ANTENATAL CARE & MANAGEMENT

INTRODUCTION

Every Year there are an estimated 200 million pregnancies in the

world. Each of these pregnanciesis at risk for an adverse outcome for
the woman and her infant. While risk can not be totallyeliminated,
they can be reduced through effective, and acceptable maternity
care.To be most effective, health care should begin early in pregnancy
and continue at regular intervals

Systematic supervision (examination&advice) of a woman during

pregnancy is called antenatal(Prenatal) care. The supervision should
be regular and periodic in nature according to the need ofthe
individual. Antenatal care comprises of:


Careful history taking and examination(general and obstetrical)



The advicewas given to the pregnant woman

DEFINITION-1.

Antenatal care refers to the care that is given to an expected mother

from timeof conception is confirmed until the beginning of labor.2.

Planned examination and observation for the woman from conception

untilthe beginning of labor.
AIMS AND OBJECTIVE
The aims are-
1.To screen the ‘high risk’ cases.
2prevent or to detect and treat at the earliest any complications.
3.To ensure continued risk assessment and to provide ongoing
primary preventive healthcare.
4.To educate the mother about the physiology of pregnancy and labor
by demonstration,charts,and diagrams, so the fear is removed,
and psychology is improved.
5.To discuss with the couple about the place, time and mode of
delivery, provisionally andcare of the newborn.
6.To motivate the couple about the need for family planning and
appropriate advice to acouple seeking medical termination of
pregnancy.
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OBJECTIVE
–
1.

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

healthy mother.2.

Prevention, early detection,and treatment of pregnancy-related

complications as Pre-eclampsia, eclampsia,andhemorrhage.3.

Prevention, early detection and treatment of medical disorders

as anemia and diabetes.4.

Detection of early malpresentation,

malposition’s
,and disproportion that may influence thedecision of labor.5.

Instruct the pregnant woman about hygiene, diet and warning

symptoms.6.

Laboratory studies of parameters may affect the fetus as blood group,

Rh typing,toxoplasmosis,and syphilis.CRITERIA OF A NORMAL
PREGNANCY
–
Delivery of a single baby in good condition at term ( 38
–
42 weeks), with a fetus weight of2.5 kg or more and with no maternal
complication.FREQUENCY OF ANTENATAL VISIT S
–

Generally,a check-up isdone at an interval of 4 weeks upto 28 weeks,

at an interval of 2 weeks upto 36 weeks and thereafter till delivery.


WHO recommends the visit may be curtailed to atleast 4 visits,1

st
 visit
–
around 16 weeks2
nd
visit
–
Between 24 -28 weeks3
rd
visit
–
around 32 weeks4
th
visit
–
around 36 weeksPROCEDURE AT THE FIRST VISIT -The first
visit should not be referred beyond the second missed
period.OBJECTIVES
–
1.

To assess the health status of the mother and fetus.2.

To assess the fetal gestational age and to obtain baseline

investigation.3.

To screen out the

“at risk” pregnancy and to formulate the plan of subsequent
management.HISTORY TAKING
–
1.

Vital statisticsa)

General Examination of the Mother name, age, gravida, parity,

expected date ofdelivery.b)

Period of gestation
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Gravida denotes a pregnant state both present and past irrespective of

theperiod of gestation.


Parity denotes the state of previous pregnancy beyond the

period of viability.c)

Duration of marriage- This is relevant to note the fertility or

fecundity. Apregnancy long after marriage without taking any method
of contraception iscalled low fecundity and soon after marriage is
called high fecundity. A woman with low fecundity is unlikely to
conceive frequently.d)

Religione)

Occupation
–
It is helpful to interpret symptoms of fatigue due to excessphysical
workor stress occupation hazard. Such women should be informed
toreduce such activities.f)

Occupation of husband-


To access the socioeconomic condition of the patient,



To anticipate the complications likely to be associated with low

socialstatus such as anaemia, pre-eclampsia, prematurity etc.


To give reasonable and realistic antenatal advice during family

planningguidance.g)

Period of gestation- The duration of pregnancy is to be expressed in

terms ofcompleted weeks, a fraction a week of more than 3 days is to
be considered ascompleted week. In the early pregnancy it
is calculated from the first day of lastnormal menstrual period(LNMP)
and in later month of pregnancy it iscalculated from the expected date
of delivery.2.

ComplaintsCategorically, the genesis of complaints is to be noted,

even if there is no complaint,inquiry is to be made about the
sleep appetite, bowel habit and urination.3.

History of present illnessElaboration of the chief complaints as regard

their onset, duration, severity, use ofmedications and progress.4.

History of Present pregnancy



Last menstrual dates

–
Calculate expected date of delivery


Cycle regularity


History of recent oral contraceptive pill use

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Early ultrasound assessment of gestational age.



Important complications in different trimestersof the present

pregnancy are to be notedcarefully these are hyperemesis
andthreatened abortion in first trimester,features of pyelitic, in second
trimesterand anaemia, pre-eclampsia andantepartum hemorrhage, in
the lasttrimester number of previous antenatal visits immunization
status must be notedany medication or radiation exposurerarely
pregnancy or medical surgical eventsduring pregnancy must be
noted.5.

Past Obstetrical
History Ask for details, Date of pregnancy, Outcome, Gestation, Weig
ht and sex of the baby, wellbeing now, Problems in labor or
pregnancy, delivery mode.6.

Menstrual
History Age at menarche, frequency, duration and amount of flow, pr
emenstrual symptoms,dysfunctional uterine bleeding.Calculation of
the expected date of delivery(EDD)-
This is done according to Naegele’s
formula by adding 9 calendar month and seven days to the first day
of the last menstrualperiod. Alternatively, one can count back 3
calendar months from the first day of lastperiod and then add 7 days
to get the expected date of delivery.7.

Past medical HistoryRelevant history of past medical illness that is

urinary tract infection tuberculosis is to beinquired.8.
Past surgical History Any previous pregnancy e.g. General or
gynecological, if any, is to be inquired.9.

Family HistoryFamily History of diabetes, hypertension, tuberculosis,

multiple pregnancy, non-hereditarydisease if any or twinning,
congenital anomaly of fetus is to be inquired.
Calculation of EDD
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10.

Personal History


About the nutrition, morning sickness, weight gain.



Rest and sleep 8 hours during night and 2 hours during day time.


Activity and exercise.



Habits such as alcoholism, smoking, tobacco chewing.



Marital, any consanguineous marriage and duration of marriage.



Contraception such as pills or intra uterine devices.



Drugs during pregnancy



Sexual history- any intercourse during pregnancy.


Elimination- Frequency of micturition, Constipation.11.

Previous Gynecological Problems

STI’s endometriosis, infertility, surgery, polycystic ovarian diseases.
PHYSICAL EXAMINATION-1.

General Physical Examination:



Build-obese/average/thin


Nutrition- Good/Average/Poor


Height- Short Stature is likely to be associated with a small pelvis.



Weight- Weight should n=be taken in all cases in an accurate weighi

ngmachine. Repeated weight checking in subsequent visit should be
done in thesame weighing machine.


Pallor- The sites to be noted as lower Palpebral conjunctiva, dorsum

of thetongue and nailbeds.


Jaundice- The sites to be noted as vulbarconjunctiva, under surface of

thetongue, hardpalape skin.


Tongue,
teeth’s
, gums and tonsils- Evidence of malnutrition are evident fromglossitis
and stomatitis. Any infection in mouth is to be eradicated, any
sourceof infection is to be eradicated.

Neck- Neck veins, thyroid gland, Orlive glands are looked for
any abnormality.


Odema of the legs- Both the legs are to be examine the sites are over
the medialmalleolus and interrail surface of the lower 1/3 RD of the
Tibiya.2.

Vital Signs: Assess the pulse, BP, respiration and temperature.3.

Systemic Examination:Heart, lungs, Liver and spleen- are to be check

for any abnormality.
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Breast- needs to be checked for nipples (Cracked or depressed and

skin conditionareola).4.

Obstetrical Examination


Eyes: Pallor, Jaundice



Breast: Nipple cracked/ depressed, symmetry, Secondary areolar,

montubergtubercle


Abdominal Examination


Vaginal Examination5.

Routine Investigation


Examination of the blood



Urine is examined routinely for protein, Sugar and pus cells.6.

Special Investigation


Serological tests for rubella and hepatitis B virus


Ultrasonography examination


Maternal serum alpha Feto protein7.

Booking should be done.

Procedure at the subsequent Visits
Generally check up is done at interval of 4 weeks up to 28 weeks ; at
interval of 2 weeks up to36 weeks and there after weekly till-the
expected date of delivery. In the developing countries,as per WHO
recommendation, the visit may be curtailed to at least 4 ; first in
second trimesteraround 16 weeks, second between 24-28 weeks, the
third visit at 32 weeks and fourth visit at 36 weeks.
Objectives
To assess


Fetal well being



Lie, presentation, position and number of fetuses.



Anaemia, pre-eclampsia, amniotic fluid volume and fetal growth.



To organize specialist antenatal clinics for patients with problems like

cardiac diseaseand diabetes.


To select, time for ultrasonography amniocentesis or chorionic villous

biopsy whenindicated.
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History Collection
Appearance of any new complaints, quickening, lightening,
examination. Weight, pallor, oedema of legs, BP monitoring
Abdominal examination.1
st
trimester: Height of the fundus2
nd
trimester: External ballotment, fetal movements, palpation of the fetal
parts, fundal height3
rd
trimester: Identify lie, presentation, position, growth pattern,
engagement, girth of theabdomen, fundal height.
Uncover the patient’s abdomen from the xiphisternum
to the public hairline, ensuringadequate exposure while allowing for
patient modesty. Abdominal wall relaxation is maximizedby the
patient resting her arms alongside her abdomen, rather than behind
her head. The
patient’s legs may also be slightly flexe
d at the hips to aid relaxation.
Inspection:
The presence of an abdominal mass arising from the pelvis consistent
withpregnancy, scars, pigmentation or other skin lesions are noted.
Fetal movements may be observed.
Fundal Palpation(First Maneuver)


Fundal palpation can be doneusing the finger tips or palmarsurface of

the fingers.


First nurse should facetowards the women head.



Whole fundal area ispalpated by both hands laidflat on it to find

which pole offetus is lying in the fundus.


Palpate for size, size, shape,consistency and mobility ofthe fetal part
in the fundus.


Round, hard, readily,movable part, ballotablebetween the fingers of

bothhands is indicative of head.


Irregular, bulkier, less firmand not well defined ormovable part is

indicative ofbreech.


Neither of the above isindicative transverse lie.

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Lateral Palpation(Second Maneuver) orUmbilical grip

Continue to face the womanhead side



Place the hands on bothside of the uterus aboutmidway between

thesymphysis pubis and thefundus.

 Apply pressure with onehand against the side of theuterus pushing
the fetus tothe other side andstabilizing it there.


Palpate the other sideabdomen with theexamining finger from

themidline to the lateral sideand from the fundus usingthe smooth
pressure androtator movements.


Repeat the procedure for theopposite.



A smooth, curved, hardresistant surface indicateback.



Small, knob irregular partsor modules indicate limb.

Pawlicks grip(Third Maneuver)

Continue to face the womanhead side.



Woman should be placed asknee bent.



Grasp the portion of thelower abdomenimmediately above

thesymphysis pubis betweenthe thumb and middlefinger of one of the
hand.


If the fetal head is abovebrim, it will be readilymovable and

ballotable.


If it is not ballotable, itindicates head is engaged.

Pelvic Palpation(Fourth Maneuver)


Nurse should face towardsthe woman feet side, womanshould be

placed as knee bent.


Place the hands on the sidesof the uterus, with the palm ofthe hands
just below the levelof the umbilicus and fingersdirected towards
thesymphysis pubis.


Press deeply with fingertipsinto the lower abdomen andmove them

towards the pelvic


This maneuver determinesthe engagement of thehead.



If the head is presenting,the fingers of one

hand will feel the occiput andthose of the other handthe cephalic
prominence.

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inlet.


The hand coverage aroundthe presenting part when thehead is not

engaged.
FHR monitoring
: A Normal fetal heart rate is 110-160 beats per minute. The fetal
heart is bestheard over the fetal back, particularly when listening with
a pinard stethoscope.
Vaginal Examination:
Vaginal examination in the early weeks of pregnancy helps


To establish the diagnosis of pregnancy



To decide whether the pregnancy is uterine or extra uterine.



To ascertain whether there there are any tumors or abnormalities in

the genital tractcomplicating pregnancy.In the later weeks and
particularly near team, it helps in the diagnosis of the presentation
andposition of the fetus and in assessing the pelvis. The risk of
infection by a careless vaginalexamination is always present: hence
the examination should be with all antiseptic solution.