A G4 P2+1 has arrived in the antenatal clinic you are the attending doctor.

When you enquire her she tells that her Last menstrual period (LMP) was on 12-01-2011 What is her estimated date of delivery (EDD)

Today is 28-03-2011 how far advanced she is in her pregnancy

This is her booking visit what are the investigations you will order

y Plan her further antenatal visits y What are the symptoms that the pregnant

lady can have at this gestation

DEFINITION
Antenatal care is defined as a comprehensive antenatal care program that involves a coordinated approach to medical care and psychosocial support that optimally begins before conception and extends throughout the antenatal period

ANTENATAL CARE
Care of the women from the time of conception till the labour starts To ensure that the expectant mother maintains good health throughout her pregnancy and is delivered safely of a healthy, live child.

FIRST ANTENATAL VISIT

The first visit should be as soon as there is a likelihood of pregnancy Ideally it should not be later than the second missed period

Aims of Antenatal Care

Provision of education, reassurance and support to

the woman & her partner

Advice on minor problems & symptoms of

pregnancy
Assessment of maternal & fetal risk factors at

onset of pregnancy & as they develop throughout pregnancy

Provision of prenatal screening &

management of abnormalities detected

Determination of timing & mode of delivery

where complications arise

Purpose of Antenatal Care

Mother to reach the end of pregnancy

physically and mentally prepared for labour & motherhood

To ensure that the fetus is provided with the

best possible environment for the growth & development

To ensure that abnormalities of pregnancy

are detected & treated promptly

The risks of labour are minimized by

planning & provision of facilities

To cope with any difficulties which may be

anticipated

Importance of early attendance

Early weeks of pregnancy are critical for fetus Growth is rapid Organogenesis is at its peak

Detection if possible & correction of factors

which may influence fetal development

y y y y

Nutritional deficiencies Infections Hazardous drug therapy Baseline for blood pressure weight

More accurate assessment of gestational age Better rapport to provide health care

Antenatal Visits
y Booking Visit y After every 4 wks till 28 weeks y After every 2 weeks till 36 weeks y Then weekly till delivery y In uncomplicated pregnancies

First Trimester
y Booking visit after the first missed period y Detailed History Examination y y y

Establish gestational age Identify any maternal or fetal risk factors To alleviate any of the patients anxieties

GENERAL HISTORY
Name, Age, Parity, Socioeconomic status Diseases like diabetes, hypertension, Hereditary diseases

Diseases in childhood like rickets, rheumatic fever, renal disease, which may affect pregnancy and labour, should be recorded.

It is important to ascertain whether or not steroidal contraceptives were used before pregnancy and if so when they were used Enquiries should also be made into any allergy to drugs like penicillin Immunisation history of the patient

OBSTETRIC HISTORY
The following definitions are needed for an accurate obstetric history

PARITY

The number of pregnancies reaching viability A woman who has never completed a pregnancy to viability

NULLIPARA

PRIMIPARA

A woman who has been delivered only once of viable fetus or fetuses

MULTIPARA

A woman who has carried two or more fetuses to viability

GRAVIDA

A woman who is or has been pregnant

NULLIGRAVIDA

A woman who has never been pregnant

PRIMIGRAVIDA

A woman who is pregnant for the first time A pregnant woman who has been pregnant earlier

MULTIGRAVIDA

GENERAL MEDICAL EXAMINATION

At the initial visit, apart from complete examination of all the systems cardiovascular, respiratory, alimentary the height, weight and blood pressure should be determined and recorded.

The breasts and nipples require special attention, and the sources of infection, if any, must also be looked for.

OBSTETRIC EXAMINATION
In the first trimester, in a normal pregnancy, it may not be possible to palpate the enlarged uterus per abdomen unless the duration is 12-14 weeks or more. A careful, gentle vaginal examination should be carried out for the following reasons

To confirm the diagnosis of pregnancy To decide whether pregnancy is uterine or extra uterine

To determine the presence or absence of any adnexal pathology and congenital anomalies of the genital tract itself

A speculum examination will help to rule out any lesions In the cervix A Pap smear should be obtained

Inspection of the vulva will reveal the presence or absence of any pathological lesions

LABORATORY TESTS
The routine tests include Haemoglobin estimation Urinalysis Syphilis Screen Pap smear HIV testing if risk case urine culture Blood grouping & Rh factor

SUBSEQUENT PRENATAL VISITS The pregnant mother should be seen by a doctor early in pregnancy In the absence of complications at specified periods throughout her pregnancy and delivery -

usually once a month till the 28th week once a fortnight till the 34th week from then on once a week till term

In uncomplicated pregnancies fewer visits may be acceptable

On the contrary, women with complicated pregnancies may need to see the doctor every other week. The aim of these visits is to ascertain the well-being of the mother and the fetus

At each of these visits, the blood pressure and weight should be measured,

Urine should be analysed for protein and glucose, uterine size and fetal heart sounds should be recorded

History of symptoms like headache, vomiting, abdominal pain, bleeding or leakage of fluid from the vagina should be recorded.

Hemoglobin and syphilis serology (if prevalent in the population) should be repeated at 28 to 32 weeks The other laboratory tests may not be repeated if they were normal at the initial visit.

For women at risk of diabetes, screening is recommended between 24 and 28 weeks

Routine ultrasound is not currently recommended in low-risk pregnancies. However it may be performed as and when indicated. Depending on the findings, the patient should be suitably advised.

INSPECTION y Enlargement
y Shape. Pear shaped if singleton, globular if multiple. y Pigmentation: Linea nigra (not always present), Striae

gravidarum
y Surgical scars: especially transverse suprapubic hidden

below hairline and laparoscopy scars

Below umbilicus (it is often helpful to ask the woman if she has had any abdominal surgery as these scars are occasionally very difficult to see Fetal movements.

ABDOMINAL PALPATION
This must be done as a matter of routine and the observations recorded. Between 18 and 32 weeks of gestation there is clear correlation between the gestational age of the fetus in weeks and the height of the uterine fundus in centimetres

when measured as the distance over the abdominal wall from the top of the symphysis pubis to the fundus

After 20 weeks the SFH approximates to the number of weeks. If reduced by 2 cm before 36 weeks and 3cm thereafter then IUGR is suspected and an ultrasound scan should be performed. Transverse lie is often associated with reduced SFH

Therefore, it is important to carefully record the height of the fundus. The presentation and position of the fetus and its condition in the last trimester should be ascertained by palpation and fetal heart auscultation.

Whenever malpresentations persist beyond 34 to 36 weeks, it is necessary to identify the causative factor

FUNDAL GRIP

LATERAL GRIP

PAWLIK S GRIP

PELVIC GRIP

Lie and presentation: from 28 weeks onwards (and not usually before) in a patient who is not obese, palpation of the uterus will reveal the lie and presentation of the fetus.

Lie - direction of the fetal spine with respect to the long axis of the uterus longitudinal, oblique or transverse. Whilst the lie is being determined, consider fetal size and volume of amniotic fluid.

ABDOMINAL AUSCULTATION
This helps to diagnose whether the fetus is alive and, by a careful recognition of the point of maximum intensity of the fetal heart sounds, to also locate the position of the fetus.

As a general rule, the point of maximum intensity of the fetal heart sound is below the umbilicus in all cephalic presentations,

Above the umbilicus in podalic presentations, and almost on level with the umbilicus in oblique or transverse lie

VAGINAL EXAMINATION
Vaginal examination late in pregnancy provides valuable information. It confirms the presenting part, identifies the station of the presenting part,

Estimates the pelvic capacity and identifies the consistency, effacement and dilatation of the pelvis.

Advice To The Expectant Mother

The expectant mother is instructed about diet, relaxation and sleep, bowel habits, exercise, bathing, clothing, avoidance of hard and tiring work, recreation and follow-up visits.

The need for regular attendance at the clinic should be impressed upon the patient.

Un-necessary alarm should not be raised even in the presence of minor ailments, as one of the most essential factors for a successful outcome is the right mental attitude of the expectant mother.

Usually, it is possible to assure her that she may anticipate an uneventful pregnancy followed by an uncomplicated delivery

Restriction of sexual intercourse and its avoidance in the first and last few weeks of pregnancy are beneficial. The prospective mother should maintain an equable temperament and should avoid mental excitement.

Reading books on motherhood is helpful in maintaining the requisite mental environment. At the same time she should be tactfully instructed about the following danger signals which should be reported immediately

bleeding per vaginum abdominal or pelvic pain swelling of the face of limbs blurring or dimness of vision fever

Persistent vomiting Dysuria Escape of fluid from the vagina and marked changes in the frequency or intensity of fetal movements.

Nutrition and Diet during Pregnancy In a country like India where malnutrition is rampant, affecting both maternal & fetal well- being, it is essential that the pregnant mother be suitably advised regarding her diet.

Nutritional advice should take into account foods available locally and beliefs regarding them, cooking facilities, patterns of meals, and whether the pregnant woman is a working woman and the type of work she is doing.

In general, the pregnant woman should be advised to eat whatever she likes in amounts she desires and salted to taste as long as the diet contains calories, proteins and various nutrients in recommended amounts.

The aim should be a weight gain of 11-16 kg in a woman with normal body mass index. Elemental iron (60 ml) should be supplemented after the first trimester

IMMUNISATION
It is important that all pregnant women be immunized against tetanus, as neonatal tetanus is one of the common causes of high perinatal mortality. When the patient is seen in the first trimester

Tetanus toxoid can be given in two doses each separated by eight weeks, the first at 16-20 weeks, and the second at 20-24 weeks. For those who have already been immunised one booster dose

Of tetanus toxoid should be given in a subsequent pregnancy, preferably four weeks before the expected date of delivery

COMMON CONCERNS DURING PREGNANCY

Exercise Pregnant women can exercise provided they do not get excessively fatigued.

Women who are accustomed to aerobic exercises before pregnancy may continue this during pregnancy but should not intensify the exercise.

In women who were previously sedentary, activity more strenuous than walking is not recommended.

Women with hypertensive disorders, multiple pregnancy, growth restricted fetus and heart disease benefit from sedentary existence.

Bowel habits constipation is common in pregnancy because of prolonged transit time and compression of the large bowel by the uterus.

If there is a history of previous abortion, intercourse should be avoided in the second and third months. Intercourse does not affect the fetus but is best avoided from the 36th week of pregnancy till six weeks after delivery.

Drugs It is advisable to avoid using drugs, if possible, particularly in the early weeks when embryogenesis is taking place Most drugs cross the placenta to reach the embryo or the fetus.

If a drug is administered during pregnancy, the advantage to ulnar nerve median nerve be gained must clearly outweigh any risks inherent in its use.

BACKACHE
Low backache pregnancy is very common in

It can be minimized by having women squat rather than bend over to reach down, using back support while sitting and avoiding high-heeled shoes

HAEMORROIDS
These are exaggerated during pregnancy due to increased pressure in the rectal veins caused by obstruction of venous return by the large uterus

Heartburn The cause is gastroesophageal reflux due to relaxation of the lower esophageal sphincter

Focused (goal-directed) antenatal care (ANC) each element is designed to address the prevention, early detection, and/or management of a condition that affects pregnancy outcome for mother and/or newborn.