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Prenatal Advice

Interventions and Counselling
• 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

• 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

• Advice about personal care, nutrition, family planning, parenting
• Identification of high risk cases and referral if necessary
• 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
-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.
• 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, childrearing, 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: