INTRODUCTION:

Every year there are an estimated 200 million pregnancies in the world. Each of these pregnancies is
at risk for an adverse outcome for the woman and her infant. While risk can not be totally eliminated, 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.
DEFINITION:
Systemic supervision of woman during pregnancy is called antenatal care. The supervision should
be regular and periodic in nature according to the need of the individual. Actually prenatal care is the care
in continuum that starts before pregnancy and ends at delivery and the postpartum period.
-D.C.DUTTA

INCIDENCE:
According to NIH-
Over the past two decades, India has seen a 70% fall in overall maternal mortality ratio (MMR) from
398/100,000 live births to 99/100,000 live births in 2020. In 2015–2016, for example, only 51% of
women aged 15–49 in India attended antenatal care at least four times during pregnancy. Using data from
the fifth iteration of India’s National Family Health Survey, our study aims to explore factors related to
the underutilization of antenatal care in India.

AIMS OF ANTENATAL CARE:

 To screen the high risk cases

 To prevent or detect or treat at the earliest any complications
 To ensure continued medical surveillance and prophylaxis
 To educate the mother about the physiology of pregnancy and labour by demonstrations,
charts and diagrams
 To discuss with the couple about the place, time and mode of the delivery, provisionally
and care of the newborn
 To motivate the couple about the need of family planning as well as appropriate advice
about MTP.
 To advice the mother about breast-feeding, post-natal care and immunization

OBJECTIVES OF ANTENATAL CARE:

 Prevention ,early detection & treatment of pregnancy related complications as pre-
eclampsia,eclampsia, haemorrhage.
 Prevention ,early detection & treatment of medical disorder as anaemia & DM
 Detection of malpresentations, malpositions & disproportion that may influence the
decision of labor.
 Instruct about the hygiene, diet pattern & warning signs of pregnancy
 Instruct about the need of the lab tests i.e. Hb, USG, blood sugar ,Rh factor, syphilis etc.

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CRITERIA OF NORMAL PREGNANACY:
Delivery of a single baby in good condition at term ( between 38 weeks – 42 weeks), with the
weight of 2.5 kg or more and with no maternal complications.

ANTENATAL VISITS:
According to WHO in 2016-

1st trimester : 1 visit

2nd trimester : 2 visits
3rd trimester : 5 visits

According in Indian Govt. –

pregnant women make at least four antenatal care (ANC) visits, including the first visit and any
home visits:

First visit: As soon as pregnancy is suspected

Second visit: Between 4–6 months (around 26 weeks)
Third visit: In the 8th month (around 32 weeks)
Fourth visit: In the 9th month (36–40 weeks)

FIRST VISIT:
OBJECTIVES:
 To assess the health status of the mother and fetus to screen out the risk pregnancy and
formulate the plan subsequent management.
 To obtain baseline information.
PROCEDURES IN FIRST VISIT : • History taking • Examination • Investigation
1. HISTORY TAKING :
 Vital statistics:
Name ,Date of 1st examination,Address, Age ,LMP , Obstetrical score (G P(A+B) A L), Duration of
marriage , Occupation, Period of gestation
 Chief complaints
 History of present illness : elaboration of the chief complaints as regard their
onset,duration,severity,uses of medication & progress is to be made.
 History of present pregnancy : Nausea & vomiting.
Abdominal pain, Headache, Urinary complaint,Vaginal bleeding, Edema,Backache.

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 Heartburn,Constipation etc.
 Obstetrics history : this is only related to the multigravida

No. Year Pregnancy Labor Method Puerperium Baby

& of
events events
mont delivery
h
Miscarriages / Eventful/ NVD/ Eventful/ -Wt.
well-covered -Condition
uneventful cesarea Uneventful
/uneventful n/ at birth
evacuat -Breast
ion feeding
-immuniza-
tion
 Menstruation history : cycle ,Duration, Amount of blood flow, LMP for calculate EDD
1st day of LMP −3 months +7 days, and change the year.
 Past & present medical history
 Past & present surgical history
 Family history
 Personal history
 Dietary history

2. PHYSICAL EXAMINATION:
General examination , Systemic examination , Routine investigations ,Special investigations
, Repetition of investigations

 GENERAL EXAMINATION : • Appearance •Build •Nutrition • Vital signs • Height of

patient • Weight of patient • Pallor • Anemia • Jaundice • Edema in legs • Neck •
Tongue ,teeth , gums
 SYSTEMIC EXAMINATION : • Heart • Lungs • Liver • Spleen • Breast • Abdomen •
Vagina
 ROUTINE INVESTIGATIONS :
-Blood: Hb ,hematocrit ,ABO ,Rh grouping, bloog glucose , VDRL .Serology screening is
done in selected cases.
-Urine : Protein ,sugar & pus cells. If significant proteinuria is found
“clean catch” specimen of midstream urine is collected for culture & sensitivity test.
Cervical cytology study by Papanicolaou stain has become a routine in many clinics.

 SPECIAL INVESTIGATIONS:
-Serological tests for rubella, hepatitis B virus & HIV
-Genetic screening: maternal serum alpha fetoprotein (MSAFP), triple test at 15-18 weeks for
mother at risk of carrying a fetus with neural tube defect, Down syndrome or other
chromosomal abnormalities.
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 - ultrasound examination : first trimester scan either TAS OR TVS helps to detect early
pregnancy, accurate dating, no of fetus , gross fetal anomalies any uterine pathology

 REPETITION OF INVESTIGATIONS :
-Hb estimation is repeated at 28th & 36th week.
-Urine tested ( dipstick) for protein & sugar

SUBSEQUENT VISIT SCHEDULE

Generally- •At interval of 4 weeks up to 28 weeks •At interval of 2 weeks up to 36 weeks •At weekly
interval up to EDD As per WHO recommendation at least 4 visit- •1st visit around 16 weeks •2nd visit
between 24-28 weeks •3rd visit at 32 weeks •4th visit at 36 weeks

OBJECTIVES
• To assess fetal well being
• To assess lie , presentation , position
• To assess anaemia , pre eclampsia ,amniotic fluid volume ,fetal growth .
• To organise specialist antenatal clinics with cardia disease and diabetes .
• To select time for ultra sound for amniocentesis ,chronic villus sampling when indicated.
IN SUBSEQUENT VISIT : History taking , Examinations
1. HISTORY TAKING
 Appearance any new symptoms ( headache , dysuria)
 Date of quickening

2. EXAMINATIONS :
General: • weight • pallor • edema in legs • blood pressure
Abdomen examination: • Inspection • Palpation • percussion • Auscultation

INSPECTION:
Shape of the uterus Striae gravidarum Linea Niagara scar mark Fetal movements
PALPATION • Assessment of fundal height • Abdominal girth • external ballotment • fetal movement •
palpation of the fetal parts
• Lie • presentation • position • growth pattern • volume of the liquor •engagement
AUSCULTATION Checked by pinard stethoscope or Doppler Normal FHR is 120-160 b/m  Foetal
tachycardia (>160 b/m) Foetal bradycardia (<120 b/m)
Vaginal examination : beyond 37 weeks

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 WARNING SIGNS :
 Leakage of fluid from vagina
 Vaginal bleeding
 Abdominal pain
 Headache , visual changes
 Decrease or loss in fetal movements
 Fever , rigor, excess vomiting, diarrhea

ANTENATAL ADVICE:
PRINCIPLES :
1.To impress the patient about the importance of regular check up
2.To maintain or improve the health status of the woman to the optimum till delivery by judicious advice
regarding diet, drugs and hygiene
3.To improve the psychology and to remove the fear of pregnancy by counselling to the patient and
explaining the principle changes and events likely to occur during pregnancy.

ANTENATAL ADVICE • Diet • Rest & sleep • Bowel • Personal cleanliness • Clothing, shoes & belt •
Dental care • Care of breast • Coitus • Travelling • Smoking and alcohol • Immunization • Drug
DIET Diet should be: 1.nutritious 2.balanced 3.light 4.easily digestible 5.rich in protein, mineral and
vitamin 6.with woman’s choice
DDA OF A WOMAN DURING PREGNANCY (2ND HALF) Food element pregnancy Kilocalories
2500 Protein 60 gm. Iron 40 mg Folic acid 400 µg Calcium 1000 mg Vitamin A 6000 I.U.
REST AND SLEEP • 8 hour sleep at night • At least 2 hour sleep after mid-day meal • Hard strenuous
work should be avoided in first trimester and last 4 weeks
BOWEL • Regular bowel movement may be facilitated by regulation of diet, taking plenty fluid,
vegetable and milk Coitus Should be avoided in •1st trimester •last 6 weeks
BATHING • The woman should take bath daily but be careful against slipping in bathroom due to
imbalance
CLOTHING ,SHOES, BELT • Woman should wear loose comfortable garments. High heel shoes should
better be avoided in advanced pregnancy when the centre of balance alters.
DENTAL CARE • The dentist should be consulted at the earliest if necessary this will facilitate
extraction or filling of the caries tooth ,if required comfortably in 2 nd trimester the best time for such
procedure.

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 CARE OF BREAST • If the nipples are anatomically normal nothing is to be done beyond ordinary
cleanliness. If the nipples are retracted ,correction is to be done in the later months by manipulation.
TRAVELLING Should be avoided in •1st trimester •last 6 weeks Air travelling is contraindicated in
•Placenta praevia •Preeclampsia •Severe anemia
SMOKING AND ALCOHOLISM • Smoking and alcohol are injuries to health during pregnancy. •
Heavy smokers have low birth weight babies and abortion • Alcohol during pregnancy leads to fetal
growth retardation
IMMUNIZATION Indicated- •TT •HAV •HBV •Rabies Contraindicated- •Live virus vaccine (rubella
measles, mums, varicella)
DRUGS • Most of the drugs cross the placenta to reach the fetus while prescribing the physician should
keep in mind
PRECONCEPTIONAL CARE  Preconceptional care is the one step ahead of antenatal care.  When
a couple is seen and counseled about pregnancy, its course and outcome before the time of actual
conception, is called Preconceptional care.  Objective: to ensure that, a woman enters pregnancy with
an optimal state of health which would be safe both to herself and the fetus.
PRECONCEPTIONAL CARE INCLUDES:  Identification of high risk factor  Basal level health
status including BP recording  Rubella & Hepatitis immunization  Folic acid supplementation 
Maternal health is optimized preconceptionally such as overweight anemia  Patient with medical
disease like hypertension, diabetes are stabilized in an optimal state by intervention
PRECONCEPTIONAL CARE INCLUDES: (CONT’D)  Drugs used before pregnancy are verified and
changed if required to prevent any adverse effect of the fetus; e.g., warfarin is replaced with heparin, oral
anti-diabetic drug with insulin  Advise to stop smoking, alcohol and drug abuse  Proper counseling to
those with history of recurrent fetal loss or family history of congenital abnormalities  Counseling
regarding health care cost  Find out supporting or helping people to help the mother and care of the new
born