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) v The advice was given to the pregnant woman AIMS AND OBJECTIVE - The aims are- . To screen the ‘high risk’ cases. . To prevent or to detect and treat at the earliest any complications. . To ensure continued risk assessment and to provide ongoing primary preventive health care. . 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. . To discuss with the couple about the place, time and mode of delivery, provisionally and care of the newborn. . To motivate the couple about the need for family planning and appropriate advice to a couple seeking medical termination of pregnancy. OBJECTIVE - . To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother. . Prevention, early detection, and treatment of pregnancy-related complications as Pre-eclampsia, eclampsia, and hemorrhage. . Prevention, early detection and treatment of medical disorders as anemia and diabetes. . Detection of early malpresentation, malposition’s, and disproportion that may influence the decision of labor. . 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, 1* visit - around 16 weeks 2™ visit - Between 24 -28 weeks 3" visit - around 32 weeks 4" visit - around 36 weeks 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. . 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. CCateulaton of £00 . 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. . 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. . Past medical History Relevant history of past medical illness that is urinary tract infection tuberculosis is to be inquired. . Past surgical HistoryAny previous pregnancy e.g. General or gynecological, if any, is to be inquired. . 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. 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. 1. 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 tiltthe 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Ioassess 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. 1* trimester: Height of the fundus 2” trimester: External ballotment, fetal movements, palpation of the fetal parts, fundal height 3 trimester: Identify lie, presentation, position, growth pattem, 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. First nurse should face towards the women head. Whole —_fundal area is palpated by both hands laid flat on it to find which pole of fetus is lying in the fundus. Palpate for size, size, shape, consistency and mobility of the fetal part in the fundus. fingers of both hands is indicative of head. Irregular, bulkier, less firm and not well defined or indicative of breech. Neither of the above is indicative transverse lie. Lateral Palpation (Second Maneuver) or Umbilical grip Continue to face the woman head side Place the hands on both side of the uterus about midway between the symphysis 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 A smooth, curved, hard resistant surface indicate back, Small, knob irregular parts or modules indicate limb.and rotator movements. Repeat the procedure for the opposite. Pawlicks grip (Third Maneuver) Continue to face the woman head side. Woman _ should be placed as knee bent. Grasp the portion of the — lower abdomen immediately above the symphysis pubis between _—the thumb and middle finger of one of the hand. If the fetal head is above brim, it will be readily movable and ballotable. if it is not ballotable, it indicates head is engaged. Pelvic Palpation (Fourth Maneuver) Nurse should face towards the woman feet side, woman should be placed as knee bent. Place the hands on the sides of the uterus, with the palm of the hands just below the level of the 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 This maneuver determines the engagement of | the head. If the head is presenting, the fingers of one hand will feel the occiput and those of the other hand the cephalic prominence.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. Posi 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 occipitoposterionROP)(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%) © Left mentoanterior(LMA) © Left mentoposterior(LMP) o Left mentotransverse(LMT) © Right mentoanterior(RMA) o Right mentoposterior(RMP) © Right mentotransverse(RMT) ‘ Brow presentation (point of direction : nose root) Left frontoanterior(LFA) Left frontoposterior(LFP) Left frontotraverse(LFT) Right frontoanterior(RFA) Right frontoposterior(RFP) o Right frontotransverse(RFT) * Pelvic presentation(breech)(4%) © 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) oo0000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%): designations as above o Buttocks variety(70%) © 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) 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 :- ° Is Still growing and is not adequately equipped to cope 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. Is not psychologically prepared for the responsibilities of marriage, pregnancy and rearing children. This created tensions and discord in the family. 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 ° ° Having babies too late in life, leads to increased risk of complications in pregnancy and labor which include:- Heavy bleeding before and after child birth. Malpresentation resulting in difficult labor. Include/Aggravated blood pressure Forceps delivery or by caesarean operation Delay in expulsion of placenta. Low birth weight babies. ©) 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: ° ° ° ° Malnutrition leading to anaemia. Antepartum and postpartum haemorrhage Difficult and obstructed labor resulting in perineal tear, uterine rupture involving immediate surgical intervention. Prolapse of uterus Still birth Neonatal death Premature delivery Low birth weight baby 4) 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. Associated medical conditions This includes: o Heart disease High blood pressure Kidney disease Tuberculosis Diabetes Repeated attacks of malaria o Hepatic disorder Other conditions in mothers These includes: © 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. Mothers having less than 40 kg of weight: usually underweight mothers are malnourished and anaemic and have high risk of developing complications in pregnancy. 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. 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:-Antepartum haemorrhage, threatened abortion. Preeclampsia and eclampsia Malpresentations, twins, hydramnios. Intrauterine death, stillbirth, manual removal of placenta. 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. o0000 Prevention of High Incidence of High Risk Pregnancies By improving pre pregnancy health of women. Providing quality antenatal care. Screening all pregnancies for high risk. Provide appropriate clinical and technological care by specialist on time. © Health education on MCH-FP care. e000 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 Principl 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 ¢) 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