ANTENATAL CARE & MANAGEMENT

Introduction –
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 of the individual.

Antenatal care comprises of:

 Careful history taking and examination (general and obstetrical)

 The advice was given to the pregnant woman

AIMS AND OBJECTIVE –

The aims are-
1. To screen the ‘high risk’ cases.
2. To prevent or to detect and treat at the earliest any complications.
3. To ensure continued risk assessment and to provide ongoing primary
preventive health care.
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 and care of the newborn.
6. To motivate the couple about the need for family planning and
appropriate advice to a couple seeking medical termination of
pregnancy.

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, and hemorrhage.
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 the decision 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 of 2.5 kg or more and with no maternal
complication.

FREQUENCY OF ANTENATAL VISIT S –

 Generally, a check-up is done at an interval of 4 weeks up to 28

weeks, at an interval of 2 weeks up to 36 weeks and thereafter till
delivery.
 WHO recommends the visit may be curtailed to at least 4 visits,
1st visit – around 16 weeks
2nd visit – Between 24 -28 weeks
3rd visit – around 32 weeks
4th visit – around 36 weeks

PROCEDURE 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 statistics
a) General Examination of the Mother name, age, gravida,
parity, expected date of delivery.
b) Period of gestation
 Gravida denotes a pregnant state both present
and past irrespective of the period 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. A pregnancy long after marriage without taking any
method of contraception is called low fecundity and soon after
marriage is called high fecundity. A woman with low fecundity
is unlikely to conceive frequently.
d) Religion
e) Occupation – It is helpful to interpret symptoms of fatigue due
to excess physical work or stress occupation hazard. Such
women should be informed to reduce such activities.
f) Occupation of husband-
 To access the socioeconomic condition of the patient,
 To anticipate the complications likely to be associated
with low social status such as anaemia, pre-eclampsia,
prematurity etc.
 To give reasonable and realistic antenatal advice during
family planning guidance.
g) Period of gestation- The duration of pregnancy is to be
expressed in terms of completed weeks, a fraction a week of
more than 3 days is to be considered as completed week. In
the early pregnancy it is calculated from the first day of last
normal menstrual period(LNMP) and in later month of
pregnancy it is calculated from the expected date of delivery.
2. Complaints

Categorically, 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 illness

Elaboration of the chief complaints as regard their onset, duration,

severity, use of medications and progress.

4. History of Present pregnancy

 Last menstrual dates – Calculate expected date of delivery
 Cycle regularity
 History of recent oral contraceptive pill use
  Early ultrasound assessment of
gestational age.
 Important complications in
different trimesters of the
present pregnancy are to
be noted carefully these
are hyperemesis and
threatened abortion in first
trimester, features of
pyelitic, in second
trimester and anaemia,
pre-eclampsia and
antepartum hemorrhage, in
the last trimester number of
previous antenatal visits
immunization status must be noted
any medication or radiation exposure rarely pregnancy or
medical surgical events during pregnancy must be noted.

Calculation of EDD
5. Obstetrical History
Ask for details, Date of pregnancy, Outcome, Gestation, Weight 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,
premenstrual 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 menstrual period. Alternatively, one can
count back 3 calendar months from the first day of last period and then
add 7 days to get the expected date of delivery.

7. Past medical History

Relevant history of past medical illness that is urinary tract infection
tuberculosis is to be inquired.

8. Past surgical History

 Any previous pregnancy e.g. General or gynecological, if any, is to be
inquired.

9. Family History
Family History of diabetes, hypertension, tuberculosis, multiple
pregnancy, non-hereditary disease if any or twinning, congenital
anomaly of fetus is to be inquired.

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
weighing machine. Repeated weight checking in subsequent
visit should be done in the same weighing machine.
 Pallor- The sites to be noted as lower Palpebral conjunctiva,
dorsum of the tongue and nailbeds.
 Jaundice- The sites to be noted as vulbar conjunctiva, under
surface of the tongue, hardpalape skin.
 Tongue, teeth’s, gums and tonsils- Evidence of malnutrition
are evident from glossitis and stomatitis. Any infection in
 mouth is to be eradicated, any source of 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 medial malleolus 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.
Breast- needs to be checked for nipples(Cracked or depressed and
skin condition areola).
4. Obstetrical Examination
 Eyes: Pallor, Jaundice
 Breast: Nipple cracked/ depressed, symmetry, Secondary
areolar, montuberg tubercle
 Abdominal Examination
 Vaginal Examination
5. 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 protein
7. 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 to 36 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
trimester around 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 disease and diabetes.
 To select, time for ultrasonography amniocentesis or chorionic
villous biopsy when indicated.

History Collection

Appearance of any new complaints, quickening, lightening, examination.

Weight, pallor, oedema of legs, BP monitoring Abdominal examination.
1st trimester: Height of the fundus
2nd trimester: External ballotment, fetal movements, palpation of the fetal
parts, fundal height
3rd trimester: Identify lie, presentation, position, growth pattern,
engagement, girth of the abdomen, fundal height. Uncover the patient’s
abdomen from the xiphisternum to the public hairline, ensuring adequate
exposure while allowing for patient modesty. Abdominal wall relaxation is
maximized by the patient resting her arms alongside her abdomen, rather
than behind her head. The patient’s legs may also be slightly flexed at the
hips to aid relaxation.

Inspection: The presence of an abdominal mass arising from the pelvis

consistent with pregnancy, scars, pigmentation or other skin lesions are
noted. Fetal movements may be observed.

Fundal Palpation  Fundal palpation  Round, hard,

(First Maneuver) can be done readily, movable
using the finger part, ballotable
tips or palmar between the
 surface of the fingers of both
fingers. hands is
 First nurse should indicative of
face towards the head.
women head.  Irregular, bulkier,
 Whole fundal less firm and not
area is palpated well defined or
by both hands movable part is
laid flat on it to indicative of
find which pole of breech.
fetus is lying in  Neither of the
the fundus. above is
 Palpate for size, indicative
size, shape, transverse lie.
consistency and
mobility of the
fetal part in the
fundus.
Lateral Palpation  Continue to face  A smooth,
(Second Maneuver) the woman head curved, hard
or side resistant surface
Umbilical grip  Place the hands indicate back.
on both side of  Small, knob
the uterus about irregular parts or
midway between modules indicate
the symphysis limb.
pubis and the
fundus.
 Apply pressure
with one hand
against the side
of the uterus
pushing the fetus
to the other side
and stabilizing it
there.
 Palpate the other
side abdomen
with the
examining finger
from the midline
to the lateral side
and from the
fundus using the
smooth pressure
 and rotator
movements.
 Repeat the
procedure for the
opposite.
Pawlicks grip  Continue to face  If the fetal head
(Third Maneuver) the woman head is above brim, it
side. will be readily
 Woman should movable and
be placed as ballotable.
knee bent.  If it is not
 Grasp the portion ballotable, it
of the lower indicates head is
abdomen engaged.
immediately
above the
symphysis pubis
between the
thumb and
middle finger of
one of the hand.
Pelvic Palpation  Nurse should  This maneuver
(Fourth Maneuver) face towards the determines the
woman feet side, engagement of
woman should be the head.
placed as knee  If the head is
bent. presenting, the
 Place the hands fingers of one
on the sides of hand will feel the
the uterus, with occiput and those
the palm of the of the other hand
hands just below the cephalic
the level of the prominence.
umbilicus and
fingers directed
towards the
symphysis pubis.
 Press deeply with
fingertips into the
lower abdomen
and move them
towards the
pelvic inlet.
 The hand
coverage around
 the presenting
part when the
head is not
engaged.

A Normal fetal heart rate is 110-160 beats per minute. The fetal heart is
best heard over the fetal back, particularly when listening with a pinard
stethoscope.

Other: FHR monitoring.

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 tract complicating pregnancy.

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

The fetus – in - Utero

1. Lie: The lie refers to the relation of the long axis of the fetus to the
long axis of the uterus or maternal spine. The lie may be
longitudinal(99%), it may be transverse or oblique.
2. Presentation: The part of the fetus which occupies the lower pole of
the uterus. The presentation may be cephalic(96%), podalic(3%),
shoulder and other (0.5%).
3. Presenting Part: The part of the presentation which overlies the
external os. Thus in cephalic presentation the presenting part is
vertex(commonest), brow or face, depending upon the degree of
flexion of the head.
4. Attitude: The relation of the different part of the fetus to one another.
The common attitude is flexion.
5. Denominator: It is an arbitrary bony fixed point which comes in
relation with the various quadrants of the maternal pelvis. The
following are the denominator of the different presentation occiput in
 the vertex, mentum in the face, frontal eminence in brow, sacrum in
breech and acromian in shoulder.
6. Position: It is the relation of the denominator to the different
quadrants of the pelvis. The pelvis is divided into equal segments of 45
degree to place the denominator in each segment. Thus there are 8
positions with each presenting part. The situation of the fetus in the
pelvis, determined and described by the relation of the given arbitrary
point in the coronal plane of the maternal pelvis(Maternal Index).
Ceplalic Presentation
Vertex presentation(Point of direction: Lambdoid, occipital, posterior,
smaller or triangular fontanelle; commonly occiput)(95%).
 Left occipitoanterior (LOA)(Left ileo-pectineal eminence)(60%).
 Left occipitoposterior(LOP)(Left sacroiliac symphisis)(3%).
 Left Occipitotransverse(LOT)
Right Occipitoanterior (ROA)(Right ileo-pectinal eminence)(6%).
 Right occipitoposterior(ROP)(Right sacral symphisis)(30%).
 Right occipitotransverse(ROT)
 Bregma presentation (Point of direction : bregmatic, frontal
or larger fontanelle)
 Face presentation (Point of direction : chin) (0.5%)
o Left mentoanterior(LMA)
o Left mentoposterior(LMP)
o Left mentotransverse(LMT)
o Right mentoanterior(RMA)
o Right mentoposterior(RMP)
o Right mentotransverse(RMT)
 Brow presentation (point of direction : nose root)
o Left frontoanterior(LFA)
o Left frontoposterior(LFP)
o Left frontotraverse(LFT)
o Right frontoanterior(RFA)
o Right frontoposterior(RFP)
o Right frontotransverse(RFT)
 Pelvic presentation(breech)(4%)
o Complete breech presentation(25-3-%, expecially in
multiparae): feet crossed and thighs flexed on abdomen;
buttocks and feet against the outlet(point of direction:
sacrum)
o Left sacroanterior(LSA)
 o Left sacroposterior(LSP)
o Left sacrotransverse(LST)
o Right sacroanterior(RSA)
o Right sacroposterior(RSP)
o Right sacrotransverse(RST)
 Incomplete breech presentation(30-35%): same
designations as above
o Buttocks variety(70%)
o Incomplete variety with procidentia: one or more little
parts(footling, knees) precede the buttocks
 Shoulder presentation(point of direction: acromion)(<0.5%)
o Left sacpulanterior(LScA)
o Left scapuloposterior(LScP)
o Right scapuloanterior(RScA)
o Right scapuloposterior(RScP)

Risk Approach of obstetrical nursing care and screening of high risk

pregnancy

High risk pregnancy is one in which mother, fetus and new born is or will be
at increased risk for modality and morbidities due to problems and
complication during pregnancy.

The risk approach strategy is expected to have far-reaching effects on the

whole organization of MCH/FP services and lead to improvements in both the
coverage and quality of health care, at all levels, particularly at primary
health care level. Inherent in this approach maximum utilization of all
resources including some human resources that are not conventionally
involved in such care like traditional birth attendants, community health
workers, women’s group.

Risk Approach of Obstetrical Nursing Care

The risk approach is a managerial tool for improved MCH care.

Purpose

To provide better services for all, but with special attention to those who
need the most.
A high-risk pregnancy is one in which some condition puts the mother, the
developing fetus or both at higher-than-normal risk for complications during
or after the pregnancy and birth.

High Risk Mothers

The high risk mothers are :-

1. Women below 18 years of age over 35 years in primigravida.

2. Women who have had four or more pregnancies and deliveries.
3. Elderly grandmultiparas.
4. Women who have had a history of previous C?S, instrumental delivery.
5. Short statured primi(140 cm and below)
6. Malpresentation like breech, tranverse lie, shoulder presentation etc.
7. Antepartum haemorrhage
8. Preeclampsia and eclampsia
9. Anaemia
10. Twins, hydramnios
11. Manual removal of placenta
12. Previous stillbirth, intrauterine death and Abortion.
13. Prolonged pregnancy(14 days – after expected date of delivery)
14. Pregnancy associated with medical disease like cardiac desiease,
epilepsy, psychiatric illness, thyroid disorder, spinal injury, kidney
disease, hypertention, diabetes, tuberculosis, liver disease etc.
15. Unmarried mother of low economic status.
16. Those who have practiced less than 2 years or more than 10 years
or more than 10 years of birth spacing.
17. Obstructed labor
18. Congenital abnormalities of fetal.
19. Those with cephalon pelvic disproportion(CPD).
20. The mother with blood -Rh negative.
21. Those with obesity or malnutrition.

Maternal Risk Factors

Maternal risk is defined as the probability of dying or experiencing serious

injury as a result of pregnancy or child birth. The risk of developing
problem and complications varies. Some are at risk than other depend
upon various risk factors. These are discussed as under:-

a) Young Primi i.e. below 19 years

 There is a grave risk to both mother and the child because the
teenage mother :-
o Is Still growing and is not adequately equipped to cope with
pregnancy and labor. There is increasing chance of abortion,
poor uterine function during labor premature labor, low birth
weight baby, poor breast feeding due to incomplete
development of breasts.
o Is not psychologically prepared for the responsibilities of
marriage, pregnancy and rearing children. This created
tensions and discord in the family.
o Has increasing nutritional requirements by virtue of her own
growth and the growing foetus thus has greater risk of
anaemia, malnutrition and low birth weight baby.
b) Elderly Primi i.e. 30 years and over
o Having babies too late in life, leads to increased risk of
complications in pregnancy and labor which include:-
o Heavy bleeding before and after child birth.
o Malpresentation resulting in difficult labor.
o Include/Aggravated blood pressure
o Forceps delivery or by caesarean operation
o Delay in expulsion of placenta.
o Low birth weight babies.
c) Having too many babies
When the mother bears more than three babies, she is at high risk
of developing problems due to repeated pregnancies and labor. This
is due to weakening of tissues, depletion of nutrients and overall
poor physical health of the mother which happens because of
repeated pregnancies. Some of the complications due to multiparity
includes:-
o Malnutrition leading to anaemia.
o Antepartum and postpartum haemorrhage
o Difficult and obstructed labor resulting in perineal tear,
uterine rupture involving immediate surgical intervention.
o Prolapse of uterus
o Still birth
o Neonatal death
o Premature delivery
o Low birth weight baby
d) Having too close pregnancies
 When the interval between the two pregnancies is less than three
years, it can create problems during the pregnancy. It is because
mother did not get enough time to recover completely and fully
from the stress and strain of the previous pregnancy. Repeated
pregnancies at short interval can cause nutrional deficiency,
anaemia, low birth weight baby and all the rest of the problems
mentioned earlier when also the number of the children being born,
increases.
Pregnancy at short intervals not only affects the health of the
mother and child being born but also the health of other children in
the family because they get neglected as mother cannot give her
attention to them.
e) Associated medical conditions
This includes:
o Heart disease
o High blood pressure
o Kidney disease
o Tuberculosis
o Diabetes
o Repeated attacks of malaria
o Hepatic disorder
f) Other conditions in mothers
These includes:
o Mothers with short height i.e. less than 145 cms having a
small and inadequate pelvis. Such mothers usually have
difficult labor and require caesarean delivery to avoid
complications.
o Mothers having less than 40 kg of weight: usually
underweight mothers are malnourished and anaemic and
have high risk of developing complications in pregnancy.
o Mothers having more than 70 kg of weight have difficulty
during childbirth. They may also develop respiratory distress
and problem while in anaesthesia. Sometimes it may be fatal
to mother.
o Mothers having malnutrition and anaemia. These mothers are
weak and find it difficult to tolerate the stress and strain of
pregnancy and child birth.
g) Previous abnormal obstetrical history
These includes history of:-
 o Antepartum haemorrhage, threatened abortion.
o Preeclampsia and eclampsia
o Malpresentations, twins, hydramnios.
o Intrauterine death, stillbirth, manual removal of placenta.
o Instrumental or caesarean delivery.
These conditions can pose serious problem to the life of both
mother and baby. These can be reduced considerably with
adequate proper care and timely medical attention.

Prevention of High Incidence of High Risk Pregnancies

o By improving pre pregnancy health of women.

o Providing quality antenatal care.
o Screening all pregnancies for high risk.
o Provide appropriate clinical and technological care by specialist on
time.
o Health education on MCH-FP care.

Screening of High Risk Pregnancy

A) Biophysical Assessment
1. Ultrasonography
2. Radiology in Obstetrics
3. Magnetic Resonance Imaging
B) Biochemical Assessment
1. Amniocentesis
2. Alpha-fetoprotien (AFP)
3. Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis
4. Chrionic Villus Sampling
5. Maternal Blood Assessments
6. Placental Biopsy
C) Electronic Monitoring
1. Nonstress test
2. Contraction Stress Tests/ Oxytocin Challenge test
3. Daily Fetal Movement Count (DFMC) or Kick Counts.

Antenatal Advice
Principles:

1) To counsel the women about the importance of regular checkup.

 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 the unknown by
counselling the women.

Diet: The diet during pregnancy should be adequate to provide-

a) good maternal health

b) optimum fetal growth
c) the strength and vitality required during labor and
d) successful lactation. During pregnancy, there is increased calorie
requirement due to increased growth of the maternal tissues, fetus,
placenta and increased basal metabolic rate.
The increased calorie requirement is to the extent of 300 over
the non- pregnancy state during second half of pregnancy.
Generally the diet in pregnancy should be with woman’s choice as
regard the quantity and the type. Woman with normal BMI should eat
adequately so as to gain the optimum weight(11 kg). Overweight
women with BMI between 26-29 should limit weight gain to 7 kg and
obese women (BMI>29) should gain less weight. Excessive weight gain
increases antepartum and intrapartum complications including fetal
macrosomia.

Antenatal Hygiene: In otherwise uncomplicated cases, the following

advises are to be given.
Rest and Sleep: The patient may continue her usual activities
throughout pregnancy. However, excessive and stremous work should
be avoided specially in the first trimester and the last 4 weeks.
Recreational exercise (parental exercise class) are permitted as long
as she feels comfortable.
Bowel: Constipation is common. It may cause backache and
abdominal discomfort. Regular bowel movement may be facilitated by
regulation of diet taking plenty of fluids, vegetables and milk or
prescribing tool softners at bed time. There may be rectal bleeding,
painful fissures or haemorrhoids due to hard stool.
Bathing: The patient should take daily bath but be careful against
slipping in the bathroom due to imbalance.
Clothing, shoes and belt: The patient should wear loose but
comfortable garments. High heel shoes should better be avoided in
advanced pregnancy when the centre of balance alters. Constricting
belt should be avoided.
Dental care: Good dental and oral hygiene should be maintained. The
dentist should be consulted, if necessary. This will facilitate extraction
or filling of the caries tooth, if required, comfortably in the 2 nd
trimester.
Care of the breasts: Breast engorgement may cause discomfort
during late pregnancy. A well fitting brassiere can give relief.
Coitus: Generally coitus is not restricted during pregnancy. Release of
prostaglandins and oxytocin with coitus may cause uterine
contractions. Women with increased risk of miscarriage or preterm
labor should avoid coitus if they feel such increased uterine activity.
Travel: Travel by vehicles having jerks are better to be avoided
specially in first trimester and the last 6 weeks. The long journey is
preferably be limited to the second trimester. Rail route is preferable
to bus route. Travel in pressurized aircraft is safe upto 36 weeks. Air
travel is contraindicated in case with placenta praevia, pre-
eclampsia, severe anaemia and sickle cell disease. Prolonged sitting in
a car or aeroplane should be avoided due to the risk of venous stasis
and thromboembolism. Seat belt should be under the abdomen.
Smoking and alcohol: In view of the fact that smoking is injurious to
health, it is better to stop smoking not only during pregnancy but even
thereafter. Heavy smokers have smaller babies and there is also more
chance of abortion. Similarly alcohol consumption is to be drastically
curtailed or avoided, so as to prevent fetal maldevelopment or growth
restriction.

IMMUNISATION:
Fortunately most of the life threatening epidemics are rare. In the
developing countries immunization in pregnancy is a routine for
tetanus; others are given when epidemic occurs or travelling to an
endemic zone or for travelling overseas.

Live virus vaccines (rubella, measles, mumps, yellow fever) are

contraindicated. Rabies, Hepatitis A and B vaccines, toxoids
can be given as in nonpregnant state.

Tetanus: Immunization against tetanus not only protects the mother

but also the neonates.
 Drugs: Almost all the drugs given to mother will cross the placenta to
reach the fetus. Possibility of pregnancy should be kept in mind while
prescribing drugs to any woman of reproductive age.

GENERAL ADVICE:

The patient should be persuaded to attend for antenatal check up

positively on the schedule date of visit. She is instructed to report the
physician even at an early date if some untoward symptoms arise such
as intense headache, disturbed sleep with restlessness, urinary
troubles, epigastric pain, vomiting and scanty urination.

She is advised to come to hospital for consideration of admission in the

following circumstances:
 Painful uterine contractions at interval of about 10 minutes or
earlier and continued for at least an hour- suggestive of onset of
labor.
 Sudden gush of watery fluid per vaginam- suggestive of
premature rupture of the membrane.
 Active vaginal bleeding, however slight it may be.

ABSTRACTS-

1. A questionnaire study of mothers' views of the antenatal care provided in

Belfast showed general satisfaction. Retrospective examination of their
charts, however, showed in some cases that insufficient attention was
paid to the medical and obstetric history in the selection of the type of
care made by the women and their doctors. Some women with high-risk
factors were booked for shared care and some patients at low risk were
booked for total hospital care. The reasons for this are unclear. The
mothers felt that continuity of care and communication at the health
center were better than at the hospital. Analysis of the number of
hospital attendances showed that shared care patients appeared to be
making an excessive number of visits to the hospital. Many total hospital
care patients also admitted that they were attending their general
practitioners. There appeared to be marked duplication of effort as a
result of poor communication between patient, general practitioner and
hospital. Alternative ideas for care are suggested a more integrated
 system for sharing antenatal care, and the development of general
practitioner units within the specialist obstetric hospital.[ CITATION McK14
\l 1033 ]

2. Both the under 18 conception and birth rates are falling. However, despite
this, the United Kingdom has a high rate of teenage pregnancy
compared to similar countries in Western Europe. Young mothers and
their babies have poorer access to maternity care and experience worse
obstetric outcomes than older mothers. It is likely that the risks
associated with teenage pregnancy reflect a significant interplay
between the socio-demographic status of many of these teenagers, their
nutritional status and their uptake of antenatal care. This review looks at
the complications associated with teenage pregnancy and how the
implementation of specialized antenatal care aims to improve outcomes.
[ CITATION Whi17 \l 1033 ]

3. Within the continuum of reproductive health care, antenatal care (ANC)

provides a platform for important healthcare functions, including health
promotion, screening and diagnosis, and disease prevention. It has been
established that, by implementing timely and appropriate evidence-
based practices, ANC can save lives. Endorsed, by the UN Secretary-
General, this is a comprehensive WHO guideline on routine ANC for
pregnant women and adolescent girls. It aims to complement existing
WHO guidelines on the management of specific pregnancy-related
complications. The guidance aims to capture the complex nature of the
issues surrounding ANC health care practices and delivery and to
prioritize person-centered health and well-being, not only the prevention
of death and morbidity, in accordance with a human rights-based
approach. "To achieve the Every Woman Every Child vision and the
Global Strategy for Women's Children's and Adolescents' Health, we
need innovative, evidence-based approaches to antenatal care. I
welcome these guidelines, which aim to put women at the center of care,
enhancing their experience of pregnancy and ensuring that babies have
the best possible start in life." Ban Ki-moon, UN Secretary-
General[ CITATION WHO13 \l 1033 ]

4. Early and frequent antenatal care attendance during pregnancy is

important to identify and mitigate risk factors in pregnancy and to
encourage women to have a skilled attendant at childbirth. However,
many pregnant women in sub-Saharan Africa start antenatal care
attendance late, particularly adolescent pregnant women. Therefore they
do not fully benefit from its preventive and curative services. This study
assesses the timing of adult and adolescent pregnant women's first
antenatal care visit and identifies factors influencing early and late
 attendance. The study was conducted in the Ulanga and Kilombero rural
Demographic Surveillance area in south-eastern Tanzania in 2008.
Qualitative exploratory studies informed the design of a structured
questionnaire. A total of 440 women who attended antenatal care
participated in exit interviews. Socio-demographic, social, perception-
and service-related factors were analyzed for associations with the
timing of antenatal care initiation using regression analysis. The majority
of pregnant women initiated antenatal care attendance with an average
of 5 gestational months. Belonging to the Sukuma ethnic group
compared to other ethnic groups such as the Pogoro, Mhehe, Mindo and
others, perceived the poor quality of care, late recognition of pregnancy
and not being supported by the husband or partner were identified as
factors associated with a later antenatal care enrolment (p < 0.05).
Primiparity and previous experience of a miscarriage or stillbirth were
associated with an earlier antenatal care attendance (p < 0.05).
Adolescent pregnant women started antenatal care no later than adult
pregnant women despite being more likely to be single. Factors including
poor quality of care, lack of awareness about the health benefit of
antenatal care, late recognition of pregnancy, and social and economic
factors may influence the timing of antenatal care. Community-based
interventions are needed that involve men and need to be combined
with interventions that target improving the quality, content, and
outreach of antenatal care services to enhance early antenatal care
enrolment among pregnant women.[ CITATION Gro12 \l 1033 ]

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