Objectives:

At the end of the lecture the student will be able to:

• Define the antenatal care.

• Explain the component of antenatal care.
• Estimate the expected date of delivery.
• Classify the schedule of antenatal visits.
• Calculate the gestational weeks and time of different tetanus toxoid
doses during pregnancy.
• Categorize the information typically collected at the initial & follow-
up antenatal visits.
• Compare between various maneuvers of abdominal examination
during pregnancy.
• Apply maneuvers of abdominal examination during pregnancy &
auscultation of fetal heart sound.
• Illustrate the key components of antenatal education.
• Choose appropriate professional attitudes and behaviors in
different situations.
 Introduction

Once a pregnancy is suspected and confirmed

by a home pregnancy test, the woman should
seek antenatal care to promote a healthy
outcome.
Appropriate nursing management starting at
conception and continuing throughout the
pregnancy can have a positive impact on the
health of pregnant women and their unborn
children.
 Definition of
antenatal care

A comprehensive health supervision of a

pregnant woman so that she will be able to go
through pregnancy, labor, and puerperium
without complication to herself or her baby.
 Objectives of antenatal care

• Ensure a healthy mother and newborn.

• Estimation of gestational age and expected
date of delivery.
• Early detection and prevention of any diseases
that may occur during pregnancy.
• Proper management of any diseases that may
occur during pregnancy.
Components of antenatal
booking visit
Comprehensive health history.

Physical examination.

Laboratory investigation.

Health education.

Management of any health

problems and referral
History
 Personal history.
 Reason for seeking care.
 past history.
 Family medical history.
 obstetric history.
 Menstrual history.
 Gynecolgical history.
 Present history .
 Personal history
• Name.
• Age as the lowest rate of maternal mortality is 20-26 years.
• Duration of marriage.
• Residence.
• Occupation as certain occupations have certain risk e.g.
medical personnel may be liable to infectious diseases and
anesthetic gases, while factories worker may be exposed
to radiation.
• Exercise and activity level.
• Smoking habits as smoking causes vasoconstriction in the
mother leading to reduced placental perfusion. As a result,
the new born may be small for gestational age.
• Use of alternative and complementary therapies.
• Sleep patterns.
• General lifestyle e.g. pets causes risk of toxoplasmosis
 B. Reason for seeking care:

• 1) Woman may report that she has missed

her menstrual period.
• 2) Ask the woman about the date of her last
menstrual period (LMP).
• 3) Ask the woman about any presumptive or
probable signs of pregnancy that she might be
experiencing.
 C. Past history
• 1) Past medical history: presence of any chronic
disease as hypertension, diabetes mellitus.
• 2) Past surgical history: previous operations
including cesarean section
• 3) Drugs which may affect pregnancy or fetus
e.g. oral anticoagulant.
• 4) Contraceptive history.
• 5) Previous blood transfusion
• 6) Presence of allergy to drugs or foods or
environmental substance
• 7) Mental health problems such as depression or
anxiety.
• Family history
• Diabetes mellitus → screen
• Hypertension → investigate
• Congenital fetal anomalies → screen
• Twins → suspect
 E. Menstrual history

• 1) Age at menarche.
• 2) Regulatory, duration and interval.
• 3) Typical flow characteristics.
• 4) Any discomfort experienced.
• 5) Use of contraception.
• 6) Date of LMP to determine the expected date of
birth (EDB). Several methods may be used to
estimate the date of birth which will be discussed
later.
 F- Obstetric history
• Woman's past pregnancies, including any problems during the last
pregnancy, Labor, delivery, and puerperium
• Space between pregnancies: time less than two years between
pregnancies may indicate liability to abortion and pre-term labor.
• Ante partum period: In case of repeated hypertension the nurse
should be expected its recurrence, previous diabetes mellitus screen
for it, and in case of previous ante partum hemorrhage or
premature rupture of membrane expect recurrence.
• Onset of delivery : Spontaneous – induced
• Mode of delivery: If easy vaginal delivery expects another, and in
case of caesarean section determine the cause.
• Postpartum complications especially post-partum hemorrhage.
• Condition of the newborn: Alive or dead – male or female.
• .
Systems may be used to document a woman's obstetric history.
These systems often break down the category of Para more
specifically
•
• GTPAL or TPAL
• G = gravida, T = term births, P = preterm births.
• A = abortions, L = living children.
• G – The current pregnancy to be included in count
• T – The number of term gestations delivering between 38
and 42 weeks.
• P – The number of preterm pregnancies ending > 20 weeks
or viability but before completion of 37 weeks.
• A – The number of pregnancies ending before 20 weeks or
viability.
• L - The number of children currently living.
 G- Gynecologic history

• Ask about any reproductive tract surgeries

that woman has undergone. For example,
surgery on the uterus may affect its ability to
contract effectively during labor. A history of
tubal pregnancy increases the woman's risk
for another tubal pregnancy.
 General Examination
o Height: if less than 150 cm be aware of cephalopelvic
disproportion.
o • Weight: if obese be aware of diabetes mellitus,
hypertension, macrosomia and dystocia.
o • Vital signs:
o Blood pressure abnormalities such as elevated blood
pressure suggest pregestational hypertension.
o Pulse abnormalities especially in heart disease.
o Temperature especially in infection.
o • Head and neck:
o Assess for any previous injuries.
o Range of motion.
o Palpate for any enlarged lymph nodes
o Not any edema of the nasal mucosa
Chest:
• Auscultate heart sounds for any abnormalities.
• Auscultate the chest for breath sounds, which should be
clear.
• Inspect and palpate the breasts and nipples for symmetry
and color.
• Extremities:
• Inspect and palpate both legs for dependent edema, and
varicose veins.
• If edema is present in early pregnancy, further evaluation
is needed to rule out gestational hypertension.
• During the third trimester, dependent edema is a normal
finding in specific parts of the women body.
• Ask the woman if she has any pain in her calf that
increases when she ambulates, which might indicate a
deep vein thrombosis (DVT).
 local examination:

o Abdominal examination.
o Pelvic examination.
1.Abdominal examination
 Inspection
 Palpation
 Auscultation
 Inspection
Size and shape
 The uterus is normally visible in the abdomen at 12-14
weeks of gestation.
 The size and shape of the uterus should be regular and
symmetrical unless there are multiple pregnancies or
polyhydramnios.
Scars
 Previous caesarean section.
 Previous surgery.
Skin Changes
 Striaegravidarum, or stretch marks, are caused by
pregnancy hormones.
 Striaealbicanes are stretch marks from previous
pregnancies. They appear as white and silvery.
These stretch marks are more common in the
lower abdomen, upper thighs and buttocks.
 Linea nigra is the dark line between umbilical and
symphysis pupis
Fetal movements
Fetal movements are visible after 24 weeks.
Umbilicus
The umbilicus becomes flattened as the
pregnancy progresses to term May become
flattened and everted in multiple pregnancy
and polyhydramnios.
 Palpation

Measurement of Fundus Height

oPosition of the patient:

The patient should lie in the supine position
and should have an empty bladder.
 Place the ulnar border of the left hand just below
the xiphisternum and move it down the abdomen
until the fundus is felt.

 Measure the number of fingers, which can fit

between the fundus and xiphisternum, or measure
the distance from the symphysis pubis to the
fundus using a tape measure.
o At 12 week: the fundus height will be at the
level of symphysis pubis.
o At 16 week: the fundus height will be at
midway between symphysis pubis & umbilicus.
o At 24 week: the fundus height will be at the
level of the umbilicus.
o At 30 week: the fundus height will be at midway
between xiphisternum& umbilicus.
o At 32 week: it will be 4 fingers below the
xiphisternum
o At 36 week: the fundus height will be at the level
of xiphisternum.
o At 40 weeks: it returnsto 4 fingers below the
xiphisternum. (As lightening take place.
 Pelvic examination
• External genitalia
• The external genitalia are inspected visually.
• They should be free from lesions, abnormal
discharge, hematomas, varicosities, and
inflammation upon inspection.
• Internal genitalia
• After insertion of the speculum, the cervix will be
softened (Goodell sign), the uterine isthmus will be
softened (Hegar's sign), and there will be a bluish
coloration of the cervix and vaginal mucosa
(Chadwick's sign).
•
• A Papanicolaou smear may be obtained.

• A rectal examination is done last to assess for

lesions, masses, prolapse, or hemorrhoids.
 3.Laboratory investigation:

• A series of tests ordered during the initial visit so that

baseline data can be obtained.
• The urine is analyzed for albumin, glucose, ketones, and
bacteria casts.
• Blood studies include:
• A complete blood count (hemoglobin, hematocrit, red and
white blood cell counts, and platelets).
• Blood typing and Rh factor.
• Glucose screening for high-risk women.
• Rubella titer.
• An additional laboratory study is determined by a
women's history, physical examination findings, current
health status, and risk factors identified in the initial visit.
 Health education
• A) Self-care measures
• Personal hygiene which includes; perineal care,
dental and breast care.
• Nutrition.
• Clothing.
• Exercise.
• Sleep and rest.
• Sexual activity.
• Employment.
• Travel.
• Immunization and medications.
• Techniques for fetal movement counts.
• A) Self-care measures
• Personal hygiene which includes; perineal care,
dental and breast care.
• Nutrition.
• Clothing.
• Exercise.
• Sleep and rest.
• Sexual activity.
• Employment.
• Travel.
• Immunization and medications.
• Techniques for fetal movement counts.
• B) Danger signs of pregnancy
• Spotting or bleeding (miscarriage).
• Painful urination (infection).
• Severe persistent vomiting (hyperemesis gravidarum).
• Fever > 37.7 (infection).
• Lower abdominal pain at one side with dizziness and accompanied by shoulder
pain (ruptured ectopic pregnancy).
• Regular uterine contractions (preterm labor during the second trimester).
• Pain in calf, often increased with the dorsiflexion of the foot (blood clot in deep
vein).
• Sudden gush or leakages of fluid from vagina (premature rupture of membranes
in the second trimester).
• Absence of fetal movement for more than 12 hours (possible fetal distress in
second trimester).
• Sudden weight gain during the third trimester
• Facial edema, severe upper abdominal pain, or headache with Tvisual changes
(pregnancy – induced hypertension during third trimester).
• A decrease in fetal daily movement for more than 24 hours (possible demise
during third trimester).
 C) The follow up visits:
• Continues prenatal care is important for successful
pregnancy out come:
• The recommended follow up schedule for pregnant
women is:
• A schedule of future visits is given for each client
 Up to 28 weeks gestation every 4 weeks
 29-36 weeks every 2 week
 37-40 weeks every week
 Up to 28 weeks gestation :
1. Weight and blood pressure monitor and compared to baseline
value.

2. Urine test for protein, glucose and ketones.

3. Fundal hight.

4. Assessment for queening to determine fetal wellbeing (5 month).

5. Assess fetal heart rate(audible 4 month).

6. Answer question and provide guidance.

 29-36 weeks:
1.As previous assessment visit.
2.Assess of edema.
3.If mother is RH negative her antibodies titer is
evaluated.
• RHOGAM is given to prevent development
of antibodies.
 37-40 week
1.As previous assessment.
2.Feta presentation and position
3.Signs and symptoms of labor.
4.Evaluate client desire to for family planning
methods afterbirth and her decision to breast
fed or bottle feeding.
 Estimation of the expected date of delivery (EDD)

• Estimation of the expected date of delivery (EDD)

• In case of Known date of LMP
• Menstrual delivery interval: Add 280 days = 40 weeks
=10 lunar months = 9 calendar months and one week
• Nagele's rule: Add 7 days and 9 calendar months
• Or Subtract 3 months from the month of her LMP
and add 7 days to the first day of the LMP. Then correct
the year by adding 1 to it where necessary.
• In case of not known date of the LMP
• Coital delivery interval: Add 270 days to this date
 Estimation of the expected date of delivery (EDD)
• Quickening delivery interval: Add 22 weeks + or – 2
weeks to this date. Quickening is usually perceived by
the client between 16 and 20 weeks gestation
(primgravida 18:20 weeks after LMP and in
multigravida 16 weeks after LMP)
• Lightening + 2 week :Lightening means the descent of
the uterus into the pelvic cavity due to fetal head
engagement, occurring toward the end of pregnancy,
changing the contour of the abdomen and facilitating
breathing by lessening pressure under the diaphragm.
• Fundal level measurement.
• Ultrasound is typically the most accurate method of
dating a pregnancy.