CENTRAL OBJECTIVE

At the end of the seminar the group gets adequate

knowledge regarding antenatal care, develops a right attitude towards antenatal care and apply this knowledge in their professional and personal life.

SPECIFIC OBJECTIVES:
At the end of the seminar, the group

Enlists common terminologies

Discusses pre conceptional care Defines antenatal care

Discuss aims and objectives of antenatal care

Explains antenatal visits Describe antenatal advices

Explains subsequent ante natal visits

Discusses minor ailments in pregnancy Discusses values of antenatal care.

COMMON TERMINOLOGIES:
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 woman in labour

 Nulligravida: 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 woman who has just given birth

ANTENATAL CARE
Definition:

Systematic supervision ( examination and advice ) of a women during pregnancy is called antenatal or prenatal care.

Aims and Objectives:

Aims are; To screen high risk cases To prevent or to detect and treat at the earliest any complications To ensure continuous medical surveillance and prophylaxis To educate the mother about the physiology of pregnancy and labour by demonstrations, charts and diagrams so that 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 of family planning and also appropriate advice to couple seeking medical termination of pregnancy

Objective: To ensure a normal pregnancy with a delivery of a healthy baby from a healthy mother.

ANTENATAL VISITS

Services as per WHO recommendation: Atleast 4 visit 1st visit around 16weeks 2nd visit between 24-28 weeks 3rd visit at 32 weeks 4th visit at 36 weeks

Generally At interval of 4 weeks up to 28 weeks At interval of 2 weeks up to 36 weeks At weekly interval up to EDD

The First Visit

History taking
Physical Examination Investigation

Risk Determination
Antenatal Advice

1. History taking
Age Gravida and Parity Duration of marriage Occupation Occupation of Husband Period of Gestation Complaints History of Present illness

 History of Present Pregnancy

Obstetric History Menstrual History

Past Medical History

Past Surgical History Family History:

Contraceptive History

PHYSICAL EXAMINATION
General Examination

Obstetrical Examination

Obstetrical Examination:
Abominal Examination

Inspection

Palpation
Auscultation Vaginal Examination

INVESTIGATIONS
Examination of Blood:
Urinalysis Cervical Cytology Study

Special Investigations:

Recommended Intervals for Routine and Indicated Tests and Procedures During Prenatal Care

Initial

Hemoglobin Urinalysis, including microscopic examination and infection screen Blood group and D type Antibody screen Rubella antibody titer Syphilis screen Cervical cytology Hepatitis B virus screen

8-18

Ultrasound Amniocentesis Chorionic villous sampling

16-18

Maternal serum alpha-fetoprotein

26-28

Diabetes screening Repeat hemoglobin or hematocrit

28

Repeat antibody test for un sensitized D-negative patients Prophylactic administration of anti-D immune globulin Repeat hemoglobin

RISK DETERMINATION
Risk factors that may raise during pregnancy are ;
Fetal movement pattern reduced or changed Hb lower than 10g/dl

Poor weight gain

weight loss Proteinuria, glycosuria bacilluria

BP systolic of or above 140mmHg, diastolic of above

90mmHg or 15mmhg or more above booking diastolic Uterus large or small for gestational age

 Excess or decreased liquor

Malpresentation Head not engaged in primigravid woman at term

Any vaginal, cervical or uterine bleeding

Premature labour Infection Any Chronic or acute illness or disease in the woman Relevant sociological or psychological factors

ANTENATAL ADVICE
1. DIET: The diet during pregnancy should be adequate to provide (a) the maintenance of maternal health, (b) the needs of the growing fetus, (c) the strength and vitality required during labour and (d) successful lactation.

2. Rest and sleep Bowel Bathing Clothing, shoes and belt Dental care Care of the breasts Coitus Travel Smoking and alcohol Exercise IMMUNISATION

Advice on Use of Various Vaccines During Pregnancy:

Live Virus Vaccine Measles: contraindicated Mumps :contraindicated Poliomyelitis: not routine; increased risk of exposure Yellow fever----travel to high risk areas only

Inactivated Bacterial Vaccine

Cholera: to meet international travel requirements Pneumococcus: same as non pregnant

Plague: selective vaccination of exposed persons

Typhoid: travel to endemic areas Hyper Immune Globulin Hepatitis B: post exposure prophylaxis; give along

with Hepatitis B vaccine initially, then vaccine alone at 1 and 6 months Rabies: post-exposure prophylaxis Tetanus: post-exposure prophylaxis Varicella: Consider for post exposure (within 96 hours)

Inactive Virus Vaccines Influenza: Underlying Disease Rabies: same as non pregnant Hepatitis B: at high risk and negative for B antigen Toxoids Tetanus: diphtheria - same as non pregnant Pooled immune serum globulins Hepatitis A: post-exposure prophylaxis Measles: post-exposure prophylaxis

SUBSEQUENT VISITS
Maternal weight gain

Blood pressure
Assessment of the size of the uterus and height of

the fundus Clinical assessment of excess liquor

MINOR AILMENTS IN PREGNANCY

Nausea and vomiting Backache

Constipation
Leg cramps Acidity and heartburn

Varicose veins

 Ankle oedema Vaginal discharge Pelvic joint pain Incontinence Stretch marks

 To screen the high risk cases

VALUES OF ANTENATAL CARE

Detection of high risk factors deserves no credit unless

proper steps are taken to rectify it Pregnancy should be regularly supervised Antenatal care is said to be the strategy, the intranatal care is the tactics in obstetrics Acceptance of advice

 It is an opportunity to make the patient realise that

childbirth is a physiological process and to boost up the psychology The net effect is marked reduction in maternal mortality (about I/7th) and morbidity

DRAWBACKS
Trifling abnormality may be exaggerated for which

unnecessary medications or risky operative interference is prescribed Quality is not always maintained specially in the developing countries with increasing population. Faulty dietary advice and prescription of harmful drugs produce injurious effects on the mother and/or the baby.

PRECONCEPTIONAL COUNSELLING
When a couple is seen and counselled about

pregnancy, its course and outcome well before the time of actual conception is called preconceptional counselling.

PRECONCEPTIONAL VISIT, RISK ASSESSMENT AND EDUCATION

Base level health status including blood pressure is

recorded. Rubella and hepalitis immunization in a non-immune woman is offered. Folic acid supplementation (4 mg a day) starting 4 weeks prior to conception upto 12 weeks of pregnancy , is advised Maternal health is optimised preconceptionally

 Patient with medical complications should be educated

about the effects of the disease on pregnancy and also the effects of pregnancy on the disease. Drugs used before pregnancy are verified and changed if required Woman should be urged to stop smoking, taking alcohol and abusing drugs. Addicted woman is given specialised care. Inheritable genetic diseases (sickle cell disease, cystic fibrosis) are screened before conception and risk of passing on the condition to the offspring is discussed

 Importance of prenatal diagnosis for chromosomal or

genetic diseases are discussed Inheritable genetic diseases could be managed either by primary prevention Couples with history of recurrent fetal loss or with family history of congenital abnormalities (genetic, chromosomal or structural) are investigated and counselled appropriately

PRENATAL GENETIC COUNSELING

Genetic counselling is the practice of assisting individuals

and families to comprehend the natural history of genetic and congenital conditions, as well as the psychosocial and reproductive implications

Prenatal Genetic Counseling May be Beneficial to:

Women, 35 or older, who are pregnant or wish to be pregnant

and are concerned about the risk for chromosomes problems during pregnancy. Couples in which one or both have a history of birth defects or genetic disease. Couples who have had a child or pregnancy affected with certain birth defects or genetic disease. Individuals interested in carrier screening for genetic disease due to family history or ethnic background.

 Couples who have found (through carrier screening)

that they are both carriers of the same genetic condition Pregnant women coping with abnormal genetic test results. Women concerned about a drug, environmental hazard, or other exposure during pregnancy. Couples who have been diagnosed with infertility

TIMING OF PRENATAL SCREENING AND TESTING

First trimester screening (9 weeks to 14 weeks of pregnancy) The first trimester screen is a combination of an ultrasound scan and a maternal serum screening test. The maternal serum screen is optimally performed between 9 and 10 weeks (extending to a maximum of 13.6 weeks) and measures the levels of two products, -hCG and PAPP-A. The ultrasound scan is optimally performed between 11 and 13.6 weeks of pregnancy and measures the nuchal translucency (NT), determines the presence of the nasal bone and assesses structural development of your baby.

 Second trimester screening (16 to 23 weeks of

pregnancy) This second trimester screening test is a combination of a maternal serum screening test and an ultrasound scan. The maternal serum screening test is optimally performed between 14 and 18 weeks and measures the levels of three products (triple test); estriol, free -hCG and alpha-fetoprotein or four (quadruple test) by including inhibin-A. The ultrasound scan, also called a Fetal Anomaly Scan, is ideally performed between 18 and 23 weeks of pregnancy and is used to measure the nuchal fold, assess structural development of your baby, and detect major and minor structural markers.

 A result from your second trimester screen test

determines the risk for your baby to have a birth defect, chromosomal abnormality or genetic condition, compared to your basic age related risk. If the risk is significantly greater than the age related risk then you will be offered a prenatal diagnostic test, such as an amniocentesis. The ultrasound scan can detect structural abnormalities e.g. a neural tube defect

Screening Prenatal Tests

Who

Diagnostic Prenatal Tests

Pregnancies with an increased risk for a birth All pregnant women defect or genetic condition. Often identified through prenatal screening Diagnosis of a birth defect Risk for a birth defect or genetic condition (inconclusive) (mostly conclusive) Maternal serum screen (9 13.6 weeks) Chorionic villus

Result

Ultrasound examination sampling or CVS (11 to 14 First Trimester Tests (9 (10.5 14 weeks) measure weeks) detects specific to 14 weeks gestation) chromosomal the nuchal translucency, abnormalities or genetic detect nasal bone and conditions assess structural development (heart, brain)

Maternal serum screen or triple screen (14 to 18 weeks) Ultrasound or Fetal Anomaly scan (18 to 23 weeks) measure nuchal fold, assess development, detect major structural abnormalities and identify markers associated with genetic conditions.

Second Trimester (16 to 23 weeks gestation)

Amniocentesis (16 to 20 weeks) detects specific chromosomal abnormalities or genetic conditions

Third Trimester Ultrasound (from 24 (very limited) weeks)

Cordocentesis (18 weeks or later) detects specific chromosomal abnormalities or genetic conditions

TYPES OF PRENATAL TESTS

1.

NON-INVASIVE TESTS
Ultrasound scan(ultrasonography or sonar)

Maternal serum screening 2. INVASIVE PRENATAL TESTS Chorionic villus sampling (cvs) Amniocentesis

RECURRENT PREGNANCY LOSS

BIBLIOGRAPHY
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Betty.R.Sweet, Mayers midwifery : Text book of midwifery,2000, Tindal publishers, 12th Edition, Pp 208 239 Lowdermilk, Perry, Maternal and Womens Health Care, 1997, 6th Edition, Mosby Publishers, Missouri Fraser and Cooper, Myles Text Book of Midwifery, 2009, 15th Edition, Churchill- Livingstone Publishers, London, Pp 263 289 D.C.Dutta, Text Book of Obstetrics, 2004, 6th Edition, New Central Publishers, Kolkotha, Pp 95 113 Kamini Rao, Text Book of Midwifery and Obstetrics for Nurses, 2011, 1st edition, Elsevier Publishers, Kundli, Pp 95 120 www.everychildmatters.gov