This document provides information on antenatal care including definitions, objectives, components, strategies and high risk pregnancies. It begins with defining antenatal care and listing its objectives such as promoting mother and baby health, detecting high-risk cases, preventing complications, reducing mortality and morbidity. Components of antenatal care include risk identification, preventing/managing pregnancy diseases, and health education. Strategies involve antenatal visits, prenatal advice, specific health protections, mental preparation and family planning. High risk pregnancies are identified based on maternal medical conditions, obstetric history, current pregnancy complications, and certain signs. The document outlines the steps for antenatal exams, tests, advice and identifying warning signs.

1. ANTENATAL
CARE
Dr Bushra Jabeen
Assistant Professor
Department of Community Medicine,
ESIC Medical College and Hospital,
Kalaburagi.
1

2. Specific
learning
objectives
Student should be able to:
1. Define antenatal care
2. Enlist components, objectives
and strategies of Antenatal care
3. Estimate number of expected
pregnancies per year.
4. Describe at risk approach
5. Enlist high risk pregnancies.
2

3. Contents
3
Introduction
Statistics
Components
Objectives
Strategies
High risk approach
Summary

4. INTRODUCTION
• Definition
“the systematic supervision of women during pregnancy to monitor the progress of foetal
growth and to ascertain the wellbeing of the mother and foetus”
• Antenatal period - from the time of conception to the onset of labour
• Aim –
• To preserve the physiological aspect of pregnancy and labour
• To prevent or detect all pathological disorders as early as possible
• To achieve a healthy mother and a healthy baby
• Early diagnosis during pregnancy can prevent maternal mortality, foetal death,
infant mortality and morbidity
4

5. 5
STATISTICS
Karnataka

6. 7
STATISTICS

7. 9
STATISTICS

8. COMPONENTS
OF
ANTENATAL
CARE
11
Risk identification;
Prevention and management
of pregnancy-related or
concurrent diseases;
Health education and health
promotion.

9. OBJECTIVES
12
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
associated with
delivery

10. OBJECTIVES
13
5. To reduce maternal and
infant mortality and
morbidity
6. To teach the mother
elements of childcare,
nutrition, personal hygiene
and environmental
sanitation
7. To sensitize the mother
to the need for family
planning, including advice
to cases seeking medical
termination of pregnancy
8. To attend to the under-
fives accompanying the
mother

11. STRATEGIES
14
Antenatal visits
Prenatal advice
Specific health protection
Mental preparation
Family planning
Paediatric component

12. HOME VISITS
15
Backbone of all MCH services
Even if the expectant mother is attending the antenatal clinic regularly, it is suggested that she
must be paid at least one home visit by the Health Worker Female or Public Health Nurse
More visits are required if delivery is planned at home
Benefits:
Mother is generally relaxed at home
Home visit will win her confidence
Opportunity to observe the environmental (separate room,
lighting, ventilation, cattle, water supply) and social conditions
Opportunity to give prenatal advice

13. 1.VISITS
To confirm pregnancy - urine examination
• On the basis of presence of human chorionic
gonadotrophin hormone in the urine
• Nishchay- GOI Program Under NRHM MOHFW
• Home based 5 minute pregnancy test card
• Free of cost kit are made available at public health care
system accessed through ASHA/ANM
• Objective- Early detection of pregnancy and take
necessary action
• Rationale - To address the anxiety due to delayed or
missed menstrual cycle
16

14. I. ANTENATAL VISITS
17
Ideally
0 to7 m – once a month
8 m – twice a month
9 m –once a week
Recommended 1st visit — within 12 weeks
2nd visit — between 14 and 26 weeks
3rd visit — between 28 and 34 weeks
4th visit — between 36 weeks and term

15. I.
ANTENATAL
VISITS
First visit
( within 12 weeks)
• To confirm
pregnancy
• To register the
mother
• Calculate EDD
• To give FA
• To detect 'high-risk'
mothers
• To give antenatal
advice
Second visit
(14- 26 weeks)
• Auscultate for FHS
• To deworm her
• To give first dose of
tetanus toxoid
• Anomaly scan
• To give antenatal
advice
• To decide the place
of delivery
• To give warning
signals
• To give one pack of
(100) iron tabs
1
8

16. I.
ANTENATAL
VISITS
Third visit
(28-34 weeks)
by Medical Officer.
• To give 2nd dose of
TT
• To detect position
and presentation of
the foetus
• To exclude
cephalopelvic
disproportion
• To give antenatal
advice
Fourth visit
(36 wks- term)
• To give
disposable
delivery kit to
the mother in
the rural areas
• To give
antenatal advice
• Signs of labour
1
9

17. Importance
of detection
of early
pregnancy
Confirm if the pregnancy is wanted and if not, then refer the
women at the earliest to a 24 hours PHC or FRU that provides
safe abortion services to avoid illegal abortions
Facilitates proper planning and adequate care during
pregnancy for both mother and foetus
Record the date of LMP and calculate EDD
Assessment of mother’s health status to detect medical or
surgical illness
Obtain and record the baseline information
(BP, weight, haemoglobin)
Timely detection of complications at an early stage so as to
manage them appropriately by referral as and when required
Good interpersonal relationship between the care giver and
the pregnant woman
20

18. Estimation of number of pregnancies in a
specified area and pregnancy tracking
21
To ensure complete registration
ANM should know the estimated number of pregnancies to be
registered annually in her area
Significance:
• Judge how good her pregnancy registration is
• Adequate stock of the supplies required to provide routine ANC (such as
TT injections, IFA tablets and ANC record forms)
• Tackle any complications that arise during this period

19. Number of expected pregnancies
per year :
• Expected number of live births
= Birth rate (per 1000 population) x population of the area /1000
• As some pregnancies may not result in a live birth (i.e. abortions and stillbirths
may occur), the expected number of live births would be an under-estimation of the
total number of pregnancies
• Correction factor of 10% is required, i.e. add 10% to expected number of live
births
• As a rule, in any given month, approximately half the number of pregnancies
estimated above should be in records

20. Preventive services
for mothers
1. History taking
2. Physical examination
3. Abdominal examination
4. Assessment of gestational age
5. Laboratory investigations
23

21. 1.History-
taking
1. Age
2. Type of marriage - non/consanguineous
3. Obstetric score
4. Identify complications during previous
pregnancy/confinement
5. Identify any existing medical/ surgical or
obstetric condition
6. Calculate the expected date of delivery =
LMP + 9 months + 7 days
7. Calculate POG – in completed weeks
8. Record symptoms indicating complications
9. Record family history of hypertension,
diabetes, tuberculosis, and thalassaemia;
twins or congenital malformation
10.History of drug intake or allergies
24

22. 2.Physical examination
Pallor
Icterus
Pulse :
• Normal - 60 to 90 beats/min
• Persistently low or high, with or without other symptoms, the woman needs referred
Respiratory rate :
• Normal - 18-20 breaths/min.
• Especially with complaints of breathlessness
Oedema :
• Physiological – Lower limbs appears in the evening and disappears in the morning after a full night's
sleep
• Pathological - face, hands, abdominal wall and vulva
• Associated with high blood pressure, cardiac pathology, anaemia or proteinuria, the woman should
be referred to the medical officer
• Non-pitting oedema – Hypothyroidism and filariasis 25

23. 2.Physical examination
6. Blood pressure :
• Measure at every visit
• To rule out hypertensive disorders of pregnancy
• Hypertension –
2 consecutive readings taken 4 hrs apart show systolic blood pressure
to be ≥140 mmHg and/or the diastolic blood pressure to be ≥ 90
mmHg
• Signify - Pregnancy-Induced Hypertension (>20wks POG) and/or
chronic hypertension(<20wks POG)
• Check her urine for albumin
• Pre-eclampsia –
Presence of albumin (+2 or ≥0.1g/L ) + high B.P.
• Eclampsia – Pre-eclampsia + convulsion and/or coma
26

24. 2.Physical examination
7. Weight :
• Checked at each visit
• Weight taken during the first visit/ registration should be treated as the
baseline weight
• Normally - gain 9-11 kg
• Ideally, after the first trimester, gains 2 kg every month
• Inadequate dietary intake can be suspected if the gain is <2 kg/month
• Leads to Intrauterine Growth Retardation and thus a low birth weight
baby
• Excessive weight gain (>3 kg in a month) should raise suspicion of
multiple pregnancy, preeclampsia or diabetes
27

25. 2.Physical examination
8. Breast examination :
• To prevent feeding difficulties postnatally
• Observe the size and shape of the nipples
• Flat nipples – Rolled out manually, do not
interfere with breast feeding
• Inverted – has to be corrected as breast
feeding will be disturbed
• Crusting and sore nipples – breast hygiene
and emollients
28

26. 3.Abdominal examination
• To monitor the progress of the
pregnancy and foetal growth
• Helps confirming the calculated
duration of pregnancy
• Includes the following :
1. Inspection: Scar ; Linea nigra, striae
gravidarum
2. Measurement of fundal height :
Enlargement of the uterus and the height of
the uterine fundus
3. Foetal heart sounds : Heard after 20 weeks;
Normal - 120 to 140 beats/min
4. Foetal movements : Appreciated 18-22nd
week by gently palpation
5. Foetal parts : Felt after 22nd week and after
the 28th week, it is possible to distinguish
the head, back and limbs
6. Foetal lie and presentation : Relevant only
after 32 weeks of pregnancy
29

27. 5.Laboratory
investigations
3
0
At the sub-centre:
• Pregnancy detection test
• Haemoglobin estimation
• Urine test for albumin
and sugar
• Rapid malaria test
At the
PHC/CHC/FRU:
• Blood group,
including Rh factor
• VDRL
• HIV testing
• Rapid malaria test
• Blood sugar testing
• HBsAg

28. Essential components of every Antenatal check-up
31
Take the patient's
history.
1
Conduct a physical
examination-
measure the
weight. blood
pressure and
respiratory rate
and check for
pallor and oedema.
2
Conduct
abdominal
palpation for foetal
growth, foetal lie
and auscultation of
foetal heart sound
according to the
stage of pregnancy.
3
Carry out
laboratory
investigations,
such as
haemoglobin
estimation and
urine tests for
sugar and proteins.
4

29. Essential
components
of every
Antenatal
check-up
Interventions and counselling:
1. Iron and folic acid supplementation and
medication as needed.
2. Immunization against tetanus.
3. Group or individual instruction on
nutrition, family planning, self care,
delivery and parenthood.
4. Home visiting by a female health
worker/trained dai.
5. Referral services, where necessary.
6. Inform the woman about Janani Suraksha
Yojana and other incentives offered by the
government.
32

30. RISK APPROACH
• “Managerial tool based on the strategy for efficient
utilization of scarce resources with more care for
those in need and proportionate to the need”
• Mothers and children are most susceptible to good or
harmful influences that will permanently affect their
health
• These influences can be promoted in a very short time
• Thus preventive and promotive elements of primary
health care will have greatest yield if applied by using
risk approach in MCH
33

31. HIGH
RISK
ANC
3
4
• Age -
• <18 years or > 35 years (especially in primigravida)
• Multiparity -
• (> 4)
• Short stature -
• ( < 140 cms )
• Weight -
• < 40 Kg / weight gain < 5 Kg
• Rh negative
Maternal Factors
• Cardiac (RHD, CHD, Valve defects)
• Renal, Endocrine (Thyroid) or Gastrointestinal disease.
• Infections - TB, Leprosy, Malaria
• Hypertension, Diabetes, Seizures disorders
• Anaemia
Medical Disorders
• Recurrent abortions
• ( 2 x1st trimester or 1 mid-trimester)
• Intrauterine death or stillbirth
• Prolonged labour, birth asphyxia , early neonatal death
• Previous caesarean section / scar dehiscence
• Postpartum haemorrhage
• Baby which is LBW, SFD or large for date, congenitally
malformed
• Malpresentation, instrumental delivery, ectopic pregnancy
• Twins, poly/oligo-hydramnios, pre-eclampsia.
Bad Obstetric History

32. HIGH RISK ANC
1. Bleeding PV at any point
2. Excessive vomiting
3. Hypertension
4. Pre-eclampsia, eclampsia
5. Severe anaemia
6. Abnormal weight gain
7. Multiple pregnancy
8. Polyhydramnios,
oligohydramnios
9. Abnormal presentation in
9th month
10.Preterm Labour, PROM
35
• Pregnancy at any stage can be classified as high risk if :

33. MAINTENANCE OF RECORD
Mother and Child Protection Card or Tayi
cards
Developed by the Ministry of Health
and Family Welfare and Ministry of
Women and Child Development
Contains a registration number,
identifying data, previous health history
and main health events
Case record is handed over to the woman
and instructed to bring during all
subsequent visits and also at time of
delivery
36

34. MCPC/
Tayi
card
37
Help the service provider to know the details of
previous ANCs/PNCs both for routine and
emergency care
To ensure uniformity in record keeping
Should be duly completed for every woman
registered
Information contained in the card should also be
recorded in the antenatal register as per the
Health Management Information System format

35. 38
OLD
NEW

36. II.PRENATALADVICE
• Mother is more receptive to advice concerning herself and her baby at this
time than at other times
(i) DRUGS : That are not absolutely essential should be discouraged
(ii) RADIATION : Exposure to radiation to be avoided
(iii)DIET : A Pregnancy in total duration consumes about 60K Kcal, over
and above the normal metabolic requirement.
39
Calories
(kCal/d)
Proteins
(g/d)
Iron
(mg/d)
Calcium
(mg/d)
Sedentary 1900 55 21 600
Moderate 2230 55 21 600
Heavy 2850 55 21 600
Pregnancy +350 78 35 1200
Rich food Rice, Banana,
Potatoes
Dal, Cheese,
Meat
Jaggery,
Dates, Palak
Ragi, Milk,
Egg

37. II.PRENATALADVICE
(iv)PERSONAL HYGIENE :
Personal cleanliness
Rest and sleep
Bowels
Exercise
Smoking and alcohol
Dental care
Sexual intercourse
Warning signs
Birth preparedness
Child care 40

38. II.PRENATALADVICE
(v) WARNING SIGNS:
The mother should be instructed
to report immediately in case of
the following warning signals :
41
Swelling of feet Excessive vomiting
Fits Continuous sever
abdominal pain
Headache Reduced urine output
Blurring of vision Disturbed sleep
Bleeding or discharge PV Fast or difficulty
breathing
Decreased or absent foetal
movements
Fever

39. II.PRENATAL
ADVICE
(vi) BIRTH PREPAREDNESS:
• Institutional delivery
• Signs of labour – Pain the lower abdomen radiating
to inner thighs and lower back – increasing in
intensity and duration
• Schemes – Pradhan Mantri Surakshit Matritva
Abhiyan, Janani Suraksha Yojana, Madilu kit
(vii) CHILD CARE:
Mother-craft education consists of nutrition education,
advice on hygiene and childrearing, cooking
demonstrations, family planning education and family
budgeting
42

40. III.SPECIFIC HEALTH
PROTECTION
a. Anaemia
b. Other nutritional deficiencies : protein,
vitamin and mineral iodine deficiency
c. Tetanus
d. Toxaemias of pregnancy
f. Syphilis
g. German measles
h. Rh status
i. HIV infection
j. Hepatitis B infection
k. Prenatal genetic screening
43

41. IV.MENTAL PREPARATION
• Sufficient time and opportunity must be given to the expectant mothers to talk on all
aspects of pregnancy and delivery
• Remove her fears about confinement
• Mothercraft classes at the MCH centres
V.FAMILY PLANNING
• Educational and motivational efforts must be initiated during the antenatal period.
• The All India Postpartum Programme services are available to all expectant mothers in
India
VI.PAEDIATRIC COMPONENT
• Paediatrician should be in attendance at all antenatal clinics to pay attention to the under-
44

42. Important
questions
45
Long
Essay/
Short
Essay
What is ‘at risk approach’. List the high-risk
pregnancies in ANC and describe how you
would prevent them.
Short
Essay
Antenatal care-objectives/components (essential
elements)
Discuss the specific health protection given to
antenatal cases.
Short
Answer
Antenatal care
What advice is given during antenatal period?
Preventive measures for anemia in pregnancy.
Congenital syphilis

43. REFERENCES
• K.Park Text book of Preventive and Social
Medicine 23rd edition
• Community Medicine with Recent
Advances, A.H.Suryakanta, 4th Edition
• Preventive and Social Medicine, Sunder
Lal, 3rd edition
• Guidelines for Antenatal Care and Skilled
Attendance at Birth by ANMs/LHVs/SNs,
Ministry of Health and Family Welfare,
2010
• D.C. Dutta’s Textbook of Obstetrics, 7th
edition
• Family welfare statistics in India, 2011
46

44. THANK YOU
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