Dr.Rajkumar PatilAsstt.Prof.,Dept. of Community Medicine

A V Medical College,Pondicherry

Antenatal Care

Care of the woman during pregnancy

Objectives of Antenatal care

To promote,protect and maintain the health of pregnant mother

To detect and manage “high risk”cases

To remove anxiety associated with delivery

To reduce maternal and infant mortality and morbidity

To educate mother about nutrition,hygiene,child care, sanitation and family planning (including MTP)

To attend to the other children (under 5) of pregnant mother

Antenatal Visits

Ideally 13 visits 7 in first 7 months 2 in 8th month 4 in 9th month

Minimum 4 visits

I : As soon as the pregnancy is suspected

(For registration & first check-up)

II : 26 weeks

III: 32 weeks

IV : 36 weeks

(At least one visit at home by health worker)

Why early registration is required?

To assess the health status

To identify and manage high risk cases

To estimate EDD more accurately

To give the first dose of TT (after 12 weeks)

To help the woman for an early and safe abortion (MTP)

if it is required by her

To start the regular dose of folic acid during the first trimester

Antenatal services for mothers

Health history Physical examination Laboratory Examination Urine/Stool/Blood(Count)/Hb/Serological/Blood group(Rh also) Pap test(if facilities)/ Chest X-Ray and Gonorrhoea test(if needed) High risk approach IFA and necessary medications TT Immunization Health education Home visit Referral(if needed)

Maintenance of records

Antenatal CardAntenatal register

Antenatal Checkup

History

(i) to diagnose pregnancy (ii) to identify any complications during previous pregnancies (iii) to identify any medical/obstetric condition(s) that may complicate this pregnancy

Calculation of EDD

Ask for the first day of the last menstrual cycle (LMP)Ask for the date when the foetal movements were first felt(quickening)Also assess the fundal height to estimate the gestational ageAsk for any test done to confirm pregnancy EDD= LMP + 9 months + 7 days

Age of the woman

Complications when <16 years/>40 years

Order of the pregnancy

Primigravidas and multiparas are at risk

Birth interval

Ideally should be >3 years

Symptoms during the present pregnancy

Symptoms indicating discomfort

nausea and vomiting

heartburn

constipation

frequency of urination

Symptoms indicating that a complication may be arising

fever

vaginal discharge/bleeding

palpitations

breathlessness at rest

generalized swelling of the body;puffiness of the face

oliguria

decreased or absent foetal movements

Previous pregnancies/Obstetric history

number of earlier pregnancies/abortions/deliveries

number of premature birth(s)/stillbirth(s)/neonatal deaths

hypertensive disorders of pregnancy (history of convulsions)

prolonged/obstructed labour

malpresentation

APH/PPH

modes of deliveries(normal/assisted/caesarean section)

birth weight of the previous baby

any surgery on the reproductive tract

iso-immunization (Rh-ve) in the previous pregnancy

(any costly inj. given to her within 72 hours of her previous delivery)

History of any systemic illness(es)

hypertension

diabetes

heart disease

tuberculosis

renal disease

convulsions

asthma

rashes

jaundice

Family history of systemic illness

above illnesses

thalassaemia

delivery of twins or delivery of an infant with congenital malformation

History of drug intake or allergies

History of intake of habit-forming substances (tobacco,alcohol)

Physical examination

General examination

1.Weight

At the time of registration-baseline weight

Normal weight gain in pregnancy: 9-11 kg

After the first trimester: 0.5 kg weight per week (gain)

Low weight gain >>>> IUGR

Excessive weight gain>>>> pre-eclampsia/twins

2.Blood pressure

High BP (>140/90 mmHg) indicates pre-eclampsia

3.Pallor

See the lower palpebral conjunctiva,tongue,oral mucosa,palms and nails

4.Respiratory rate (RR)

RR >30 breaths/minute and pallor indicates severe anaemia

5.Generalized oedema/puffiness of the face

Indicates pre-eclampsia

6.Abdominal examination

Progress of pregnancy /foetal growth/foetal lie and presentation

Fundal height

o If the height of the uterus is more than that expected,it may be due to:

wrong date of LMP/full bladder/multiple pregnancy

polyhydramnios/hydatidiform mole/pregnancy with a pelvic tumour

o If the height of the uterus is less than that expected,it may be due to:

wrong date of LMP/IUGR/missed abortion/IUD/transverse lie

Foetal lie and presentation

Longitudinal, transverse or obliquePresenting part is the vertex/breech/face/brow

Foetal heart sound (FHS) and rate(FHR)

120-160 beats per minuteFHS is usually heard after 20-24 weeks

Multiple pregnancy

An unexpectedly large uterus Multiple foetal parts are felt on abdominal palpation

Laboratory investigations in pregnancy

Haemoglobin (Hb)

< 7 to 11 g/dl as moderate anaemia,

< 7 g/dl as severe anaemia

Blood grouping

Urine albumin

Uristix

Urine sugar

Diastix

Interventions

Folic acid supplementation: 5 mg/day, till 12 weeks

Iron folic acid (IFA) supplementation

Prophylaxis:IFA tab (100 mg elemental iron+0.5 mg folic acid)-100 days

Treatment (if 7-11 g/dl Hb): 2 tablets of IFA per day

How to take IFA tablets?

• Early in the morning on an empty stomach or with meals or at night

• Side effect:black stools,constipation(drink more water)

• Avoid tea/coffee for 30-60 min.after food as well as after tablets

TT Immunization

2 doses or booster(0.5 ml/dose,deep IM,Deltoid) one month apart after 16 wk

Inform the woman about swelling, pain & redness at the inj. site for 1-2 days

Fundal Height Foetal palpation

Risk approach in pregnancy

Use of screening tools to identify individuals who are at more risk of suffering from severe morbidity or mortality

Use of all possible resources:TBAs,Health Workers,Women’s groups

1.Age: elderly primi >30 years,elderly grand multi-paras2.Height: <140 cm3.Mal-presentations4.Threatened Abortion5.Antepartum Haemorrhage6.Preeclampsia and eclampsia7.Anaemia8.Twins,Hydramnios9.Prolonged preganancy(>42 weeks)10.Medical conditions: cardiovascular disease,kidney disease,diabetes, tuberculosis,liver disease etc.11.History of: Stillbirth/IUD/manual removal of placenta/CS/instrumental delivery

Antenatal Advice

1.Diet 300 kcal extra per day

Avoid taking tobacco/tea/coffee especially within 1 hour of a meal

Fibres should be consumed to avoid constipation

Advise on food taboos

Avoid alcohol or smoking

2.Rest Night 8 hours ,Day 2 hours (Lt side)

Avoid heavy work (especially lifting heavy weights)

Avoid the supine position

(especially in late pregnancy,if it is necessary, a small pillow under

the lower back at the level of the pelvis should be used)

2.Personal Hygiene

3.Sex:Restricted in first and last trimester

4.Drugs:thalidomide,iodide containing preparations,

corticosteroids

5.Radiation:Avoid X-rays

6.Danger/warning signs

7.Health education:Education about breast feeding,

nutrition,family planning

Danger signs•High fever with/without abd.pain,feels too weak to get out of bed

•Fast/difficult breathing

•Decreased or absent foetal movements

•Excessive vomiting (woman is unable to take food/fluids)

•Any bleeding P/V during pregnancy

•Heavy (>500 ml) vaginal bleeding during and following delivery

•Severe headache with blurred vision

•Convulsions or loss of consciousness

•Labour lasting longer than 12 hours

•Failure of the placenta to come out within 30 minutes of delivery

•Preterm labour

•Premature or prelabour rupture of membranes (PROM)

•Continuous severe abdominal pain

Specific Health Protection

1.Nutritional disorders:Anaemia and others

2.Toxemias in pregnancy

3.Tetanus

4.Syphilis:Abortion,perinatal death,congenital syphilis

5.Rubella:Abortion,congenital defects

6.Haemolytic disease(Rh):Mother Rh –ve,foetus Rh +ve

7.HIV

8.Prenatal genetic screening

Intranatal Care Objectives of Intranatal Care

1.Thorough asepsisDelivery kit(DDK)

Five "cleans" HTSSC”(Hands,Tie,Surface,Stump,Cut)

2.Delivery with minimum injury to mother and child3.Ready to deal with complications4.Care of the newborn at the time of delivery

Signs of labourBleeding/sticky discharge P/V after 22 weeks

Painful abdominal contractions every 20 min or less

The bag of waters has broken,

and she has clear fluid coming out P/V (leaking)

Monitoring of progress of labour

Partograph-

Graphic record of progress of labour & conditions of mother and foetus.

Domicilliary Care

Advantages:Familiar,No chance of nosocomial infection,mental easeDisadvantages:Less medical/nursing supervision,less rest

Danger signals during labour

Less/no pains after rupture of membraneProlapse of the cord/handMeconium stained liquorAbnormal FHRExcessive “show” or bleeding during labourCollapse during labourPlacenta not separated within 30 minutesPPHFever

Institutional Care

For all high risk cases

Rooming In

Keeping the baby’s crib by the side of the mother’s bedEase for breast feedingMother and Child relation develops better

Postnatal Care

Care of the mother and child after delivery

Objectives

To prevent complicationsTo provide care for rapid restoration of mother’s healthTo facilitate breast feedingTo provide family planning servicesTo provide basic health education

Complications in postpartum period

Infection: Genital tract(Puerperal sepsis),UTI,Mastitis Thrombo-phlebitis of legsHaemorrahge

Restoration of mother’s health

1.Postnatal checkups: Minimum 2 visits(within 2 days & 7 days) Ideally:Twice a day during first 3 days Daily till the umbilical cord drops off After 6 weeks Once a month till 6 months

2.Anaemia:Check Hb

3.Nutrition: 550 kcal extra (first 6 months), 400 kcal extra(next 6 months)

4.Postnatal exercises: Gradual resumption of normal household duties

5.Mental health:Insecurity regarding baby

6.Contraception: Lactational Amenorrhoea

Registration of birth Within 21 days

Danger signs Excessive vaginal bleeding

i.e. soaking more than 2-3 pads in 20-30 minutes after delivery

Convulsions

Fast or difficult breathing

Fever and weakness so that she cannot get out of bed

Severe abdominal pain

Postnatal checkup

History-taking Place of delivery

Person who conducted the delivery

History of danger signs in mother and children

Any problem in the child

When did the child pass urine and/stools (meconium)?

Examination Pulse, BP and temperature

Pallor

Abdominal examination

Rule out any uterine tenderness

Examine the perineum for any tear

Postnatal Care

Care of the mother and child after delivery

Objectives

To prevent complicationsTo provide care for rapid restoration of mother’s healthTo facilitate breast feedingTo provide family planning servicesTo provide basic health education

Complications in postpartum period

Infection: Genital tract(Puerperal sepsis),UTI,Mastitis Thrombo-phlebitis of legsHaemorrahge

Restoration of mother’s health

1.Postnatal checkups: Minimum 2 visits(within 2 days & 7 days) Ideally:Twice a day during first 3 days Daily till the umbilical cord drops off After 6 weeks Once a month till 6 months

2.Anaemia:Check Hb

3.Nutrition: 550 kcal extra (first 6 months), 400 kcal extra(next 6 months)

4.Postnatal exercises: Gradual resumption of normal household duties

5.Mental health:Insecurity regarding baby

6.Contraception: Lactational Amenorrhoea