more firm, hard and round

that moves independently of the

body.
 Breech is less well defined that

moves only in conjunction with the

body.
 Second manaeuver:Umbilical Grip

 Purpose:
1. To identify location of fetal back.
2. To determine position.

• Procedure:
One hand is used to steady the uterus on one side of
the abdomen while the other hand moves slightly on
a circular motion from top to the lower segment of
the uterus to feel for the fetal back and small fetal
parts. Use gentle but deep pressure.

FINDING…
 Fetal back is smooth, hard, and resistant surface

 Knees and elbows of fetus feel with a number of

angular nodulation
Third manaeuver:Pawlik’s Grip
 Purpose:
1. To determine engagement of presenting
part.

• Procedure:
 Using thumb and finger, grasp the lower

portion of the abdomen above symphisis

pubis, press in slightly and make gentle
movements from side to side.
 FINDING….

 The presenting part is not engaged if it

is not movable.

 It is not yet engaged if it is still

movable.
 Fourth manaeuver:Pelvic Grip
Purpose:
1. To determine the degree of flexion of fetal head.
2. To determine attitude or habitus.
• Procedure:
 Facing foot part of the woman, palpate fetal head

pressing downward about 2 inches above the

inguinal ligament.
Use both hands.
 FINDING….

 Good attitude – if brow correspond to the

side (2nd manaeuver) that contained the

elbows and knees.
 Poor atitude – if examining fingers will meet

an obstruction on the same side as fetal back

(hyperextended head) Also palpates infant’s
anteroposterior position. If brow is very easily
palpated, fetus is at posterior position (occiput
pointing towards woman’s back)
 Pelvimeter measure
for intrauterine foetal
wt. determinaion
 Superior border of
symphysis pubis to
fundus (L )
 Transverse diameter of
uterine cornu (T)
 Wt; L*(1/2T)2*1.44
Auscultation
 Fetal heart sound ;
 Are heard best through the
back (left scapula region) in
vertex and breech
presentation
 Max intensity of FHS is
below umblicus in cephalic
presentation
 In occciputo-anterior
position ,heard in the middle
of spino-umbilical line of
same side
investigation
 Sonography;
at 18- 20 wks for placental
localisation ,fetal
anatomy, and integrity of
cervical canal, gestational
age by bpd,
foetal fluid volume to
detect oligohydramion
(afi<5) or polyhyramion
(afi >25)
 Antenatal advice
 Diet cereals 440+35 g
 Food chart is prepared and given Pulses 45+15
 Increase calorie by +300kcl over Green leafy veg 100
non pregnant stage Other veg 40
 Food avoided for preeclampsia Roots n tuber 50

prone pt.; Milk 150+100

Oils n fat 25
pickle,fried food,spiced food,
sugar 20+10
Rest and sleep :
avg. for 10 hrs in bed (8 hrs in
the night and 2hrs at noon)
In late pregnancy lateral posture
for sleep
 Supplementary nutritional therapy;
for all >16 wks POG
Hb >10 gm % 1 tab of ferrous sulphate cont. 60
mg of elemental iron for 100 days
Hb<10 gm% bd
prenatal vitamins that contain folate 400 μg
(0.4 mg), taken once/day; folate reduces risk of
neural tube defects. For women who have had
a fetus or infant with a neural tube defect, the
recommended daily dose is 4000 μg (4 mg).
Supplementary vitamins
 Regular bathing
 Loose clothing
 No high heel shoes
 Dental care
 Care of breast
if retracted ,
corrected by
manipulation
 Physical activity :
 moderate physical activities and exercise
Sexual intercourse is avoided during first trimester and also
during last 6 weeks
TRAVEL :
 The safest time to travel during pregnancy is between 14
and 28 wk.
 Pregnant women should wear seat belts regardless of
gestational age and type of vehicle. Travel on airplanes is
safe until 36 wk gestation.but contraindicated in cases with
placenta praevia, pre-eclampsia,severe anaemia , and sickle
cell disease.
 Immunizations:

Tetanus : 0.5ml tetanus toxoid ,i.m., at 6 wks interval 2dose

first between 16-24 wks ( in non immunised pt.)
if immunised in past 1 booster dose of 0.5ml in last trimester
vaccine for measles, mumps, rubella, and varicella should not be used .
The hepatitis B vaccine can be safely used if indicated, and the
influenza vaccine is strongly recommended for women who are pregnant
or postpartum during influenza season.
 women with Rh-negative blood and thus at risk of developing Rh (D)
0
antibodies are given Rh0(D) immune globulin 300 μg IM after any
significant vaginal bleeding or other sign of placental hemorrhage or
separation (abruptio placentae), after a spontaneous or therapeutic
abortion, after amniocentesis or chorionic villus sampling,
prophylactically at 28 wk, and, if the neonate has Rh 0(D)-positive blood,
after delivery.
 Modifiable risk factors
known or Suspected Teratogens
 should not use alcohol and tobacco.  ACE inhibitors

 Alcohol
 avoid exposure to chemicals or paint
fumes, direct handling of cat litter  Methotrexate

(due to risk of toxoplasmosis),  Norprogesteron

prolonged temperature elevation (eg,  Penicillamine
in a hot tub or sauna  Carbamazepine
 Drugs and vitamins that are not  Phenytoin
medically indicated should be
 Danazol
discouraged During organogenesis
 Streptomycin
(between 20 and 56 days after
fertilization)  Diethylstilbestrol

 large amounts (> 7 cups of coffee/day)  Tetracycline

increases risk of stillbirths, preterm  Thalidomide

deliveries, low birth weight, and  Lithium

spontaneous abortions.  Valproate
Minor Ailments 
of Pregnancy  

 Nausea and Vomiting (I) 

 Nausea and vomiting of pregnancy (NVP) is the most common medical
condition in pregnancy.
 usually most severe in the morning (Morning Sickness)  
 Physiology
 The vomiting reflex is triggered by stimulation of chemoreceptors in the
upper GI tract and mechanoreceptors in the wall of the GI tract which are
activated by both contraction and distension of the gut
 Afferent nerves to the vomiting center arise from abdominal splanchnic and
vagal nerves, vestibulo-labyrinthine receptors, the cerebral cortex and the
chemoreceptor trigger zone (ctz )
 The CTZ is exposed to emetic stimuli of endogenous origin such as hormones
associated with pregnancy and to stimuli of exogenous origin such as drugs .
 Nausea and Vomiting (II)  

 results from rapidly rising serum levels of human chorionic gonadotropin- hCG. During the
first trimester, serum hCG levels may be as high as 100,000 mIU/mL
 Extreme nausea and vomiting ; sign of multiple gestation or molar pregnancy and
SHOULD be distinguished from idiopathic NVP.
 Treatment of NVP  

 For uncomplicated nausea consists of light dry foods, small frequent meals, and emotional
support.
 high-dose B6 therapy and the preconceptional use of prenatal vitamins.
 Antinauseant drugs ; Promethazine, prochlorperazine and Metoclopramide
Nausea and Vomiting (III)  

 Protracted vomiting associated with dehydration and ketonuria (hyperemesis gravidarum

HG) is defined as persistent vomiting that leads to weight loss greater than 5% of pre-
pregnancy weight, with associated electrolyte imbalance and ketonuria.
 It usually presents in T1
 Management of HG:
 Admit to hospital.
 Doxylamine succinate 10mg with vit B6.
 Gastric Reflux (Heartburn) 
 occurs as a result of delayed gastric emptying, decreased intestinal motility, and
decreased lower esophageal sphincter tone.
 lifestyle modification
 dietary modifications (e.g. small frequent meals, eat slowly, reduction of high-fat
foods and caffeine).
 Antacid Preparations containing aluminium hydroxide are favoured.
 H2 receptor antagonists or proton pump inhibitors
Constipation  

 Reduced motility of large intestine (progesterone effect).

 Increased water reabsorption from large intestine (aldosterone effect).
 Pressure on the pelvic colon by the pregnant uterus..
 Advice includes drinking plenty of fluids, high fibre foods and get plenty of
exercise.
 fibre supplementation
 stimulant laxative
    Oedema and varicose veins in the lower limbs & vulva
 i -  Venous pressure .
 ii - Relaxation of the smooth muscles in the wall of the veins by progesterone
 iii -  Osmotic pressure in blood .
 iv -  Capillary permeability (due to   progesterone and aldosterone).
 Varicose Veins treatments 
 Avoid long periods of standing and encourage active exercise.
 Avoid constricting clothes.
 Keep the legs elevated while sitting and during sleep.
 Use of elastic stockings:    These should be removed at night and applied with leg
elevated before getting out of bed in the morning (empty veins).

Fatigue and insomnia 

 Fatigue is very common in early pregnancy and reaches a peak at the end of the first
trimester. Rest, lifestyle adjustment and reassurance are usually all that is required.

Fatigue also occurs in late pregnancy, when anaemia should be excluded.
 Vaginal discharge 
 usually produce more vaginal discharge during pregnancy.
 If the discharge has a strong or unpleasant odour, is associated with itch or
soreness or associated with dysuria, then infection needs to be excluded.
 Trichomoniasis is associated with adverse pregnancy outcomes,
 A topical imidazole is an effective treatment for thrush which is common
during pregnancy
  
 Skin Changes 
 Spider telangiectasis & palmar erythema :
 Due to increased estrogen or cutaneous
vasodilatation. 
 Hyperpigmentation:
     Due to increased estrogen or melanocyte stimulating hormone or
ACTH
  Backache:
often first develops during the 5th to 7th months of
pregnancy.
Encourage light exercise and simple analgesia,
Exercising in water, massage therapy   
 Leg cramps:
Leg cramps occur in 1 in 3 pregnancies.
occur in late pregnancy and are usually worse at night.
Massaging the affected leg and elevation of the foot of the
bed may help.