INTRODUCTION

Ante natal care refers to the care that is given to a pregnant women from the time that
conception is confirmed until the beginning of labour.Ante natal care is the care given during
pregnancy in the interest of both the mother and the fetus and is very much an exercise in
preventive medicine. Complications may arise in any pregnancy and although good
management avoids some others will inevitably occur and their early detection and treatment
is of prime importance. The midwife will provide a women centered approach to the care of
the women and her family by sharing information with the women to facilitate her to make
informed choices about her care.

DEFINITION

Systematic supervision (examination and advice)of a woman during pregnancy is called ante
natal care.

AIMS OF ANTE NATAL CARE

The aim of ante natal care is to monitor the progress of pregnancy in order to support
maternal health and normal fetal development.

• Developing a partnership with the woman.

• Providing a holistic approach to the women’s care that meet her individual needs.

• Promoting an awareness of the public health issues for the women and her family.

• Exchanging information with the women and her family and enabling them to make

informed choices about pregnancy and birth.

• Being an advocate for the women and her family during her pregnancy.

• Recognizing complications of pregnancy and appropriately referring women with the

multidisciplinary team.

• Facilitating the women and her family in their preparations to meet the demands of

birth , and making a birth plan.

• Facilitating the women to make an informed choice about methods of infant feeding

and giving appropriate and sensitive advice to support her decision.

• Offering education for parenthood with in a planned programme or on an individual

basis.

• Working in partnership with other pertinent organizations.

Studies have shown that if women carry their own maternity records it enhances their
satisfaction with ante natal care and their feeling towards pregnancy. The midwives should
try to use language that is easily understood by women to alleviate anxiety.

THE BOOKING VISIT(THE INITIAL ASSESSMENT)

The first visit that the women makes to the health care facility is called the booking visit. This
should be as easily as possible and preferably in the first trimester . In order to direct high
risk pregnancies and also to offer MTP if required.

AIMS OF BOOKING VISIT.

• To assess levels of health by taking a detailed history and to offer appropriate

screening tests.

• To identify risk factors by taking accurate details of past and present midwifery ,

obstetric, medical, family and personal history.

• To give public health advise and that pertaining to pregnancy in order to maintain the

health of the mother and the healthy development of the fetus.

• To build the foundation for the trusting relationship in which the women and midwife

are partners in care.

• To ascertain baseline recordings of blood pressure , urinalysis, blood values, uterine

growth and fetal development to be used as a standard for comparison as the

pregnancy progress.

HISTORY COLLECTION

Identification and demographic data.

Name:-
Age :- age less than 18 years or over 35 years.

A women having her first visit pregnancy at the age of 30 or above is called elderly
primigravida.

Gravida : Gravida denotes a pregnant state both present and past, irrespective of the period of
gestation.

Parity: denotes a state of previous pregnancy beyond the period of viability.

Nullipara : Is one who has never completed a pregnancy to the stage of viability. She may or
may not have aborted previously.

Primipara : Is one who has delivered one viable child.

Multigravida : Is one who has previously been pregnant. She may have aborted or have
delivered a viable baby.

Parturient: Is a women labour.

Nulli gravida : Is one who is not now and never has been pregnant.

Primigravida : Is one who is pregnant for the first time.

Multipara: Is one who has delivered two or more children.

Puerpera : Is a women who has just given birth.

Duration of marriage :- A pregnancy long after marriage with out taking recourse to any
method of contraception is called low fecundity and soon after marriage is called high
fecundity.

Religion:-

Occupation:- It may be helpful in interpreting symptoms due fatigue or occupational hazards.

Occupatiopn of the husband:- A fair idea about the socio-economic condition of the patient
can be assessed.

Period of gestation:- the duration of pregnancy is to be expressed in terms of completed

weeks. A fraction of a week of more than 3 days is to be considered as completed week. In
calculating the weeks of gestation in early part of pregnancy , counting is to be done from the
first day of last menstrual period and in later months of pregnancy, counting is to be done
from expected date of delivery.

Menstrual history

Cycle, duration, amount of blood flow and first day of the last normal menstrual period are to
be noted.

Calculated of the expected date of delivery- This is done according to Naegele’s formula by
adding 9 calendar months and seven days to the last normal period.

Obstetric history

• Present obstetric history.

First trimester(till 12 weeks of gestation)

Amenorrhoea

Confirmation of pregnancy.

Booked/ unbooked.

Number of visits for ante natal care.

Nausea, vomiting.

Fever and rashes.

Heartburn.

Itching, jaundice.

Drug intake.

Radiation exposure.

Any episode of leaking of fluid per vagina or(LPV) or bleeding per vagina(BPV).

Breast tenderness.

Fatigue.

Frequency of micturation.

Second trimester(12 weeks-28 weeks)

 Continuing amenorrhoea.

Quickening.

Tetanus toxoid(TT) immunization.

Iron, folic acid(IFA) and calcium supplementation.

LPV/BPV.

Vaginal discharge or irritation.

Reduced fetal movements.

History suggestive of Hypertension(weight gain, headache, oliguria, pedal edema,

epigastric pain, giddiness or blurring of vision..

Third trimester. (after 28 weeks)

2nd dose TT immunization.

Frequency of micturation.

Increase / decrease fetal movements.

LPV/BPV.

Iron, folic acid and calcium intake.

History of blood transfusion.

Abdominal pain or back pain.

Bowel habits.

Any dai interference.

• Past obstetric history.

The record must include the following four p’s of all previous pregnancies in chronological
order.

pregnancy
 Duration of marriage, whether conceived after treatment of pregnancy.

The duration of pregnancy.

Any complication during pregnancy.

Parturition

Date and place of delivery and conducted by whom( doctor/ nurse/ qualified or

unqualified dai)

Whether labour was spontaneous or induced.

The mode of delivery(normal/vaccum/forceps/ LSCS)

Any complications during the third stage.

Whether a blood transfusion was given.

Puerperium

The course of the peurperium.

Any history of fever/ discharge/ calf tenderness/ pain in sutureline(if episiotomy,

stiching of tear or caesarean is done)

Any costly injection given(Rh-Negative woman)

Any visit within 6 weeks of delivery for some previous complaint.

Type of contraception used.

Product

The weight and sex of baby

Condition of baby at birth(any congenital anomalies/ whether cried immediately or

not)

Whether breast fed or not, period of exclusive breast feeding.

Subsequent progress of the baby.

Present health status in child.

 Any cause whether followed by D and E( dilatation and evacuation) or not.

Specify preterm birth/still birth if applicable and possible.

No Year and date Pregnancy events. Labour events Methods of delivery.

puerperium Baby

Past medical history

History of medical illness is to be taken in to account as these may affect the present
pregnancy and produce adverse effects on the mother or the fetus. Eg

Heart diseases, tuberculosis, diabetes, hypertension, thyroid disorders, epilepsy etc.

Sexually transmitted diseases.

Human immunodeficiency virus(HIV) status, if known.

Other specific conditions depending on the regional prevalence( hepatitis, malaria,

sickle cell trait,thalassaemia, etc)

History of allergy.

Blood transfusions.

Current use of medicines- specify.

Past surgical history

Previous surgery- general or gyenacological, if any is to be enquired.

One should be careful of any previous uterine surgery, eg myomectomy, uteroplasty,

hysterectomy, dilatation and curettage. Past history of surgery on the bowel or appendix may
cause adhesions.

Family history

Family history of hypertension, diabetes, tuberculosis, epilepsy, blood dyscrasia, known

hereditary diseases if any or twinning is to be enquired.

Personal history
Enquire about

 Dietary habits (veg or nonveg)

 Total daily caloric intake at home calculated from one 24hr dietary recall.

 Protein intake.

 Other nutrients.

 Smoking or alcohol habits.

 Other drugs of addition

 History of vaccination.

 Contraception history.

EXAMINATION

 Physical examination

• Look at the general appearance of the patient.

• Built and nutritional status.

• Gait

• Check for severe anemia; pale, complexion, finger nail, conjunctiva, oral mucosa, tip
of tounge and shortness of breath.

• Record weight and height

Height of the women is checked at the time of first visit. Height over 160cm is an indication
of normal pelvis.

Weight must be checked at every visit and the rate of gain to be assessed. Obesity is
associated with an increased risk of gestational diabetes and pregnancy induced hypertension.

System wise examination

• Integumentary system
Rashes , moles, lesions, pruritis, bruises, hirsutism, pigmentation, moisture, scars, tumors and
turger.

• Hair and scalp

General character, scalp infections, lice, dandruff, alopecia, and lumps.

• Head

Head ache, dizziness, fainting, sinusitis, involuntary movements.

• Eyes

Blurring of vision, blind spots in vision, diplopia , photophobia, lacrimation discharge,

redness, burning, glasses or contact lenses, injuries, infections, colour of conjunctiva,
pupillary size and reaction to light.

• Ears

Hearing acuity, ear aches or discharges, tinnitus, vertigo, infection, tenderness, lesions, and
placement on head.

• Nose

Size, placement, potency of nostrils, epitaxis, discharge, sense of smell, and septal deformity

• Mouth and throat

Condition of lips, gum, teeth, tongue and mucosa; sense of taste, voice, speech, odor of
breath, any inflammation or surgery.

• Neck

Movement, lymph node enlargement, vein distention, position of trachea.

• Breasts

Nipples- normal flat or inverted, discharge, skin an glandular changes.

• Gastrointestinal system

Appetite, nausea, vomiting, heart burn, belching, flatulence, bowel pattern, hemorrhoids, food
allergies, hernias.

• Cardiorespiratory system
Breathing pattern, cough, wheezing, infection, respiration rate and rhythm, auscultation
findings.

• Genitourinary system

Urination difficulties and deviations, genital lesions and infections, history of hormone
therapy.

• Muscular , skeletal and vascular systems

Status of joints, muscles and extremities, appearance of nails and fingers.

• Central nervous system

-speech and memory, complaints of vertigo, convulsions or loss of consciousness.

-mental status

-motor symptoms

-sensory symptoms

• Lymphatic and hematopoietic system

Lymph nodes, bruising tendencies, blood dyscrasias

 Obstetric examination

It mainly include

Inspection, palpation, auscultation, vaginal or bi manual examination(pelvic examinations)

Before starting the examination, the following pre caution should be taken.

• The women should be comfortable on the bed with one pillow under the head.

• The abdomen is exposed from the xiphisternum to a little below the symphysis pubis.

• The bladder should be empty.

• The patient should be examined from the right side.

• The hands should be warm especially in cold weather as it may stimulate uterine
contraction.

Inspection
• Assess the size of the uterus.

• The shape of the uterus.

• When the women is standing see for lightening.

• Assess for pendulous abdomen or anterior obliquity of the uterus( in primigravid it is

a serious sign as it may be due to pelvic contraction)

• Assess for skin changes( stretch marks from previous pregnancies appear silvery and
recent ones appear pink.)

• Linea nigra may be seen( this is a normal dark line of pigmention running
longitudinally in the centre of the abdomen below and some above the umbilicus.)

Palpation

• The midwives hand should be clean and warm.

Cold hands do not have the necessary acute sense of touch, they tend to induce
contraction of the abdomen and uterine muscles and the women may find palpation
uncomfortable.

• Arms and hands should be relaxed and the pads, not the tips, of the fingers used with
delicate precision.

• The hands are moved smoothly over the abdomen in a stroking motion in order to
avoid causing contractions.

• In order to determine the height of the fundus the midwife places her hand just below
the xiphisternum.

• Pressing gently she moves her hands down the abdomen until she feels the curved
upper boarder of the fundus.

• The distance between the fundus and the symphysis pubis can be determined with a
tape measurement.

Lateral palpation
 This is used to locate the fetal back in order to determine position. The hands are
placed on the either side of the uterus at the level of the umbilicus. Gentle pressure is applied
with alternate hands in order to detect which side of the uterus offers the greater resistance.
More detailed information is obtained by feeling along the length of each side with the
fingers. This can be done by sliding the hands down the abdomen while feeling the sides of
the uterus alternately.

Some midwives prefer to steady the uterus with one hand and, using a rotary
movement of the opposite hand, to map out the back as a continuous smooth resistant mass
from the breech down to the neck; on the other side the same movement reveals the limbs as
small parts that slip about under the examining fingers.

‘walking’ the finger tips of both hands over the abdomen from one side to the other
is an excellent method of locating the back. The fingers should be dipped in to the abdominal
wall deeply. The firm back can be distinguished from the fluctuating amniotic fluid and the
receding knobby small parts. To make the back more prominent, fundal pressure can be
applied with one hand and the other used to ‘walk’ over the abdomen. Palpating from the
neck upwards and inwards can locate the anterior shoulder.

Fundal palpation

This determines the presence of the breech or the head. This information will help to
diagnose the lie and presentation of the fetus. The midwife lays both hands on the sides of
the fundus, fingers held close together and curving round the upper boarder of the uterus.
Gentle yet deliberate pressure is applied using the palmar surface of the fingers to determine
the soft consistency and indefinite outline that denotes the breech. Sometimes the buttocks
feel rather firm but they are not as hard, smooth or well defined as the head.

The head is much more distinctive in outline than the breech, being hard and
round; it can be balloted(moved from one hand to the other) between the fingertips of the two
hands because of the free movement of the neck.

Pelvic palpation

Pelvic palpation can cause contractions of the uterus therefore it is often carried out before
fundal and lateral palpation to make the findings easier to determine. Pelvic palpation will
identify the pole of the fetus in the pelvis. It should not cause discomfort to the women.
 The midwife should ask the woman to bend her knees slightly in
order to relax the abdominal muscles and also suggest that she breathe steadily. Thes sides of
the uterus just below umbilical level are grasped snugly between the palms of the hands with
the fingers held close together, and pointing downwards and inwards.

If head is presenting , a hard mass with a distinctive round,

smooth surface will be felt. The midwife should also estimate how much of the fetal head is
palpable above the pelvic brim to determine engagement. The two handed technique appears
to be the most comfortable for the women and gives the most information. Pawlik’s
maneuver is sometimes used to judge the size.

Auscultation

Listening to the fetal heart is an important part of the process. Like all heart beats it is a
double sound, but more rapid than the adult heart. The Pinard’s fetal stethoscope is placed on
the mother’s abdomen, at right angles to it over the fetal back. The ear must be in close, firm
contact with the stethoscope but the hand should not touch it while listening because then
extraneous sounds are produced. The midwife should count the beats per minute, which
should be in the range of 110-160.

FINDINGS.

The findings from the abdominal palpation should be considered as part of the holistic
picture of the pregnant women. The midwife assesses all the information which she has
gathered from inspection, palpation and auscultation critically evaluates the well being of the
mother and fetus.

Gestational age

During pregnancy the uterus is expected to grow at a predicted rate and in early pregnancy
uterine size will usually equate with the gestation estimated by dates. Later in pregnancy,
increasing uterine size gives evidence of continuing fetal growth but is less reliable as an
indicator of gestational age.

Lie

The lie of the fetus is the relationship between the long axis of the fetus and the long
axis of the uterus. In the majority of the cases the lie is longitudinal owing to the ovoid shape
of the uterus. Oblique lie when the fetus lies diagonally across the long axis of the uterus.
When the lie is transverse the fetus lies at right angles across the long axis of the uterus.

Attitude

Attitude is the relationship of the fetal head and limbs to its trunk. The attitude
should be one of flexion. The fetus is curled up with chin on chest, arms and legs fixed,
forming a snug, compact mass, which utilizes the space in the uterine cavity more effectively.

Presentation

Presentation refers to the part of the fetus at lies at the pelvic brim or in the lower pole
of the uterus. Presentation can be vertex, breech, shoulder, face, or brow.

Denominator

‘Denominate’ means ‘to give a name to’; denominator is the name of the part of the
presentation. Each presentation has different denominator and these are as follows.

In vertex presentation it is occiput

In the breech presentation it is the sacrum.

In the face presentation it is mentum.

In the shoulder presentation it is the acromian process.

Position.

The position is the relationship between the denominator of the presentation and six
points on the pelvic brim. The denominator be found in the midline either anteriorly or
posteriorly especially late in labour. The position is often transient and is described as direct
anterior or direct posterior. Anterior positions are more favourable than posterior positions
because when the fetal back is in front it conforms to the concavity of the mothers abdominal
wall and can therefore flex more easily.

The positions in vertex presentation are

 Left occipitoanterior(LOA)
The occiput points to the left iliopectineal eminence; the sagital suture is in the right oblique
diameter of the pelvis.

 Right occipitoanterior(ROA)

The occiput points to the right iliopectineal eminence; the sagital suture is in the left oblique
diameter of the pelvis.

 Left occipito lateral(LOR)

The occiput points to the left iliopectinal line midway between the iliopectineal eminence and
the sacroiliac joint; the sagital suture is in the transverse diameter of the pelvis.

 Right occipitolateral(ROL)

The occiput points to the right iliopectinal line midway between the iliopectinal eminence
and the sacroiliac joint; the sagital suture is in the transverse diameter of the pelvis.

 Left occipito posterior (LOP)

The occiput points to the left sacroiliac joint; the sagital suture is in the right oblique diameter
of the pelvis.

 Direct occipito anterior(DOA)

The occiput points to the symphysis pubis; the sagital suture is in the anteroposterior diameter
of the pelvis.

 Direct occipitoposterior(DOP)

The occiput points to the sacrum; the sagital suture is in the anteroposterior diameter of the
pelvis.

Engagement.

Engagement is said to have occurred when the widest presenting transverse diameter has
passed through the brim of the pelvis. In cephalic presentations this is the bipareital diameter
and in breech presentation the bitrochantric diameter. Engagement demonstrate that the
maternal pelvis is likely to be adequate for the size of the fetus and that the baby will birth
vaginally.

In a primigravid woman the head normally engages at any time from

about 36 weeks of pregnancy, but in a multipatara this may not occur until after the onset of
labour. In the head does not engage in primigravid woman at term there is a possibility of a
malposition or cephalopelvic disproportion.

Presenting part

The presenting part of the fetus is the part that lies over the cervical os during labour and on
which the caput succedaneum forms. It should not be confused with presentation.