ANC

(ANTENATAL
CARE)

Department of Community Medicine and Public Health

Outline
 Definition of antenatal care
 Objectives of antenatal care
 Basics of antenatal care
 Case studies with discussion
Antenatal care (ANC)
It is defined as the care
provided by skilled
health-care
professionals to
pregnant women and
pregnant adolescent
girls in order to ensure
the best health
conditions for both the
mother and baby during
pregnancy.
Objectives
1. To promote, protect and maintain the health of
the mother during pregnancy.
2. To detect “high-risk” cases and give them special
attention.
3. To foresee complications and prevent them.
4. To remove anxiety and dread associated with
delivery.
5. To reduce maternal and infant mortality and
morbidity
Objectives
6. To teach the mother elements of child care,
nutrition, personal hygiene and environmental
sanitation.
7. To sensitize the mother to the need of family
planning, including advice to cases seeking medical
termination of pregnancy
8. To attend to the under-fives accompanying the
mother.
9. To promote institutional deliveries.
 Estimation of number of pregnancies
 Calculating the expected number of pregnancy helps the ANM to
judge her ANC registration and track down the missing ones.
 It also helps her to judge her stalk of supplies required to provide
routine ANC.

Expected no. of live Birth rate x Population

births per year (Y) = (per 1000 population) of the area
1000

As some pregnancies may not result in a live birth, the expected number of
live births would be an under-estimation of the total number of
pregnancies. Hence a correction factor of 10% is added to the figure
obtained.

Total number of expected pregnancies (Z) = Y + 10% of Y

Example
 BR = 4.5
 Population = 5000

 Expected no. of live births per year (Y) = ?

 Total no. of expected pregnancies (Z) = ?

Example
 BR = 4.5
 Population = 5000

 Expected no. of live births per year (Y) = 4.5 x 5000

1000
 Y = 22.50
 10% of Y = 2.25

 Total no. of expected pregnancies (Z) = 22.50 + 2.25

Z = 24.75
 History taking

Laboratory Antenatal Physical

investigations check-up examination

Abdominal
examination
History taking

 Confirmation of pregnancy (1st visit only).

 Identification of complications.
 Current medical/surgical/obstetric conditions that may
have an effect of present pregnancy.
 Record LMP and calculate the EDD by adding 9 months
and 7 days to the LMP.
 Record symptoms indicating complications like fever,
vomiting, etc.
 History of any current systemic illness.
 History of drug allergies and habit-forming drugs
Physical examination
 Pallor
 Pulse rate
 Respiratory rate
 Oedema
 Blood pressure Pallor +ve
 Weight
 Breast examination

Pallor -ve
 Abdominal examination
 Measurement of fundal
height
 Foetal heart sounds
 Foetal movements
 Foetal parts
 Multiple pregnancy
 Foetal lie and
presentation
 Inspection of abdominal
scar
 Laboratory investigations

At sub-centre At PHC/CHC
• Pregnancy detection • Blood group
test • VDRL
• Haemoglobin • HIV testing
examination • Blood sugar testing
• Urine test for • HBsAg for hepatitis B
presence of albumin infection
and sugar
Prenatal advice

Personal
Diet
Hygiene

Warning
Child care
signs
Tetanus
 0.5 ml i.m TD
 1st dose at 16-20 weeks
 2nd dose at 20-24
weeks
 Minimum 4 weeks gap
between the 2 doses
 One booster dose for
woman already
immunized in the last 3
years.
Case 1

Lata a 32 year old mother has 3 daughters aged 5, 2 and 1 years .Her
husband wants to have a male child. She was again 8 months
pregnant. She was feeling tired and presented with giddiness and
breathlessness on exertion and has not taken any antenatal advice
previously. On examination, she was found to have pallor. The ASHA
advised her to visit PHC .But she never visited PHC or received any
ANC. Her condition deteriorated. Her husband consulted the ASHA
again who told him to take her to CHC. But he never took her to CHC.
Ultimately Lata delivered a male baby at home.
Case 1

Q.1. What was the probable diagnosis?

Case 1

Q.1. What was the probable diagnosis?

Ans.

Anemia during pregnancy.

Anaemia during pregnancy
 Hb level < 11 gm%
 Symptoms include
weakness, exhaustion,
giddiness etc.
 Clinically examined by
looking at the lower
palpebral conjunctiva
for pallor
Case 1
Q.2. What were the factors responsible for her condition?
Case 1
Q.2. What were the factors responsible for her condition?
Ans.
1. Multiple pregnancies prior to the present one
2. Lack of proper spacing between two pregnancies.
3. No antenatal check-ups previously.
4. No prophylactic treatment to prevent anaemia.
5. Did not go to the PHC on the advice of the ASHA.
6. Did not go to the CHC on advice when her condition
deteriorated.
Case 1

Q.3. Which symptoms were suggestive of anaemia in Lata?

Case 1

Q.3. Which symptoms were suggestive of anaemia in Lata?

Ans.

She complained of weakness and breathlessness on exertion.

Other symptoms of anemia during pregnancy include:

- giddiness

- palpitation

- indigestion
Case 1

Q.4. What are the various grades of anaemia during pregnancy?

Case 1

Q.4. What are the various grades of anaemia during pregnancy?

Ans.
Normal ≥11.0 gm%

Mild Anaemia 10.0 – 10.9 gm%

Moderate Anaemia 7.0 – 9.9 gm%

Severe Anaemia 4.0 – 6.9 gm%

Very severe Anaemia <4.0 gm%

Case 1

Q.5. What is the total iron demand during pregnancy?

 Case 1

Q.5. What is the total iron demand during pregnancy?

Ans.
Total 1000 mg iron is required during a single pregnancy.

400 mg
300 mg 200 mg
Expansion of
Foetus + placenta Normal blood loss
plasma
Case 1

Q.6. How many ANC visits should Lata have had in order to
detect anemia early in the pregnancy?
Case 1

Q.6. How many ANC visits should Lata have had in order to
detect anemia early in the pregnancy?

Ans.

A minimum of 4 ANC visits are advised.

Antenatal visits
 Ideally;  Minimum;
Once a month in first 1st visit within 12 weeks
7 months

2nd visit between 14 and 26 weeks

Twice a month in the next 1
month
3rd visit between 28 and 34 weeks

Once a week thereafter 4th visit between 36 weeks and

term
Case 1
Q.7. What prophylactic treatment could be given to prevent
anemia during pregnancy?
Case 1
Q.7. What prophylactic treatment could be given to prevent
anemia during pregnancy?
Ans.
Tab. IFA 0D
(Iron Folic Acid)

60mg 0.5 mg For 100 days

during
Elemental iron Folic acid pregnancy
Case 1
Q.8. What dietary advice could be given to Lata to prevent this
condition?
Case 1
Q.8. What dietary advice could be given to Lata to prevent this
condition?
Ans.
 Improve her general diet.

 Eat iron rich food.

Dietary advice
 A normal healthy woman
gains about 9-11 Kg of
weight during pregnancy.
 Additional requirement
of 350 Kcal energy per
day.
 Total protein
requirement during
pregnancy is 78 gm per
day.
 One additional meal in
the day is advised.
 Iron rich food

* Vitamin C in citrus fruits enhances the absorption of Iron in the

diet. While milk and milk products obstruct the absorption of
dietary iron.
Case 1
Q.9. Could this condition have been prevented? If yes, what
interventions could have saved this condition?
Case 1
Q.9. Could this condition have been prevented? If yes, what
interventions could have saved this condition?
Ans.
Yes, this condition could have been prevented by the following
interventions:
1. Regular ANC visits for early identification of complications.
2. Intake of prophylactic Tab. IFA daily during pregnancy
3. Visiting the PHC timely on advice of the ASHA.
4. Use of contraception post-delivery in the earlier pregnancies
for proper spacing between two pregnancies.
Family planning
 Minimum 3 years gap
between two
pregnancies.
 If the mother has had
2 or more children she
should be motivated
for puerperal
sterilisation.
 If family is not
completed, advice for
spacing methods.
Case 1
Q.10. How would you manage the mother now?
Case 1
Q.10. How would you manage the mother now?
Ans.
 Advice her to visit the medical officer at the PHC for a proper

examination.
 Assess the level of haemoglobin and treat her accordingly.

 Advice her to have iron rich food in her diet.

Advice her for puerperal sterilisation as she has more than 2

children.
Case 2

Jhumki Devi 17 years old female had been married for 10 months. She
was brought by her mother-in-law to the sub-centre during 7th month
of her pregnancy with complaints of headache, dizziness and slight
breathlessness. The ANM gave her a DT injection and IFA tablets. She
assured Jhumki Devi and her mother-in-law that everything will be
alright if she took the tablets regularly.

Jhumki’s condition did not improve. A few days later she reported back
to ANM with complaints of blurring of vision, severe headache and
swelling on the feet. The ANM referred her to the PHC to seek the help
of the medical officer.
Case 2

The relatives lost faith in ANM and did not go to the PHC. Meanwhile Jhumki
began to have fits. The family sent for a faith healer to remove evil spirits and
to stop the fits. They put lime, shoes and other items in front of her nose.
But the fits continued. The family at this stage got worried and wanted to
take her to the hospital but could not arrange for the transport.

Jhumki was taken to the PHC on a cloth stretcher. On reaching the PHC she
was found to be unconscious and her blood pressure was 170/110mm Hg.
She had not passed urine for 12 hours. The medical officer at the PHC
referred her to the district hospital in the PHC vehicle. On way to the district
hospital Jhumki again got fits and died before she could reach the hospital.
Case 2

Q.1. What was Jhumki suffering from when she first visited the
sub-centre?
Case 2

Q.1. What was Jhumki suffering from when she first visited the
sub-centre?

Ans.
Pre-eclampsia

“It is a multi-system disorder of unknown etiology characterised

by deveopement of hypertension to the extent of 140/90 mmHg
or more with proteinuria after the 20th week of pregnancy in a
previously normotensive and non-proteinuric woman”
Case 2

Q.2. Was there a risk factor present for Jhumki Devi to develop
Pre-eclampsia?
Case 2

Q.2. Was there a risk factor present for Jhumki Devi to develop
Pre-eclampsia?

Ans. Yes, she was a young (17 yrs old) primigravida

Risk factors for • Very young or elderly

pre-eclampsia primigravida
• Family history
• Placental abnormalities
• Obesity
• Pre-existing vascular disease
Case 2

Q.3. Were there any warning signs of her condition?

Case 2

Q.3. Were there any warning signs of her condition?

Ans. Yes, she complained of:

 Headache
 Dizziness
 Breathlessness
 Blurring of vision
 Swelling of feet
 Warning signs

1. Bleeding during 2. Severe anaemia 3. High fever

pregnancy. with or without during pregnancy
breathlessness
 Warning signs

4. Convulsions or 5. Labour pain for 6. Bursting of

fits, blurring of more than 12 water bag without
vision, headache, hours labour pains
vomiting and
sudden swelling of
feet
Case 2

Q.4. What was the cause of her death?

Case 2

Q.4. What was the cause of her death?

Ans.

Eclampsia

“Pre-eclampsia when complicated with generalised tonic-

clonic convulsions (fits) or coma is called eclampsia”
Case 2

Q.5. What should the ANM have done in this case which she
failed to do?
Case 2

Q.5. What should the ANM have done in this case which she
failed to do?

Ans.

Checked her blood pressure during the first visit to rule out
pre-eclampsia.

She confused the symptoms with that of anaemia.

Case 2

Q.6. What could have been done to transport her to the PHC?
Case 2

Q.6. What could have been done to transport her to the PHC?

Ans.
 Case 2

Q.6. What could have been done to transport her to the PHC?

Ans. Called for a toll-free and free-of-cost ambulance on

“102” 0r “108”.
“102” Under JSSK specifically for transport of pregnant
ambulance women and infants to and fro from a hospital.

“108” State run free of cost call centre based ambulance

ambulance system for any medical emergencies.

Janani Decentralised district level public private

express partnership based ambulance system
Case 2

Q.7. What should the PHC Medical Officer have done before
referring the patient to the district hospital?
Case 2

Q.7. What should the PHC Medical Officer have done before
referring the patient to the district hospital?

Ans. Ensured first aid like maintaining airway, controlling fits,

reducing the BP, etc. before referring her.

Condition Treatment
Convulsions Magnesium sulphate (MgSO4)
Hypertension Labetelol
Urine retention Dopamine
Case 2

Q.5. What role could the family and the community have
played in the prevention of this death?
Case 2

Q.5. What role could the family and the community have
played in the prevention of this death?

Ans.
1. Regular ANC visits for early detection and treatment of pre-
eclampsia.
2. Timely visit to the PHC instead of sending for a faith healer.
3. Better planning and preparedness.
4. Correct age of marriage.
5. Avoid pregnancy immediately after marriage.
References
 Park’s Textbook of Preventive and Social Medicine.
K Park. 2019.
 Textbook of Obstetrics. DC Dutta. 7th ed.
 Mother and child protection card. www.nhm.gov.in
 Anaemia. www.who.int
Thank you!