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Antenatal Care

Confirmation of Pregnancy:
The simple way to confirm pregnancy in the first trimester is to conduct a urine examination using a pregnancy test kit.
The kit detects pregnancy on the basis of presence of HCG in the urine
The test can be performed soon after a missed period and simple to perform
The pregnancy test should be offered to any women who is in reproductive age group and comes with a history of amenorrhea or symptoms of pregnancy
The kit made available by the GOI is k/a ‘Nischay’
In addition, other kits are also available in the market
The kit is provided to ASHA and other link workers

Antenatal care:
• Antenatal care is the care of the woman during pregnancy
• The aim of antenatal care is to achieve a healthy mother and a healthy baby at the end of the pregnancy.
• Ideally, ANC should begin soon after conception and continue throughout pregnancy
• Regular monitoring during pregnancy can help detect complications at an early stage before they become life-threatening emergencies.
• However, one must realize that even with the most effective screening tools currently available, one cannot predict which woman will develop pregnancy-related complications.
• Hence, every pregnant woman need to be educated for ‘Birth Preparedness’ and ‘Complication readiness’

Objectives of ANC
1. To promote, protect and maintain the health of the mother during pregnancy
2. To detect ‘high risk cases and give them special attention
3. To foresee complication and prevent them
4. Ensure that ANC is used as an opportunity to detect and treat existing problems.
5. Make sure that services are available to manage obstetric emergencies.
6. Prepare pregnant women and their families for the eventuality of an emergency
7. To remove anxiety and dread associated with delivery
8. To teach the mother elements of child care, nutrition, personal hygiene and environmental sanitation
9. To reduce maternal and infant mortality and morbidity
10. To sensitize the mother to the need for family planning including advice to cases seeking MTP and
11. To attend to the under-fives accompanying the mother

Components of Ante – Natal Care
1. Antenatal visits
2. Prenatal advice
3. Specific health protection
4. Mental preparation
5. Family planning
6. Pediatric component

Antenatal visits
• Ideally, the first visit should take place in the first trimester, before or at the 12th week of pregnancy.
– However, even if the woman comes late in her pregnancy for registration, she should be registered, and care given to her according to the gestational age.
• Ideal frequency of ANC visits if everything is normal is:
– once a month till 28 weeks (first 7 months)
– once in 2 weeks from 28-36 weeks (8th month)
– once a week from 36 weeks (9th month)
• However, for a high proportion of mothers from lower socio economic group, it may not be possible to follow this schedule due to several reasons like
– The antenatal clinic may be far away from home
– Going to the clinic may result in loss of wage
– Other personal / family problems preventing the mother from attending the antenatal clinic
• In these cases, it is recommended that a minimum of 4 AN visits should be made as per the following schedule
1. 1st visit – within 12 weeks (3 months) or as soon as the pregnancy is suspected.
• This visit is utilized for registration of pregnancy and
• First antenatal check up
2. 2nd visit – between the 4th and 6th month (around 26 weeks)
3. 3rd visit – 8th month (around 32 weeks)
4. 4th visit – 9th month (36-40 weeks)
• If the pregnant woman prefers visiting the ANM for antenatal check-up,
– it is advised that the 3rd antenatal visit should be made to the Medical officer at the nearest PHC.

Early Registration of Pregnancy
Registration of pregnancy within 12 weeks is the primary responsibility of the ANM. She can use the Village Health Nutrition Day (VHND) for motivating the women for early registration
Why is early registration important?
1. It facilitates proper planning and allows for adequate care to be provided during pregnancy for both the mother and the foetus
2. Help the woman recall LMP.
– Record the date of LMP and calculate the EDD
3. The baseline information on blood pressure, weight, haemoglobin level etc. can be obtained
4. The health status and any medical illness already existing can be detected and treated
5. It helps in timely detection of complications at an early stage and helps to manage them appropriately by referral as and where required
6. It also helps to confirm if the pregnancy is wanted and if not, then refer the women at the earliest to 24 hours PHC or FRU that provides safe abortion services. The possibility of sex selective abortion should always be ruled out
7. Start the woman on a regular dose of iron folic acid during the first trimester
8. Early detection of pregnancy and provision of care from the initial stage facilitates a good inter personal relationship between the care giver and the pregnant woman.

First Antenatal Visit
• The first visit is recommended as soon as the pregnancy is suspected.
– This is meant for registration of the pregnancy and
– The first antenatal check-up
First antenatal check-up should include:
1. Detailed history
2. Complete physical examination
3. Abdominal examination
4. Assessment of gestational age and
5. Laboratory investigations
6. Detailed medical history

• Establish pregnancy as the cause of amenorrhoea
• Birth order
• Birth interval
• Confirm that pregnancy is wanted.
– This is important, during the first visit when MTP is still feasible
• Record LMP and calculate the EDD (LMP + 9 months and 7 days)
• Find out if there were any complication during previous pregnancies which might affect the present pregnancy in some way
• Detect any current medical/surgical/obstetric complication in the present pregnancy
• Record symptoms for ruling out complications like fever, persisting vomiting, abnormal vaginal discharge or bleeding, palpitations, easy fatigability, breathlessness at rest or on mild exertion, generalized swelling in the body, severe headache and blurring of vision, burning micturition, decreased or absent foetal movements
• History of any current systemic illness e.g. HT, DM, heart disease, TB, renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract infection, HIV etc.
• Family history of HT, DM, TB, thalassemia, twins, congenital malformation
• History of drug allergies, drug addiction etc.

Complete Physical Examination
This activity will be nearly the same during all the visits.
Initial readings may be taken as a baseline and compared with the later readings
1. Pallor- each visit
– examine
» conjunctiva,
» nails,
» tongue,
» oral mucosa and
» palms),
– correlate clinical pallor with Hb estimation
Grading of Pallor
2. Pulse: normal range 60 -90 beats per minute
3. Respiratory rate: normal is 18 – 20 per minute
4. Oedema: oedema appearing in evening and disappearing in the morning after full night sleep is often seen normally during pregnancy
– Any oedema of the face, hands, abdominal wall and vulva is abnormal
– Oedema is suspected when the woman complains of tightening of rings on her fingers
– If oedema is associated with HT, heart disease, anaemia or proteinuria, the woman should be referred to the medical officer
5. Blood pressure: Measure at Each visit
– Main purpose is to rule out hypertensive disorders of pregnancy
– Diagnosis of HT: two consecutive readings taken four hours apart show the systolic BP to be ≥140 mm Hg or diastolic BP is ≥90 mm Hg
– HT during pregnancy may be:
• Pregnancy induced (PIH) or
• Pre-existing
– If HT is present, check urine for albumin.
• Presence of urine albumin (+2) with HT, categorize her as pre – eclampsia, REFER IMMIDIATELY
– If diastolic BP >110 mm Hg, DANGER SIGN of imminent eclampsia
– If urine albumin is also positive REFER to FRU IMMIDIATELY
– If urine albumin is negative, refer to MO of 24X7 PHC
– A woman with:
• Pre – eclampsia
• Imminent eclampsia needs hospitalization for monitoring of BP, the level of protein in the urine and foetal condition FRU/24X7 PHC
6. Weight: measure at every visit
• Weight at the first visit should be treated as the baseline weight
• Normally, a woman should gain 9 – 11 kg during pregnancy
 2 kg per month (0.5 kg per week) AFTER the first trimester
 An inadequate dietary intake can be suspected if the woman gains less than 2 kg per month
• Low weight gain usually leads to:
• Intrauterine growth retardation (IUGR)
• Low birth weight (LBW) baby
• Excessive weight gain (>3 Kg in a month) could be due to :
• Pre-eclampsia
• Multiple pregnancy
• Diabetes
• Take her BP and test urine for albumin and sugar
• If BP is high and urine positive for albumin or sugar, Refer her to the MO
7. Breast examination
Observe the size and shape of the nipples for:
» Inverted or flat nipples
» Crusting and soreness of the nipples
» Palpate for any lumps or tenderness
1. Abdominal examination
Measure the fundal height -The fundal height indicates the progress of the pregnancy and foetal growth
– 12 weeks – fundus is just palpable per abdomen
– 20 weeks – fundus at the lower border of umbilicus
– 36 weeks – fundus felt at the level of Xiphisternum
– The duration of pregnancy should be expressed in terms of completed weeks
If the height of the uterus is more than that indicated by the period of amenorrhea, the possible reasons could be:
• Wrong date of LMP
• Full bladder
• Multiple pregnancy
• Polyhydramnios
• Hydatidiform mole
• Pregnancy with a pelvic tumor.
If the height of the uterus is less than that indicated by the period of amenorrhea, the possible reasons could be:
• Wrong date of LMP
• Intrauterine growth retardation (IUGR)
• Missed abortion
• Intrauterine death (IUD)
• Hydatidiform mole
• Listen for the fetal heart sounds (FHS)
• FHS is not heard before the 24th week of pregnancy
• 120 – 160 per minute
• Usually heard best in the midline
• After the 28th week, the location may change as the position and the lie of the fetus changes
• Both foetal bradycardia (FHR <120 beats/minute) and
• fetal tachycardia (FHR more than 160 beats per minute) indicate foetal distress
• Foetal movements: can be felt by the examiner after 18 – 22nd week by gentle palpation
• Foetal parts:
• Can be felt about the 22nd week.
• After the 28th week, it is possible to distinguish the head, back and limbs
• Multiple pregnancy:
• The uterus is usually larger than the estimated gestational age
• Multiple foetal parts are felt on palpation
• If a multiple pregnancy is suspected, refer the woman to an FRU
• Foetal lie and presentation: relevant only after 32 weeks of gestation
Assessment of gestation age
• The most accurate gold standard is the ‘routine ultrasound’ assessment with foetal measurements
» This is best done ideally in the first trimester
» Clinical assessment based on the LMP was previously the only method used before ultrasound became widespread
» ‘Best obstetric estimate’ of the gestational age combines the findings of the ultrasound and LMP
– In lower income settings
• Skilled technicians for ultrasonography may not be available
• First trimester registration may be low
• In such settings, fundal height measurement and clinical assessment of the new-born after birth can give the estimate of the gestational age
Ask the woman to empty her bladder completely immediately before proceeding with the abdominal examination.
– This is important as even a half full bladder might result in an increase in the fundal height
• At 12th week: just palpable above the symphysis pubis
• At 16th week: lower one-third of the distance between the symphysis pubis and umbilicus
• At 20th week: two-thirds of the distance between the symphysis pubis and umbilicus
• At 24th week: at the level of the umbilicus
• At 28th week: lower one-third of the distance between the umbilicus and xiphisternum
• At 32nd week: two-thirds of the distance between the umbilicus and xiphisternum
• At 36th week: at the level of the xiphisternum
• At 40th week: sinks back to the level of the 32nd week, but the flanks are full, unlike that in the 32nd week.
• Laboratory Investigations
Some of the investigations are done at the level of the sub-centre itself, for others the woman may have to go the nearest PHC/CHC/FRU
• At the sub – centre level:
– Pregnancy detection test – at the first visit
– Haemoglobin estimation
– Urine test for presence of albumin and sugar
– Rapid malaria test
• At the PHC/CHC/FRU level:
– Blood grouping and Rh typing
– HIV testing
– Rapid malaria test (if the same was not available at the sub-centre)
– Blood sugar testing
– HBsAg for Hepatitis B infection
– Bacteriuria

All Ante Natal Visits
• History
• Physical examination:
– Weight,
– BP,
– RR,
– pallor and
– Oedema
– Abdominal examination for
– Foetal growth
– Foetal lie
– Auscultation of foetal heart
– Assessment of the pelvis
– Examination of the pelvis is required to assess if it is adequate for delivering the baby vaginally.
– This should be done during the last ANC visit (at about 36 weeks of gestation) to rule out any cephalopelvic disproportion (CPD)
• Laboratory investigations
– Haemoglobin
– Urine test for
– Sugar and
– Proteins

Prenatal Advice
Interventions and Counselling
1. Iron and folic acid supplementation
– One tablet of IFA (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days.
– This is the prophylactic dose of IFA.
– If a woman is anemic (Hb <11 g/dl or she has pallor), give her two tablets of IFA per day for three months.
– This means a woman with anemia in pregnancy needs to take at least 200 tablets of IFA.
– This is the therapeutic dose of IFA.
– Start IFA at the prophylactic dose as early as possible, preferably as soon as the pregnancy is registered
– However, ensure that the woman is able to tolerate the intake of IFA, as iron has a tendency of aggravating the nausea and vomiting, which are a part of morning sickness during the first trimester

2. Tetanus toxoid immunization
Administration of two doses of Inj. TT to a pregnant woman is an important step in the prevention of neonatal tetanus
If the woman is not immunized earlier, Give Two doses of TT
– The first dose of TT should be given just after the first trimester, or as soon as the woman registers for ANC, whichever is later.
– Second dose one month after the first dose, but preferably at least one month before the EDD
– Minimum interval between the two doses – 1 month
– If the women has reported late in the pregnancy, no pregnant woman should be denied even a single dose of TT
If the woman has received Inj. TT during a previous pregnancy; One booster dose would suffice
– This booster dose would cover even the subsequent pregnancies during the next 5 years
– It is advised not to inject TT at every successive pregnancy because of the risk of hyper immunization and side effects
– However, in case of doubt, give two injections

3. Advice about personal care, nutrition, family planning, parenting
4. Identification of high risk cases and referral if necessary
5. Home visit by female health worker or trained dai
6. Inform the woman about
– Birth preparedness and
• Identification of a skilled provider for birth
• Explain to her why delivery at a health facility is recommended
• Identify support people
• Signs of labour
– Complication readiness
7. Danger signs
• Location of the nearest health centre/FRU
• Identification of transportation facilities
• Preparedness for blood donation
– Janani Suraksha Yojana and other government initiatives in the area
• The advice should cover not only pregnancy and delivery concerns but also family and child care.
8. The women should be advised regarding the following:
– Diet & rest
– Personal hygiene
– Drugs
– Radiation
– Warning signs
– Child care
– family planning education
– family budgeting etc.

Diet and Rest
Child survival is correlated with birth weight
• And the birth weight is correlated to the weight gain during pregnancy
• A normal pregnancy results in a weight gain of appx. 9 – 11 Kg; Thus pregnancy imposed the need for extra calorie and nutrient requirements
• If maternal stores of iron are poor (as may happen after repeated pregnancies), it is possible that the fetus has insufficient iron stores
– Such a baby may show a normal Hb at birth, but will lack the stores of iron necessary for rapid growth and increase in blood volume and muscle mass in the first year of life
• Stresses in the form of malaria and other childhood infections will make the deficiency more acute and many infants become severely anemic during early months of life
Lactation demands extra 550 Kcal per day
A pregnant woman needs about 300 extra kcal per day compared to her usual diet
• The woman's food intake should be especially rich in proteins, iron, vitamin A and other essential micronutrients
– Some of the recommended dietary items are
• cereals, milk and milk products such as curd,
• Green leafy vegetables and other vegetables,
• pulses, eggs and meat, including fish and poultry (if the woman is a non-vegetarian),
• nuts (especially groundnuts),
• Jaggery,
• fruits, etc.
– Food taboos must be looked into while counselling regarding her dietary intake
• Advised to sleep for
– 8 hours at night and
– rest for another 2 hours during the day.
• Advised to refrain from doing heavy work, such as construction work and full-time farm labour work, as it can adversely affect the birth weight of the baby
• All pregnant women should be told to avoid the supine position, especially in late pregnancy,
– as it affects both the maternal and the foetal physiology.
– During pregnancy, the uterus exerts pressure on the main pelvic veins
– This results in a reduced quantity of circulating blood reaching the right side of the heart.
– This causes reduced oxygenation to the brain and can therefore lead to a fainting attack, a condition referred to as the supine hypotension syndrome
Personal hygiene
• Personal cleanliness, bathing and clean clothes daily
• Rest and sleep: 8 hours of sleep + at least 2 hours of rest after mid-day meal
• Bowels: avoid constipation by regular intake of green leafy vegetables, fruit and extra fluids. Avoid purgatives like castor oil
• Exercise: light household work is advised
• Manual physical labour during late pregnancy may adversely affect the fetus
• Smoking: cut down to a minimum.
– Expectant mothers who smoke heavily produce babies much smaller than the average
• The reason is that nicotine has a vasoconstrictor influence in the uterus and induces a degree of placental insufficiency
– Adverse effects of smoking range from LBW to an increased risk of perinatal death
• Women who smoke during pregnancy give birth to babies which weigh on average 170 g less at term than the babies of non-smokers
• The perinatal mortality amongst babies whose mothers smoked during pregnancy is between 10 – 40 percent higher than in non-smokers
• Alcohol: can cause fertility problems in women
– Moderate to heavy drinkers who became pregnant have greater risk of pregnancy loss
– If they do not abort, their children may have various physical and mental problems
– Heavy drinking has been associated with Fetal Alcohol Syndrome (FAS)
• Dental care:
• Sexual intercourse:
– Safe during normal pregnancy
– Sex should be avoided during pregnancy if there is a risk of abortion (h/o previous recurrent spontaneous abortions), or a risk of a preterm delivery (h/o previous preterm labour)

• Discourage the use of drugs that are not absolutely essential
• Certain drugs may cause fetal malformations. E.g. thalidomide, a hypnotic drug which caused deformed hands and feet of the babies born, more so if taken between 4 to 8 weeks of pregnancy
– Another example is LSD. It causes chromosomal abnormality
– Streptomycin may cause 8th nerve damage and deafness in the fetus
– Iodide containing preparations may cause congenital goiter in the fetus
– Corticosteroids may impair fetal growth
– Sex hormones may produce virilism
– Tetracycline may affect the growth of bones and enamel formation of teeth
– Anesthetic agents like pethidine administered during labour can have depressant effect on the baby and delay the onset of breathing
• Later in puerperium, if the mother is breast feeding, there are certain drugs which are excreted in breast milk.
Exposure to radiation is a danger to the developing fetus
– The most common source of radiation abdominal X-ray during pregnancy
– Studies have shown that mortality rate due to leukemia and other neoplasms were significantly greater among children exposed to intrauterine X-ray
– Congenital malformations like microcephaly are also more common in such cases
– Hence, an X-ray during pregnancy should be carried out only for definite indications and that too with the X-ray dose kept to minimum
• Among women of child-bearing age, elective X-ray should be avoided in the two weeks preceding the menstrual period
Warning signs
• The mother should be given clear-cut instructions that she should report immediately in case of the following warning signals:
– Swelling of the feet
– Fits
– Headache
– Blurring of vision
– Bleeding or discharge per vagina and
– Any other unusual symptom
Child care
• advice regarding nutrition, child rearing, family planning education, family budgeting etc. should be given during antenatal visits

Antenatal Care:
Components of Antenatal Care:
Prenatal Advice:
Risk Approach in Antenatal Care:
Ensuring Complete Registration of Antenatal Women in the Jurisdiction:
Specific Health Protection during Antenatal Visits;
Lecture on Antenatal Care: