ANTENATAL CARE

“Childbirth is more admirable than conquest,

More amazing than self defense
And as courageous as either one”

- Gloria Steinem,1981
PREGNANCY

The period from conception till

birth during which women
carries fetus in her uterus
DEFINITION
Systematic supervision
which includes
examination and advices
of a woman during
pregnancy
Pre-Pregnancy health check up
Couple Planning for pregnancy
• Routine lab tests
• Health education for wife
• Health education for husband
Focus of visit
 Sex education to couple
 Tab. Iron Folic acid
 Deworming
 Stop Vices
 Come for Antenatal care when two
menses are missed.
Goals of antenatal care
 A pregnancy with minimum of mental
and physical discomfort and maximum
of gratification
 A birth under best circumstances
possible
 A normal and well baby
 Establishment of good health habits
 Smooth guided postpartum adjustment
Aims of antenatal care
 Monitor progress of pregnancy
 Support maternal health
 Monitor fetal development
 Evaluate physical, psychological,
sociological effects of pregnancy on
woman and her family.
5 GOLDEN STEPS!
 Find out what is important for woman and
her family
 Use information from clinical examination
 Seek and assess evidence to inform
decisions
 Talking it through
 Reflecting on outcomes, feelings and
consequences.
Benefits of Antenatal care for
Mother
 Health promotion
 Prevention of high risk
pregnancy
 Early screening and
referral
 Immunization against
T.T.
 Maternal safety in
childbirth
 Maternal Health
education
Benefits of Antenatal care for fetus
 Fetal health promotion
 Fetal well being assessed
 Fetal malformation
minimized
 Birth asphyxia minimized
 Protects newborn against
tetanus
 High risk fetus identified
 Safety of fetus enhanced
Demerits of Antenatal care
 Routine antenatal care can miss
abnormality
 Benefits only when woman is properly
educated
 Procedure is time consuming and
takes a lot of time from both health
care provider and women.
Plan for Antenatal Care
 Woman misses two menses
 She reports to
Village –MCH provider, Trained
dai,ANM,PHC Doctor
Town-General Practitioner ,Maternity
home
Plan for Antenatal Care
 They confirm pregnancy
 Regular MCH care
 Screening of high risk pregnancy and
referral to tertiary or secondary level
care.
DR.D.S.DAWN’S RULE OF TEN
 Ten times antenatal check up
 Ten kg maternal weight gain
 Ten hours rest and sleep
 Ten gm% of Hb
 By ten months T.T immunisation
DR.D.S.DAWN’S RULE OF TEN
 Ten to twelve hours of normal labor.
 Ten apgar score
 By ten weeks following delivery-
Nirodh, Cu-T or oral pill.
 Ten months breast feeding with
weaning
 By ten months infant immunization.
Objectives
 education and information
 screening
 early identification of complications
 treatment of complications
PRINCIPLES OF ASSESSMENT IN
FIRST TRIMESTER
 Child bearing is normal!!! Though not
comfortable developmental stage for
the family
 Focus on client and significant others as
a whole.
 Enable couples to make informed
decisions regarding their care.
 Assessment techniques may carry risks.
 Support in a nonjudgmental manner.
ASSESMENT FOCUS DURING FIRST
PRENATAL VISIT
 Existence of pregnancy
 Past and present maternal health
status
 Risk factors for child bearing and
early parenting
 Well being of embryo or fetus
 Clients educational needs
FOCUS ON RETURN VISITS

 Updated health history, physical

examination and lab tests.
 Progress of pregnancy
Patterns of routine antenatal care for low-risk
pregnancy

 assess the effects of antenatal care programmes for low-

risk women
 three trials, all conducted in developed countries,
evaluating the type of care provider
 no difference for several outcome variables including
caesarean section, anaemia, urinary tract infections and
postpartum haemorrhage
 there is a trend to lower rate of preterm delivery,
antepartum haemorrhage, lower perinatal mortality
 lack of recognition of fetal malpresentations tended to be
higher in this group
Shared antenatal care between
Family Health Services and
Hospital(Consultant) Services for
Low Risk Women
•decrease in workload to hospital clinics
•diagnosis of IUGR, malpresentation,
pregnancy induced hypertension
improved
•number of NST, hospital admission,
duration of stay reduced
GTPAL
 GRAVIDITY
 TERM BIRTHS
 PREMATURE BIRTHS
 ABORTIONS
 LIVING CHILDREN
Presumptive signs

 Increased basal temperature

 Linea nigra
 Cholasma
 Striae
 Enlargement of breast tissue
 Colostrum secretion
Assesment of physiological changes
 Integumentary changes-darkening of
pigment of nipple,areola,vulva,linea nigra

 Cardiovascular changes-increase in
resting pulse, decrease in B.P.
Assesment of physiological changes
 Respiratory changes-increased tidal
volume,epistaxis
 Hematological changes-increase in
W.B.C.
 Gi changes-Nausea and vomitting.
 Urinary changes
 Reproductive changes
Assesment of pregnancy
 Estimating EDD
 nagele’s rule
 fundal height measurement
 sonogram
Estimation of risk status
 Preterm labor
 Polyhydraminos
 IUGR
 Oligohydraminos
 Post term Pregnancy
 Chromosomal Abnormalities
PRENATAL EXAMINATION
 GENERAL APPEARANCE
 HEAD AND NECK
 CHESTS / BREASTS
 EXTREMITIES
 ABDOMEN
 WEIGHT
 BLOOD PRESSURE
 URINANALYSIS
BLOOD TESTS IN PREGNANCY
 ABO AND RH FACTOR
 FULL BLOOD COUNT
 VDRL
 HIV ANTIBODIES
 INVESTIGATION FOR BLOOD
DISORDERS
 SCREENING TESTS FOR
TOXOPLASMOSIS
Identifying psychosocial risk factors
 Patterns of self perception change
 Cognitive /perceptual aspects
 Behavioral aspects
 Coping stress tolerance
 Role and relationships
What should be reported in
USG
 number of sacs and mean gestation sac diameter
 regularity and outline of the sac
 presence of any haematoma
 presence of a yolk sac
 presence of a fetal pole
 CRL
 presence/absence of fetal heart movement
 extrauterine observations should include the
appearance of the ovaries, the presence of any
ovarian cyst or any findings suggestive of an ectopic
pregnancy
The first visit
Routine vaginal examination at
antenatal booking
 reasonable to reserve VE at the
booking antenatal clinic for women
 with a clinical indication, such as pain,
bleeding or vaginitis
 who have not had a satisfactory smear
within the past 3 years
The first visit
Pitfalls associated with cervical
screening during pregnancy
 sampling difficulty because of
enlargement of cervix, increased
mucous secretion and increased
difficulty in viewing the cervix
 cytological diagnostic pitfalls unique
to this population
FACILITIES
 PRIVATE EXAMINING ROOM
 ADEQUATE VENTILATION
 HANDWASHING FACILITIES
 TOILET FACILITIES
 WRITING SURFACES FOR CHARTING
 EXAMINATION TABLE FOR PELVIC
EXAMINATION
 MOVABLE LIGHT IN WORKING ORDER
EQUIPMENTS

 CLEAN BARRIER EXAMINING TABLE

 GLOVES
 SPATULA
 LUBRICANT
 CULTURE TUBES,SLIDES
 STETHESCOPES
 SPHYGMOMANOMETER
 FETOSCOPE
 DOPPLER
 HANDMIRROR
Nursing care of family in first
trimester
 Preparing client and family for
prenatal care
 Orientation to prenatal care
 Persons who will provide care
 Expectations during each visit
 Scheduling of prenatal visits
Nursing care of family in first
trimester
 Developing a care plan
 Supporting the client
 Recognizing cultural influences
 Facilitating informed decision making
 Promoting psychological adaptation to
early pregnancy
 Facilitating family attachment
Meeting early pregnancy
educational needs
 Normal physiologic changes in first
trimester
 Normal fetal growth and development
 Client safety
 Hazards during pregnancy
 Warning danger signs of pregnancy
Meeting early pregnancy
educational needs
 Nutrition and weight management
 Dental health
 Sexuality
 Normal psychologic reactions
 Self care practises to promote
wellness
Assisting client to cope with first
trimester discomforts
 Nausea and vomitting
 Ptyalism
 Altered taste
 Bleeding gums
 Breast tenderness
Assisting client to cope with first
trimester discomforts
 Urinary frequency
 Nasal stufiness and epistaxis
 Increased vaginal secretions
 Fatigue
NURSING DIAGNOSIS IN FIRST
TRIMESTER
 PHYSIOLOGIC
 Fatigue r/t demands of pregnancy
during first trimester
 Nutrition altered potential for
nutritional deprivation during first
trimester
 Potential asset r/t normal physical
changes in first trimester
Psychosocial

 Anxiety r/t initial encounter with

health care systems, financial
pressures
 Knowledge deficit r/t lack of
understanding of first trimester
changes,dicomforts and extent of
services avialable
Pregnancy milestones in second
trimester
 Quickening
 Placenta in anterior part of uterus
 Fetal heart tones
 Fundal height and estimated
gestations.
Assessment of change in second
trimester
 Assessment of maternal adaptations
to pregnancy
 Updating the health history
 Physiologic assessment
Prenatal diagnosis and
ultrasonogram
Referral to Prenatal Diagnosis and
Counselling Department
 advanced maternal age
 hereditary disease
 maternal exposure to teratogen
 previous abnormal children
 abnormal screening test
 suspected fetal abnormality
Prenatal diagnosis and
ultrasonogram
Possible merits of USG
 confirmation of the term date if
performed before 24 weeks
 assessment of term date when
history is unreliable
 detection of malformation
 detection of multiple pregnancy
Selected clinical findings in second
trimester
 Integumentary: darkened breasts
,areola,chloasma,strech marks, flushing.
 CVS:increase in HR,Decrease in BP,Supine
hypotension, edema on legs
 Respiratory: Dyspnea on exertion
 GI: constipation,pyrosis,hemorrhoids.
 Musculoskeletal:Backache,Pregnancy
waddle.
Selected clinical findings in second
trimester
 Urinary: trace glycosuria,trace
protienuria.
 Reproductive: Progressive
enlargement of uterus, Braxton Hicks
contraction, Breast fullness.
 Neurologic: Alert, Appropriate.
Psychosocial assessment
 Psychologic factors
 Socioeconomic, cultural and
enviournmental factors
 Adaptations to pregnancy
 Coping patterns
 Network supports
Risk assessment
 Biochemical screening tools
• Urinalysis-protein,
glucose,ketones,UTI
• Blood studies-24th to 28th week for
gestational diabetes.
Assessment of fetal well being
 Low risk assessment
• fundal height
• FHS
• Uterine activity
• Quickening
Assessment of fetal well being
 High Risk assessment
• Diagnostic USG
• Maternal screening for AFP levels
• Amniocentesis, Percutaneous
umbilical cord sampling
Helping clients to cope with second
trimester discomforts
 Heart burn
 Constipation
 Hemorrhoids
 Faintness
 Round ligament pain
 Cosmetic concerns
 Client safety
Second trimester
 Physiologic
 Potential for constipation r/t second
trimester changes in GI system
 Potential for altered tissue perfusion
r/t decreased absorption during
second trimester.
psychosocial
 Potential altered role performance r/t
lack of maternal role model
 Potential for decisional conflicts r/t
career conflicts
Assessment of change in third
trimester
 Maternal adaptations to pregnancy
 Updating health history
 Assessment of physiologic status
every 4 wks for first 28 wks,
every 2 wks to 3 wks until 36 wks
gestation,
every week from 36 wks till labor
Physical parameters during third
trimester
 Vital signs
 Uterine growth
 Uterine characteristics
 Fetal presentations
 FHS
 Maternal weight
 Blood study
 Urinalysis
 Serum glucose
Biochemical screening techniques
 Urinalysis
 Blood studies
• Hb & Hematocrit
• Ab screening
• glucose screening
• psychosocial assessment
Assessment of plans for birth and
early parenting
 Birth plan remains feasible
 Selected birthing environment
 Educational preparation for labour
and birth
 Prepared for postpartum changes
 Identify community measures
Assessment of fetal wellbeing
 Fundal height
 Johnson criteria for fetal weight
estimation:
 Fetal movement record
 Electronic fetal monitoring-NST,CST
 Fetal biophysical profile
 Leopold's maneuver’s
Nursing diagnosis in third trimester
 Potential sleep pattern disturbance
related to physical activity, shortness
of breath, pressure on bladder
 Impaired physical mobility related to
relaxation of joints and muscles and
altered balance
 Anxiety
Nursing care of family during third
trimester
 Preparing client and family for
continued care
 Preparing client and family for intra
partum care
 Updating database for diagnosis
development
 Updating strategies identified in care
plan
 Continuing to support the client
Nursing care of family during third
trimester
 Assisting client to finalize birth plans
 Discussing alternatives in event of
high risk –intrapartum,postpartum
and neonatal complications
 Promoting psychological adaptations
 Fostering family attachment
 Meeting educational needs.
Assisting client to cope with third
trimester discomforts
 Edema of feet,ankles,lower legs
 Urinary frequency
 Nocturia
 Insomnia
 Varicose veins
Assisting client to cope with third
trimester discomforts
 Lower backache
 Leg cramps
 Shortness of breath
 Carpal tunnel syndrome
ANTENATAL ADVICES
 DIET: light, nutritious, easily digestible
and rich in protein, mineral and
vitamin
 Dietary advice should be given with
due consideration of socio-economic
status, food habit and taste of
individual
 Instruction should be reasonable and
feasible(realistic)
ANTENATAL ADVICES
 SUPPLEMENTARY NUTRITIONAL THERAPY
 Supplementary iron therapy is needed for all
pregnant women 20th weeks onward
 For the mother whose Hb level is above 10gm
% one tablet of fersolate (60 mg elemental
iron) is enough
 Dose should be increased with lower level of
HB
 Calcium supplementation is also needed with
Iron
ANTENATAL ADVICES
 Antenatal hygiene
 Rest and sleep: 8 hrs in night and 2 hrs in
night
 Bowel habits, bathing, clothing shoes and
belt
 Dental care
 Care of breast
 Travel
 Smoking and alcohol should be avoided
ANTENATAL ADVICES
 IMMUNIZATION

2 doses of 0.5 ml Tetanus Toxoid is

given IM at 4-6 weeks
First dose should be given at 16 – 24
weeks
General advice
Exercise
 30 minutes or more of moderate
exercise a day should occur on most,
if not all, days of the week
 pregnant women also can adopt this
recommendation
General advice
Exercise
 avoid motionless standing
 avoid sports with high potential for
contact, risk of falling, abdominal
trauma, scuba diving
 avoid supine position after first
trimester
General advice
Work
 most jobs cause no increased hazard
to the mother or baby
 should be warned that if any
complications arise she must be able
to leave work easily
 specific hazards – chemical, physical,
biological, others
(Chamberlain & Morgan 2002 in ABC of Antenatal Care)
Preparation for breast feeding
 Breast shields
 Nipple streching
DANGER SIGNS OF
PREGNANCY
SIGNS OF PREGNANCY INDUCED
HYPERTENSION
 Persistant severe headache
 Blurred vision or visual disturbances
 Sudden swelling of hands and feet
 Sudden weight gain
Signs of problem with placenta
 Bleeding from vagina
 Abdominal pain
Signs of premature labour

 Leaking or gush of fluid from vagina

 Sudden increase in mucus discharge
 5 or more contraction in 1 hour
 Vaginal spotting or bleeding
Danger signs
 Symptoms of urinary tract infection
 Symptoms of vaginal discharge
 Any nausea or vomitting that persists
 Any change in in fetal activity
 Any persistant pain or fever.
Examination Indicator of abnormality

Edema: Exclude anemia, preeclampsia, cardiac

disease, renal disease
Weight gain: >3 Kg/month- suspect preeclampsia
< 1 Kg/month- Suspect IUGR
Blood Pressure: > 140/90 mm of Hg after 30 minutes
of rest---PIH
Fundal Height: Lesser/greater than POG
Fetal Presentation: Non-cephalic persisting after 34
weeks
FHR: <120 or > 160/minute
Hemoglobin: < 7 gms /dl (severe anemia)
Proteinuria: + or more, suspect preeclampsia
JANANI SURAKSHA YOJNA
 ANC mother has to register at the nearst
PHC or subcentre.
 Have atleast 3 antenatal checkups.
 Deliver in nearest PHC or FRU.
 Funds are sanctioned.
 700Rs /600 Rs for normal delivery
 1400Rs for caesarean birth
 ASHA -600/200Rs.
 Use expenses for indirect cost of delivery