Systematic Supervision (Examination & advice) of a woman during Pregnancy is called Antenatal Care. It should start from the beginning of pregnancy and end at delivery.
Antenatal Care Comprises of
A) Careful History Taking & Examinations (General & Obstetrical)
B) Advice given to the pregnant Woman.
AIMS OF ANTENATAL CARE
The aims of antenatal care are written below:
1) It helps to screen the High Risk Cases.
2) It helps to prevent and treat and untoward complications.
3) It helps to ensure medical surveillance and prophylaxis.
4) It helps to educate the mother about the physiology of Pregnancy and labour by Demonstrations, Charts & Diagrams (Mother Craft Classes), so that the fear is reduced and psychology is improved.
5) To discuss with the couple about place, time and mode of delivery and care of newborn.
6) To encourage the couple to start family planning.
7) To give appropriate advice to the couple seeking MTP (Medical Termination of Pregnancy).
OBJECTIVE OF ANTENATAL/PRENATAL CARE
The main objective is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
The first visit should not be deferred beyond the second missed period. It may be done earlier if the patient desires to terminate the pregnancy.
(a) To assess the health status of Mother and fetus.
(b) To screen out the high risk Pregnancy.
(c) To formulate plan of subsequent management.
(d) To obtain a baseline information against which the subsequent changes are assessed and which are of importance in the determination of the gestational age.
PROCEDURE AT FIRST VISIT
It includes the following:
1. Vital Statistics
Vital Statistics include:
(b) Date of First Examination.
(d) Age To check out elderly primigravida i.e. (pregnancy at the age of 30 or above 35 years is known as elderly Primigravida)
(e) Gravida & Parity.
(f) Duration of Marriage: It helps to note the Fertility & Fecundity.
(h) Occupation of mother: It helps in interpreting Symptoms due to fatigue or Occupational hazards.
(i) Occupation of the husband: To assess the Socio- Economic status of the family.
(j) POG (Period of Gestation)
In pregnancy the complaints are to be noted stating the mode of onset, Progress and Duration. Even if there is no complaint enquiry is to be made about the:
(c) Bowel habit
3. History of Present Pregnancy
In this the important complications in different trimesters of pregnancy are to be noted carefully as follows:
(a) First Trimester: Hyperemesis Gravidarum.
(b) Second Trimester: Threatened abortion. (c) Third Trimester: Anaemia, Pre-eclampsia & APH (Antepartum haemorrhage)
Also Note The:
(d) Number of antenatal Check-ups done previously.
(e) Any radiation or medication exposure in early pregnancy should be enquired.
(f) Note any Medical or surgical events during pregnancy.
4. Obstetrical History
It is only related with the multigravidae. It includes:
(a) No. of Living Children -Boys-? Girls?
(b) Health Status of baby/ babies/ children.
(d) Last Issue.
(e) If there is any miscarriage then it should also be noted.
5. Menstrual History
It includes the followings:
(a) Menstrual cycle
(b) The first day of the last period (LMP)
(d) From above EDOD (Expected date of Delivery) is calculated by Naegele’s Formula
(e) Amount of blood flow
6. Past Medical Disease
Any history of Past Medical Disease is to be noted.
7. Past Surgical History
Previous Surgery any i.e. general or Gynaecological is to be enquired.
8. Family History
Note the family history of: –
(a) HTN (Hypertension)
(d) Blood dyscrasia
(e) Hereditary disease
(f) Twins Pregnancy in family etc. are to be enquired.
9. Personal History
In this note about the following:
(a) Contraceptive Practice Prior to Pregnancy
(b) History of Smoking.
(c) History of alcohol Consumption.
(General as well as Obstetric) method Conducting Antenatal Examination.
The antenatal examination is divided into 2
1. General Examination.
2. Obstetrical Examination.
1. GENERAL EXAMINATION
It includes the following:
(a) Build of the Mother: Obese/Average/Thin
(b) Nutrition of the Mother: Good/Average/Poor
(c) Height of the Mother: The height is measured to screen out Short Stature. As short stature is likely to be associated with a Small Pelvis. Thus, in India a height less than 4-7″ is considered as short stature. So every pregnant woman should go for height measurements.
It should be taken in all cases and with an accurate weighing machine.
(e) Pallor: The sites to be noted are:
(i) Lower Palpebral Conjuctiva
(ii) Dorsum of tongue
(iii) Neil beds
(f) Jaundice: The sites to be noted are:
(i) Bulbar conjuctiva.
(ii) Under Surface of tongue.
(iii) Hard Palate
(g) Tongue, teeth, gums and tonsils: Check for malnutrition it is evident from glossitis and stomatitis.
(h) Neck: Neck vein, thyroid glands are looked for any abnormality. Slight physiological enlargement of thyroid gland occurs during pregnancy in 50% of cases.
(i) Odema of Legs: Both the legs are to be examined. The sites for evidence of odema are over the medical malleolus and anterior surface of lower 1/3rd of the tibia. The area is to be pressed with the thumb atleast for 5 seconds. Any varicosity in the legs should be noticed.
(j) Pulse: Pulse should be checked every 2 hrly. It helps to check the patient condition.
(k) Heart, lungs, spleen and liver-Patient check for cardiomegaly, spleenomegaly, Liver enlargement and lungs pain etc.
(l) Breast: Examination of the breasts is mandatory not only the presence of pregnancy but also to note the nipple (cracked or depressed) and skin condition of the areola. The purpose is to correct the abnormality if any, so that there will be no difficulty in breast immediately following delivery.
(2) OBSTETRICAL EXAMINATION IT
It include abdominal examination and vaginal examination
(a) Abdominal Examination: It include
(i) Inspection: It helps to note the tone of the abdominal muscles, presence of any incisional scar or presence of herniation and skin condition of the abdomen are to be looked for. At 12 weeks, the uterus’ fundus is just barely perceptible above the symphysis pubis.
(ii) Palpation: It includes Obstetric grips
Fundal grip: Help to determien if it a breech or head that is presentation.
Lateral or Umbilical grip: Help to determine position of fetal back and limbs that to determine position of fetal in utero.
First pelvic grip: Help to determine presentation, flexion of head and balloment of head.
Second pelvic grip (Pawlik’s grip): Help to see size, flexion and mobility of head/ breech and to know engagement of presenting part.
(iii) Auscultation. Auscultation of fetal heart sourds helps to diagnose a live baby only. It is heard at different parts according to the presentation of the fetus. For example,
In Vertex & breech presentation: The fetal heart sounds are best audible through the back.
In face presentation: It is heard through fetal chest.
As a rule maximum intensity of the F.H.S. is below the umbilicus in cephalic & around the umbilicus is Breech. In Occipito lateral it is heard laterally & in Occipito posterior it is heard towards the flanks-In left occipito posterior it is difficult to locate the F.H.S.
(b) Vaginal Examination: Examination is done in the antenatal clinic when the patient attends the clinic for the first time before 12 weeks. It is done:
(i) To diagnose the pregnancy. with the
(ii) To corroborate the size of the uterus period of amenorrhoea.
(iii) To exclude any pelvic pathology.
Internal Examination is however, omitted in cases with previous history of abortion, occasional vaginal bleeding in present pregnancy or specially valuable pregnancy.
Ultrasound examination (where available) has replaced routine internal examination at present. It is more informative and without any known adverse effects.
When required it is done to ensure normalcy and adequacy of pelvis to deliver the baby and to rule out any vaginal infection. It is usually done towards the end of the pregnancy.
1. Steps in vaginal examination: Vagin examination is done in antenatal clinic. The patient must empty her bladder prior to examination and is placed in the dorsal position with the thigh flexed along with the buttocks placed on the foot end of the table. Some prefer examination in lateral position. Hands are washed with soap and water and sterile glove is put the examining hand.
2. Inspection: By separating the labia-using the left two fingers (thumb and index), the characters of the vaginal discharge if any, presence of cystocele or uterine prolapse or rectocele to elicited.
3. Speculum Examination: This should be done prior to bimanual examination specially when the smear for exofoliative cytology or vaginal swab inspect is to be taken. A bivalve speculum is used. The cervix and the vault of the vagina are with the help of good light sources placed behin The characteristics bluish red colouration of cervix in pregnancy and the nature of discharg if any, coming through the cervical os or presence in the upper vagina is noted. Cervic smear for exfoliative cytology or a vaginal swa from the upper vagina, in presence of discharg may be taken.
4. Bimanual: Two finger (Index and middle) of the right hand are introduced deep into the vaginal while separating the labia by left hand. The left hand is now placed suprapubically. Do Gentle and synthetic examination are to be done to note:
(a) Cervix: Consistency, direction and any pathology.
(b) Uterus: Size, shape, position and consistency. The first stages of pregnancy are ideal for reliably correlating uterine size and gestational age.
(c) Adnexae: Any mass felt through the fornix. One finger may be inserted for inspection if the introitus is narrow. At this point, there should be no attempt to evaluate the pelvis.
There is a routine investigation during antenatal period-
EXAMINATION OF THE BLOOD
(a) Blood examination for haemoglobin estimation, ABO and Rh grouping and test for VDRL.
(b) Screening for blood glucose is done in selected cases
1. Urine is examined for protein, sugar and pus cells.
2. If protein is found “Clean Catch” specimen of midstream urine is collected to test for albumin. If protein is still/present then full urinalysis has to be done. If more than 5 pus cells per high power field is uncentrifuged urine are found, culture and scientific tests are done.
To collect mid-stream urine, the patient is advised to clean the vulva and to collect the urine in a clean container during the middle of the act of urination.
3. Cervical Cytology study by papanicolaou stain has become a routine in many clinics.
(a) Hepatitis B virus and Rubella serological testing. Antibodies to detect Rubella immunity and screening for hepatitis. B Virus.
(b) Maternal serum alpha feto portein (MSAFP) estimation or triple test at 16-18 weeks for mother at risk of carrying a fetus with neural tube defects, Down’s syndrome or other chromosomal anomaly.
First trimester scan either trans abdominal (TAS) trans vaginal (TVS) helps to detect:
(a) Early pregnancy.
(b) Accurate dating.
(c) Number of fetuses.
(d) Gross fetal anomalies.
(e) Any uterine or adrenal pathology.
Ultrasound examination at 18-20 weeks is performed as a routine at all the centres in the developed world, though doubt remains about its absolute benefit.
5. REPETITION OF THE INVESTIGATION
(a) Haemoglobin estimation is repeated at 28th and 36th week.
(b) Urine is tested for protein and sugar at every antenatal visit.
Antenatal Advice is the advice given to the pregnant woman during pregnancy
Principles: The principles are:
(a) To give the mother knowledge about the regular check-ups.
(b) To improve the health status of woman till delivery.
(c) To imporve and tone up psychology and to remove the fear of labour and delivery.
THE ANTENATAL ADVICE IS GIVEN ABOUT
(a) Diet including supplementar therapy
(b) Antenatal Hygiene.
(c) Rest and sleep.
(e) Comfort measures
(f) Sex or coitus.
(g) Antenal exercises.
(i) Smoking and alcohol.
(j) Avoidance of drugs.
(l) prepration for confinment.
(a) Diet: The pregnant diet ideally should be light, nutritious, easily digestible and rich in protein, minerals and vitamins.
It should include meat, fish, cheese, peas beans, lentils, 1 litre milk, green leafy vegetables, fresh fruits.
Advice the mother to avoid stale and spicy food and excess of fat.
Supplementary nutritional therapy:
During the pregnancy there is negative iron balance so that pregnant mother needs supplimentary iron therapy from 16 weeks onwards apart from this, extra vitamins are also given daily from 10th week. The supplementary diet is as follows:
(b) Antenatal Hygiene:
(i) The mother should take daily bath but be careful against slipping due to imbalance.
(ii) She should maintain her dental hygiene and 2nd trimerster is the best time for dental procedures.
(iii) Breast Hygiene: During the antenatal period breast hygiene is to be maintained, if the nipples are normal nothing is to be done except ordinary cleanliness.
If the nipples are retracted, correction is done by manipulation.
(c) Rest and Sleep: Advice the mother to take appropriate rest for at least 2 hrs in the afternoon and 8 hrs at night. However hard and sternous work should be avoided in first trimester and last 4 weeks.
The mother should avoid remaining in one position for long time and should elevated legs while taking rest to relieve edema in legs.
(d) Travel: Advice the mother to avoid heavy and jerky journey specially in Ist trimester and the last 6 weeks.
(e) Comfort measrues: Advise the mother to we loose and comfortable garmets like well fitting braissiere, panties, and shoes.
High heel should be avoided in advance pregnancy.
(f) Sex or Coitus: Advise the mother to avoid sexual intercourse in Ist and IIIrd trimesters as it may cause abortion in Ist trimester and infection in IIIrd trimester.
Antenatal exercises: These are the abdominal muscles and pelvic exercises which help to strengthen the abdominal muscles, support the back, help in pushing during child birth and promote recovery after child birth.
Caution: After the 4th month of pergnancy avoid doing exercises while lying flat on your back and resume exercises after the birth the baby The exercises commonly done are:
Abdominal exercises: These help to strengthen the abdominal muscles, support the back, help in pushing during child birth:
Resisted knee to chest.
This include exercises, which will, help improve posture enhance back stability and provide comfort during childbith. Advice the mother to do these exercises with caution and not to stretch to fare because pain may result from separation of the pelvic joints. So, these exercises are optional. Pelvic tilt on all fours:
Pelvic floor or kegel exercises. Lower back and thigh muscle exercises.
Tailor (Indian Style or cross legged) sit and stretch (explanation given at the back in miscellaneous.
Follow-Up: The mother is given regular follow up so as to make a check on her day to day pregnancy.
Smoking and alcohol: Advice the mother that smoking is injurious to health and she should never smoke because heavy smokers, have small babies and there are chances of abortion in the same way alcohol is not to be used as it may cause fetal maldevelopment and growth restriction.
Avoidance of Drugs: almost all the drugs are to be avoided in pregnancy as they cross the placenta and reach the fetus so over the counter drugs should be avoided in pregnancy and if are to be taken in emergencies situations then they should be as per the doctor’s prescription.
Immunization: During the pregnancy the mother is immunized against tetanus as this, not only protects the mother but also the neonate. There are mainly 2 doses to be given to the mother.
The first dose of T.T. is given between 16-14 weeks.
The second dose of T.T. a month after the initial dose.
Preparation for confinement
(i) In this collect articles for mother and baby.
(ii) Mother should know the signs of true labour.
(iii) Mother should be told the untoward Symptoms and if they appear then mother should report immediately These are
- Intense headache with disturbed sleep and restlessness.
- Urinary troubles.
- Epigastric pain and vomiting.
- Scanty urine.
- Painful uterine contractions at interval of 10 minutes or earlier and continued for at least 1hour- suggests on set of labour.
- Sudden gush of watery fluid per-vaginum suggest premature rupture of membranes
- Active vaginal bleeding however slight it may be
FAQs of Antenatal Care
Q.1. What are the causes of oedema in pregnancy?
Ans. Causes of oedema in pregnancy:
- Anaemia and hypoproteinaemia
Q.2. What are the physiological features of oedema and write about causes of physiological oedema?
Ans. The causes of physiological oedema is due to increased venous pressure of the inferior extremities by the gravid uterus pressing the common iliac veins.
Features of physiological oedema are:
- Slight degree (ankle oedema) usually confined to one leg more on the right.
2.Unassociated with any other pre-eclampsia features such as hypertension or proteinuria.
- Disappear on rest alone.
Q.3. Explain the requirement for subsequent visits during antenatal period and what is objective behind subsequent visits?
Ans. Generally check-up is done at interval of 4 weeks upto 28 weeks, at interval of 2 weeks to 36 weeks and thereafter weekly till the expected date of delivery. But Acc. to W.H.O. recommendation, the visit may be curtailed to atleast 3, first in second trimester between 16-20 weeks, second at 28-32 weeks and third at 36 weeks.
(i) First in second trimester between 16-20 weeks.
(ii) Second at 28-32 weeks.
(ii) Third at 36 weeks.
Objective of Subsequent Visits
(A) To Assess:
(i) Fetal well being.
(ii) Lie, presentation, number of fetuses and position. (iii) Growth restriction, pre-eclampsia, anaemia, polyhedramnios.
(iv) To organise specialist antenatal clinics for patient with problems like cardiac diseases and diabetes.
(B) To select time for Amniocentesis or chorion villus biopsy when indicated.
Q.4. What types of examination would you prefer at time of subsequent visits?
What procedure you will do at subsequent visits?
Ans. We would prefer 3 types of examination like:
- General Examination.
- Abdominal Examination.
- Vaginal Examination.
- General Examination
In each visit the following are recorded:
(c) Oedema legs
(d) Blood pressure (BP).
- Abdominal Examination
(a) To note the height of the fundus i symphysis pubis. from the 20th week, symphysis-fundus height increases is about 1 per week.
(b) In the second trimester, to identify the fundamental external ballotment, fetal movements, palpation of fetal parts, auscultation of heart rate sounds.
(c) In the third trimester, abdominal palpation will help to identify fetal lie, presentation, position growth pattern, volume of liquor and also any abnormality.
(i) Examination also helps to detect whether presenting part is engaged or not.
(ii) Girth of abdomen is measured at the level o umbilicus.
(iii) The girth increases by about 2.5 cm per week beyond 30 weeks and at term, measures above 95-100 cm.
Q.5. Define the following terms
(a) Nullipala, (b) Primipala and (C) Multigravida
Ans. (a) Nullipara: A nullipara is one who has se completed a pregnancy to the stage of viability. She may or may not have aborted previously.
(b) Primipara: A primipara is one who has delivered one viable child.
(c) A multigravida: A multigravida is one who l previously been pregnant. She may have aborted have delivered a viable baby.
Q.6. Why is the height of pregnant woman checked anternally?
Ans. It is often checked to rule out short sature, as short stature is related to small pelvisand usually related with caesarean section.
Q.7. How can malnutrition be detected prenatally?
Ans. Malnutriton is detected prenatally by observed the mother for glossitis and stomatitis.
Q.8. What are the causes of edema in pregnancy
Ans. The causes of edema in pregnancy are
(iv) Cardiac failure
(v) Nephrotic drome.
Q.9. Why does the physiological edema occur in pregnancy?
Ans. The physiologica edema is caused due to increased venous pressure of inferior extremities by gravid uterus essing on the common illiac veins.
Q.10. How much kilocalories should a pregnant women consume.
Ans. A pregnant woman should take 2500 kilocalories.
Q.11. Write the dietary requirement of iron, calcium, icacid, Vitamin A and Protein in pregnancy?
Ans. It is an follows
- Iron 40 mg
- Calcium 1000 mg
- Folic acid 400 kg
- Vitamin A 400 I.U
- Protein 60 gm.
Q.12. Which is the best trimester for dental procedures?
Ans. 2nd trimester.
Q.13. Why is breast care provided antenatally?
Ans. Breast care is provided antenatally in order to Hect any nipple retraction and if present to correct it amipulation antenatally so that there may not be ty feeding and sucking problem for the baby in the stnatal period or after delivery.
Q.14. When and Why should coitus be avoided uring pregnancy?
Ans. Coitus or sexual intercourse should be avoided ring the first trimester and also during the last 6 eeks as it may lead to preterm labour and abortion ring first trimester and cause infection in the last Weeks.
Q.15. What kind of immunization is the pregnant other provided during the Antenatal period?
Ans. The pregnant mother is provided immunization against Tetanus Toxoid as an it protects both the mother and fetus.
Q.16. When should the first dose of Tetanus Toxoid be given?
Ans. The first dose should be given between 16-24 weeks.
Q.17. When is the IInd dose of Tetanus Toxoid given?
Ans. The second dose is given 1 month after the first dose.
Q.18.What should mother avoid throughout the pregnancy?
Ans. Throughout the pregnancy the mother should avoid unnecessary radiation exposure and also avoid over the counter medications.
Q.19. When does the pregnant woman need immediate attention or admission to hospital?
Ans. The pregnant mother is admitted to hospital in the following circumstances.
Painful. uterine contractions at interval of 10 minutes or earlier and continued for at least 1hour suggests on set of labour. Sudden gush of watery fluid per-vaginum suggest premature rupture of membranes active vaginal bleeding however slight it may be
Q.20. List down the minor ailments in pregnancy?
Ans. The minor ailments in pregnancy are
(a) Nausea and vomiting.
(c) Acidity and heart burn
(d) Leg cramps
(f) Varicose veins
(g) Ankle edema
(h) Vaginal discharge
Q.21. What may be the causes of backache in pregnancy?
Ans. 17 in pregnancy backache is caused due to
(a) Relaxation of pelvic joints
(b) Faulty posture
(c) High heel shoes
(d) Muscular spasm
(e) Urinary infection
Q.22. How can backache be relieved?
Ans. It can be relieved by
(a) Improvement of posture
(b) Use of well filled pelvic girdle belt. Which may correct lumbar lordosis
(d) Massage of back muscles
(e) Analgesics are used to relieve pain
(f) Rest is provided
(g) If the backache is due to urinary infection or constipation it is relieved
Q.23. What are the causes of leg cramps?
Ans. Leg cramps may be due to deficiency of diffusible serum calcium or elevation of serum phosphorous
Q.24. What is the treatment for leg cramps?
Ans. To relieve leg camps:
(a) Mother is given supplimentary calcium therapy
(b) Legs are massaged
(c) Local heat is applied
(d) Vit B, (30mg) daily in prescribed
Q.25. What all kind of tests are conducted while assessing the conditions of the fetus?
Ans. The tests conducted are classified as follows
(a) Tests done at first visit
(b) Tests done at subsequent visits
(c) Special investigations
Q.26. What all tests are performed at the first-visit?
Ans. The tests care performed firs visit
(a) Haemoglobin estimation.
(b) Routine examination of urine-culture done wi indicate.
(c) Serological tests for syphilis.
(d) ABO and Rh. grouping
(e) Estimate of Post Prandial blood glucose glucose toletance test (GTT) when indicated
(f) Tests for toxoplasmosis and and phospholip antibodies in recurrent abortion or stillbirth.