ANC is very important sector of government health services

1. Antenatal Care
Devender Kumar
Maulana Azad Medical College

2. Objectives to achieve
1. History
2. Examination
3. Routine investigations
4. Risk assessment – at first visit, warning signs on
subsequent visits
5. Treatment (routine like Fe, folate & calcium and
special)
6. Number of visits and steps or “must do” on each
visit
● When to come for next visit / refer / advices

3. INTRODUCTION
❖The systematic supervision of Pregnant women
and fetus to ascertain well being of both and
healthy outcome of pregnancy
● To reduce maternal mortality to less than 100 per
100000 births
● To avoid or minimize maternal morbidity
● To reduce the perinatal morbidity & mortality

4. MATERNAL MORTALITY MAJOR
CAUSES
● Hemorrhages - Antepartum and Postpartum
● Hypertension during pregnancy
● Anemia
● Obstructed labor
● Puerperal sepsis

5. Maternal mortality reasons
Direct medical
causes
Indirect
medical
causes
Social
determinants
Health
system-related
factors
• Haemorrhage
• Sepsis
• Unsafe abortions
• Hypertensive disorders
• Obstructed labour
• Anaemia
• Malaria
• Marriage &
childbirth at young
age
• Less spacing
between births
• Low literacy level
among women
• Delay to seek
care
• Delay in reaching
the appropriate
health facility
• Delay in receiving
quality care in an
institution.
.

6. Purpose of ANC
● Diagnose and confirm normal pregnancy
● Diagnose associated medical or any other disorders
and plan its treatment
● Diagnose pregnancy related disorders like GDM, Gest
hypertension, Placental abnormalities
● To perform basic investigations
● Supplement iron and folic acid
● To monitor fetal growth and detect abnormalities
earliest

7. Purpose of ANC
● Counselling of couple regarding contraception and
future pregnancies
● Immunization of the mother and inform about
immunization schedule
● Significance of breast feeding
● Planning of place / mode of delivery
● Detect the cases which require referral to tertiary
level

8. HISTORY OF PRESENT PREGNANCY
● Find out the LMP and calculate EDD
● Identify any current or past medical/surgical or obstetric condition(s)
that may complicate the present pregnancy as below-
➢ High blood pressure (hypertension)
➢ Diabetes
➢ Breathlessness on exertion
➢ Palpitations (heart disease)
➢ Chronic cough, blood in the sputum, prolonged fever (tuberculosis)
➢ Renal disease
➢ Convulsions (epilepsy)
➢ Attacks of breathlessness or asthma
➢ Jaundice
➢ Malaria
➢ Other illnesses, e.g. Reproductive Tract Infections, HIV/AIDS

9. CALCULATION OF EDD
● Normal pregnancy average duration is counting from first day of last
menstrual period is about 280 days and 10 lunar months or 40 weeks.
● Ovulation delivery interval is 267 days (as ovulation occurs on 13th or 14th
day in 28 days cycle.
● If regular Cycles-The EDD is calculated by counting back 3 months and
adding 7 days or by counting forward 9 months and 7 days.(NAEGELE’S
rule).
● Cycles > 28 – 30 days -Add the extra number of days to arrive at EDD
● Cycles < 28 days- Subtract the number of days from the EDD.

10. DETAILED PAST OBSTETRIC HISTORY
● The number of previous pregnancies
● Confirm whether live births, stillbirth, abortion or any child who died.
● Ascertain the date and outcome of each event, (birth weight, if known).
● It is especially important to know about the last pregnancy.
● Find out if there was any adverse perinatal (period between 7 days before birth and 28
days after birth) outcome.
● Identify whether there were complications during previous pregnancy that may have a
bearing on the present one.
● Any obstetric complications - Recurrent early abortion, Post-abortion complications,
Hypertension, Pre-eclampsia or eclampsia, Ante-Partum Hemorrhage (APH),Breech or
transverse presentation, Obstructed labour, including dystocia ,Perineal injuries/tears,
Excessive bleeding after delivery, Puerperal sepsis.
● Ascertain mode of delivery-Simple vaginal delivery or obstetrical operations (caesarean
sections/ instrumental delivery/vaginal or breech delivery/manual removal of the
placenta).
● Any history of blood transfusions.

11. FAMILY HISTORY
Family history of following is important
● Hypertension,
● Diabetes
● Tuberculosis
● Thalassemia
● Twins
● Birth of malformed baby

12. PERSONAL HISTORY
● History of drug intake or allergies
● Any treatment or drugs for infertility(as a higher
chance of having twins or multiple pregnancies)
● History of intake of habit-forming or harmful
substances -chewing or smoking tobacco , alcohol,
substance abuse.

13. ANTENATAL VISIT FREQUENCY
● I visit –as soon as the pregnancy is suspected i.e.
in first three months
● Till 28 weeks- 4 weekly
● 28-36 weeks - 2 weekly
● >36 weeks - weekly
Visits may vary if any high risk factor is present

14. MINIMUM DESIRABLE VISITS
● I visit –as soon as the pregnancy is suspected i.e. in first
three months
● II visit - Around 26 wks
● III visit - 32 wks
● IV visit - 36 wks

15. FIRST VISIT
● CONFIRM THE PREGNANCY -simplest way to
confirm pregnancy in the first trimester is history &
clinical examination
● Pregnancy test kits- ‘Nischay’ have also been provided
to Accredited Social Health Activists (ASHAs) for use
during their community visits.
● Ensure that the kits are available to them and they
report positive results to you.

16. Examination
● General Examination
● Temperature, Pallor, Icterus, Edema, Height
● Thyroid, Breast
● Pulse , Blood pressure
● Systemic Examination
● Respiratory system
● Cardiovascular system
● Obstetric Examination

17. Obstetrics Examination
●Inspection
●Palpation
●Percussion
●Ausculatation
●Genital Examination

18. ABDOMINAL EXAMINATION
● Abdominal examination helps in following up fetal growth
● Fundal height- If any disparity in fundal height –refer
Height of the uterus more than period of amenorrhea
➢ Wrong date of LMP
➢ Full bladder
➢ Multiple pregnancy/large baby
➢ Polyhydramnios
➢ Hydrocephalus
➢ Hydatidiform mole
Height of the uterus less than period of amenorrhea
➢ Wrong date of LMP
➢ IUGR
➢ Missed abortion
➢ Intrauterine Death (IUD)
➢ Transverse lie

19. ● Fetal lie and Presentation-
➢ If lie Longitudinal with cephalic presentation –no intervention required
➢ Other Longitudinal lie- confirmed by p/v examination-breech,brow,face
➢ If Breech, Transverse,Oblique- Before 34 wks-no intervention
- After 34 wks –Refer as may need LSCS
➢ OTHERWISE - If left undiagnosed- can lead to obstructed labour, Rupture of uterus
and even Death of mother
➢ Multiple fetal parts felt/large uterus –suspect multiple pregnancy
● Fetal Heart Sounds(FHS)- heard after 26 wks
➢ NORMAL—120-160/min beats
➢ Fetal bradycardia - <120/min -refer
➢ Fetal Tachycardia - >160/min- refer
➢ Irregular fetal heart- refer
Foetal movements (‘quickening’, begin at around 18–22 weeks )
➢ Felt earlier in a multigravida and later in a primigravida
➢ Decreased/Absent movements-an indication of foetal distress.Refer to FRU

20. PER VAGINUM EXAMINATION
P/V EXAM
● I Trimester-
➢ To diagnose pregnacy (generally UPT done for very early pregnancy now-a-days)
➢ For cervical incompetence if previous history suggestive
➢ To rule out any adenexal masses or ectopic pregnancy if indicated’
● II trimester
➢ Generally not done
➢ For cervical incompetence
● III Trimester-
➢ Pelvic assessment
➢ Diagnose labour
PELVIC ASSESSMENT- to be discussed in section dealing with labour
management

21. LABORATORY INVESTIGATIONS
● Hemoglobin estimation
● Blood group, including Rh factor
● VDRL/RPR
● HBsAg
● HIV testing
● Blood sugar testing
● Urine-Albumin & Sugar
● Thalessemia screening(Nestroff test) if available is
desirable

22. INTERVENTIONS
● If lady reports in first trimester- start Folic Acid-5 mg/day
● IFA supplementation-Prophylactic dose: All pregnant women need
to be given one tablet of IFA (100 mg elemental iron and 0.5 mg folic
acid) every day for at least 100 days, starting at 14–16 weeks of
gestation.
● Calcium carbonate Tab-
● Dietary -Increase dietary intake of iron-rich foods: green leafy
vegetables, whole pulses, jaggery, meat, poultry and fish; high protein
diet- black gram, groundnuts, ragi, whole grains, milk, eggs, meat and
nuts,
● Administration of TT injection-GOI recommendation-The first
dose of TT should be administered as soon as possible, preferably
when the woman registers for ANC. (Ideally not to be given in the first
trimester)

23. WHEN TO REFER THE CASES-
Symptoms which indicate that a complication may
arise---
● Fever
● Vaginal discharge
● Easy fatiquability , Palpitation,& breathlessness at
rest.
● Generalized swelling of the body, puffiness of face
● Vaginal bleeding
● Decrease or absent foetal movements
● Leaking of watery fluid per vaginum
● Decrease in urinary output

24. DANGER SIGNS IN ANC
● Malpresentation
● Multiple pregnancy
● Any bleeding P/V during pregnancy (a pad is soaked in less than 5 minutes)
● Haemoglobin 7– 8g% even after consuming IFA tablets for 30 days
● Haemoglobin <7 g%
● Breathlessness at rest or Fast or difficult breathing
● Excessive vomiting, unable to take anything orally
● High BP (>140/90 mmHg) with proteins in the urine
● Severe headache with blurred vision or epigastric pain (With high BP or even without
high BP)
● Convulsions or loss of consciousness
● Reduced urinary output with high BP
● Decreased or absent fetal movements
● FHR >160/minute or <120/minute or irregular
● Continuous severe abdominal pain
● Premature rupture of membranes (PROM) before 37 weeks
● Temperature more than 38°C , with or without abdominal pain
● Foul smelling discharge before delivery/abortion
● Ruptured membranes for more than 18 hours

25. Historical perspective - ANC
●National Family Planning Programme 1952
●Family Welfare Programme 1977
●National Child Survival And Safe Motherhood Programme
1992
●Reproductive and Child Health Programme
●Phase I - 1997
●Phase II - 2005
●RMNCH+A approach – Reproductive Maternal Newborn
Child + Adolescent Health(12th Plan)

26. Paradigm shift
Item Pervious approach New approach
Goal Two child norm Enable clients to meet goals
Approach Centralized approach Decentralised, client driven
Service Family planning Full range of MCH care
Quality Not cared High Quality
Attitude to client Motivate persuade Listen, assess, inform, advice
Performance
monitoring
Targets Quality, client satisfaction, coverage
measures
Accountability To bureaucracy To client & community

27. National Programs
● Pradhan Mantri Surakshit Matritva Abhiyan
(PMSMA)
● envisages to improve the quality and coverage of
Antenatal Care (ANC),
● Diagnostics and Counselling services as part of the
Reproductive Maternal Neonatal Child and Adolescent
Health (RMNCH+A) Strategy

31. MAA
●National Breastfeeding Promotion Programme— MAA (mothers’
absolute affection) to ensure adequate awareness is generated among
masses, especially mothers, on the benefits of breastfeeding.
●Around 20% newborn deaths and 13% under-five deaths can be
prevented by early initiation of breastfeeding
●Besides it can also prevent child deaths associated with diarrhoea and
pneumonia
●The goal of the Programme is to enhance optimal
breastfeeding practices, which includes
initiation of breastfeeding within an hour of birth,
exclusive breastfeeding for the first six months, and
continued breastfeeding for at least two years.

32. KEY MESSAGES
● Register every pregnancy within 12 weeks.
● Ensure four antenatal visits to monitor the progress of pregnancy. This includes the
registration and 1st ANC in the first trimester.
● Give every pregnant woman Tetanus Toxoid (TT) injections and Iron Folic Acid (IFA)
supplementation
● Test for Blood group, Hb,Urine-A/S ,BSR, HIV, VDRL, HBsAg at earliest opportunity
● Test the blood for hemoglobin, urine for sugar and protein at EVERY VISIT.
● Record blood pressure and weight at EVERY VISIT.
● Advise and encourage the woman to opt for institutional delivery.
● Maintain proper records for better case management and follow up.
● Do not give a pregnant woman any medication during the first trimester unless
advised by a physician.
● Identify all high risk at earliest and plan management