Antenatal care involves systematic supervision of a pregnant woman throughout her pregnancy. It aims to ensure a healthy pregnancy and delivery through regular checkups, screening for medical conditions, immunizations, nutrition counseling, and fetal monitoring. Key aspects of antenatal care include at least 8 scheduled visits, monitoring maternal and fetal health at each visit, providing treatments and advice, and educating the mother and family. While antenatal care can help reduce risks, some complications may still arise unexpectedly.

1. Antenatal Care
Moderator Dr Rajeev Sood
Presentation by Dr Kanika Dhiman

2. References
1. NICE clinical guidelines routine care for healthy pregnant woman
2. ACOG care of normal pregnant patient’
3. WHO book on EmOc and Basic Obstetric care for pregnant patients
4. Gabbe obstetrics normal and problem pregnancies
5. ICOG FOGSI recommendations for routine antenatal care
6. DC Dutta’s textbook of obstetrics

3. Introduction
● Pregnancy and childbirth are momentous
events in the lives of women and families
● It is a time of intense vulnerability
● Skilled health care during pregnancy and childbirth are crucial

4. What is prenatal / antenatal care?
ACOG defines prenatal care as “ Systematic supervision
involving both examination and advice to a woman throughout
pregnancy.”
It includes :
Pre conceptional care
Prompt diagnosis of pregnancy
Initial presentation for prenatal care
Follow up prenatal visits

5. DATA (WHO)
● Pregnancy related deaths and diseases remain
unacceptably high.
● Globally only 64% women receive antenatal care four
or more times throughout the pregnancy
● In 2015
○ Estimated deaths from pregnancy related causes - 3,03,000
○ 2.7 million babies died during first 28 days of life
○ 2.6 million babies were stillborn

6. ANC is critical
❑ Reduces stillbirths and
perinatal deaths
❑ Reduces complications
from pregnancy and
childbirth
❑ Integrated care delivery throughout pregnancy
❏ A vehicle for multiple
interventions and
programmes

7. KEY POINTS
● Women centred care
● Informed decision making
● Systematic supervision
● Periodic
● Regular

8. AIMS
● to screen the “high risk” cases
● early detection and intervention
● to educate the mother about the physiology of pregnancy and
labor by demonstrations, charts and diagrams (mothercraft
classes), so that fear is removed and psychology is improved
● to discuss with the couple about the place, time and mode of
delivery, and care of the newborn
● to motivate the couple about the need of family planning
● appropriate advice to couple seeking medical termination of
pregnancy.

9. OBJECTIVES
● to give women positive pregnancy experience
● ensure a normal pregnancy (delivery of a single
baby in good condition at term (between 37 and
42 weeks), with fetal weight of 2.5 kg or more
and with no maternal complication)

10. WHO Recommendations: minimum 8 antenatal visits
● Nutritional intervention
● Maternal and fetal assessment
● Preventive measures
● Interventions for common physiological problems in
pregnancy

11. Previously: The 4-visit
WHO FANC model
Now : 8-visit WHO ANC model

14. FIRST VISIT (booking visit)
Ideally, needs to be earlier in pregnancy (prior to 12 weeks).
● History taking & examination
● Make antenatal card/ home based maternal record
● Record Weight and BP
● Advise and counsel on healthy diet, nutrition, self care and
substance abuse

15. ● Check blood group and Rh status of the mother
● Offer screening for anaemia, hepatitis B virus, HIV,
rubella susceptibility and syphilis,diabetes and
hypothyroidism
● Offer screening for asymptomatic bacteriuria
● Check tetanus toxoid immunization status
● Folic acid supplementation to be started

16. • Offer early ultrasound scan for gestational age assessment
• Screening for intimate partner violence
•
• Identify women who may need additional care
• Prepare birth and emergency plan

17. ● Offer screening for Down’s syndrome if available
– nuchal translucency at 11 to 13+6 weeks
– Serum screening
● Advise on regular antenatal checkup and next
scheduled visit

18. 16 to 20 weeks
The next appointment should be scheduled around 16 to 18
weeks:
● History of quickening
● Review, discuss and document the results of all screening
tests undertaken
● Investigate a haemoglobin level of less than 10 g/dL and start
iron supplementation
● Measure blood pressure and test urine for proteinuria
● Enquire for any new complaints
● Review birth plan
● Record all findings, treatment given and next scheduled visit
in the home based maternal card.
● At 18–20 weeks, an ultrasound scan for anatomical survey.

19. ● For woman whose placenta is found to extend across the
internal cervical os at this time, offer another scan in third
trimester

20. 24 to 28 weeks
At this appointment:
● Any fresh complaint
● Measure blood pressure and test urine for
proteinuria
● Repeat screening for gestational Diabetes and
hypothyroidism
● Offer a second screening for anemia
● Offer anti-D prophylaxis to Rhesus-negative women
where available and indicated
● Measure and plot symphysis–fundal height (in cms)

21. 30 to 36 weeks
At this visit :
■ Any fresh complains
■ Ask for fetal movements
■ Measure blood pressure and test urine for proteinuria
■ Measure and plot symphysis–fundal height
● Fetal biometry if indicated.
■ Review, discuss and document the results of screening tests
undertaken at 28 weeks
■ Reassess planned pattern of care for the pregnancy and
identify women who need additional care

22. 36 to 40 weeks
At this appointment:
■ Any fresh complaint
■ Fetal movements
■ Measure blood pressure and test urine for proteinuria
■ Measure and plot symphysis–fundal height
■ Check position of baby
■ Review ultrasound scan if placenta extended over the
internal cervical os in previous ultrasound.

23. After 40 weeks
For women who have not given birth by 41 weeks:
■ Closer antepartum vigilance
■ Measure blood pressure and test urine for proteinuria
■ Measure and plot symphysis–fundal height
■ check position of baby
■ Consider induction if inducible and favorable cervix.

24. BISHOP’S SCORE

25. � Leakage PV
� Bleeding PV
� Abdominopelvic pain
� Headache, visual disturbance
� Decrease or loss of fetal movements
� Fever, rigor, excess vomiting, diarrhea.
Advise on danger signs

26. HISTORY TAKING
� Demographic details : Name , address, occupation
� Age: pregnant women at the extremities of age are at increased risk
� Chief complaints
� History of present illness: Elaboration of the chief complaints as regard their
onset, duration, severity, progression
� History of present pregnancy: Booking status, immunization status, IFA intake
history, ultrasounds done
� History of first trimester : H/O Excessive vomiting, bleeding/discharge per
vaginum, fever with rashes,radiation exposure, unsupervised drug intake,
burning micturition.
� 2nd trimester: Quickening perception,H/O bleeding/discharge per vaginum,
headache, swelling of hands and feet, blurring of vision, epigastric pain.
� 3rd trimester: Lightening felt at,H/O pain abdomen BPV DPV,Burning
micturition, swelling of hands and feet, blurring of vision

27. OBSTETRICAL HISTORY
� Duration of marriage
� Previous obstetrical events are recorded chronologically in detail
� Gravida :Gravida denotes a pregnant state both present and
past, irrespective of the period of gestation.
� Parity: denotes a state of previous pregnancy beyond the
period of viability.

28. � Menstrual history: Menarche, PMC, LMP, EDD and POG
� Past history of any chronic medical /surgical illness,
drug intake, blood transfusion
� Personal history: education, occupation, dietary
habits, any addictions, allergies, bowel, bladder and
sleep habits
� Family history: chronic illness, CMF in babies, Twin
pregnancies.

29. GENERAL EXAMINATION
● Built: Obese/average/thin.
● Nutrition: Good/average/poor. Calculate calorie intake
● Height, Weight, BMI, BP, Pulse Rate
● Pallor: lower palpebral conjunctiva, dorsum of the tongue
and nail beds.
● Jaundice: bulbar conjunctiva, under surface of the
tongue, hard palate and skin.

30. ● Tongue, teeth, gums and tonsils
● Neck: Neck veins, thyroid gland or lymph
glands are looked for any abnormality.
● Pedal edema
● Systemic examination - Chest , CVS

31. OBSTETRICAL EXAMINATION
� Inspection:
● whether the uterine ovoid is longitudinal or transverse or oblique
● undue enlargement of the uterus
● skin condition of abdomen, linea nigra ,striae gravidarum, any
evidence of Tinea or scabies
● any incisional scar mark on the abdomen suggestive of previous
operations.

32. PALPATION
� Height of the uterus: The uterus is to be centralized, if deviated.
The ulnar border of the left hand is placed on the upper most
level of the fundus and an approximate duration of pregnancy is
ascertained in terms of weeks of gestation.
� SFH can be measured with a measuring tape in the later months
of pregnancy.

33. Fundal
height at
different
weeks

35. OBSTETRICAL GRIPS ( LEOPOLD MANEUVERS)

37. Lateral grip/umbilical grip:
● palpate the sides and front of the uterus to find
out the position of the back, limbs and the
anterior shoulder.
● The back is suggested by smooth curved and
resistant feel.
● The ‘limb side’ is comparatively empty and there
are small knob like irregular parts.
● Status of liquor also assessed.

38. LATERAL GRIP

39. � (iii) Pawlik’s grip (Third Leopold): The examination
is done facing toward the patient’s face. The
overstretched thumb and four fingers of the right
hand are placed over the lower pole of the uterus
keeping the ulnar border of the palm on the
upper border of the symphysis pubis. When the
fingers and the thumb are approximated, the
presenting part is grasped distinctly (if not
engaged) and also the mobility from side to side
is tested.
� In transverse lie, Pawlik’s grip is empty.

40. PAWLIK’S GRIP

41. � (iv) Pelvic grip (Fourth Leopold): The
examination is done facing the patient’s feet.
� Four fingers of both the hands are placed on
either side of the midline in the lower pole of
the uterus and parallel to the inguinal
ligament. Check for convergance or
divergence of finger tips.

43. � Helps in assessment of fetal well being.
� Can also tell about presentation of fetus
Auscultation

44. Vaginal Examination
done in the antenatal clinic when the patient
attends the clinic for the first time before 12
weeks.
● to diagnose the pregnancy,
● to corroborate the size of the uterus with the
period of amenorrhea
● to exclude any pelvic pathology.

45. � Vaginal examination: in the later months of
pregnancy (beyond 37 weeks)
● To assess the pelvis.
● To confirm the presentation/position of fetus.

46. Nutrition

47. DIET: Should be of woman's choice
should be adequate to provide:
� good maternal health,
� optimum fetal growth,
� the strength and vitality required during labour
� successful lactation

50. Supplementary iron therapy:
� Iron folic acid supplementation is needed for all non
anemic pregnant mothers from 14-16 weeks onwards.
� Recommended dosage:
� 60 mg elemental iron + 400ug folic acid for 6 months
(WHO)
� 100mg elemental iron + 500ug folic acid for 100 days
(GOI)

51. ANTENATAL HYGIENE
● Rest and sleep
● Bowel habits
● Bathing
● Clothing
● Dental care
● Care of breasts
● Exercise
● Coitus
● Travel
● Smoking and alcohol

52. Advice on breastfeeding
● Pregnant woman should be taken around
postnatal ward and allowed to interact with
delivered women
● Should be taught how to breastfeed their babies
and breast hygiene
● Pre pregnancy classes on labour and infant care
should be offered.

53. Contraception and birth spacing
● Focused antenatal family planning counseling has increased the
possibility of postpartum contraception use.
● Patient should be informed about all the methods available
(CAFETERIA APPROACH)
● Risks, advantages and benefits must be explained
● Should ideally begin during late third trimester

54. IMMUNIZATION
● Antenatal AntiD prophylaxis in non sensitised Rh
negative women at 28 and 34 weeks of gestation.
● Tetanus: 0.5 mL tetanus toxoid is given
intramuscularly at 4 weeks interval. Second dose to
be given at least 2 weeks before delivery.Women
who are immunized in the past 3 years, a booster
dose of 0.5 mL IM is given.
● Live virus vaccines (rubella, measles, mumps,
varicella, yellow fever) are contraindicated.
● Rabies, hepatitis A and B vaccines, toxoids can be
given.

55. MINOR AILMENTS IN PREGNANCY
● Nausea and vomiting
● Backache
● Constipation
● Leg cramps
● Acidity and heartburn
● Varicose veins
● Hemorrhoids

56. ● Carpal tunnel syndrome
● Syncope
● Round ligament pain
● Ankle edema
● Vaginal discharge

57. ANTEPARTUM FETAL SURVEILLANCE
Aims :
1. To ensure satisfactory growth and well being of the
fetus
1. To screen out high risk factors that affect the growth
of fetus

58. The primary objective is to avoid fetal death
(ACOG)

59. Rationality of antenatal fetal tests
● Must provide information superior to clinical evaluation
● Should be helpful in management to improve perinatal
outcome
● Benefits must outweigh risks and costs

60. Indications for fetal surveillance
Maternal conditions:
•Hypertension/pre eclampsia
•Diabetes
•Heart disease
•Anemia
•Multiple pregnancy
•Post dated/post term pregnancy
•Abnormal placentation
•Oligohydramnios
•Polyhydramnios
•Decreased fetal movements
•Cholestatis of pregnancy
•Unexplained stillbirth in previous
pregnancy
Fetal conditions:
•Fetal growth restriction
•Rhesus isoimmunization
•Fetal infections

61. Timing
● Should ideally start from 32 weeks of gestation
● Can be started from 26-28 wks onwards in high risk pregnancies

62. Methods
● Clinical
● Biochemical
● Biophysical

63. Biochemical
To assess the fetal pulmonary maturity
For fetal pulmonary maturity: estimate the L/S ratio
31-32 weeks-1
35 weeks- 2
More than equal to 2 → Pulmonary maturity

64. Other tests:
● Shake test (Clement’s test)
● Foam Stability Index
● Phosphatidyl Glycerol
● Saturated Phosphatidylcholine
● Fluorescence Polarization
● Amniotic fluid optical density
● Lamellar body
● Orange coloured cells
● Amniotic fluid turbidity

65. Biophysical tests
● Fetal movement count (fetal kick count)
● Ultrasound for fetal growth
● Cardiotocography
● Non stress test (NST)
● Vibro acoustic stimulation test (VAST)
● Contraction stress test
● Fetal biophysical profile (BPP)
● Doppler
● Amniotic fluid volume

68. Summary
● Careful history taking
● Thorough clinical examination
● Investigations (routine and special)
● Advice : Diet (nutrition), hygiene, specific to any
problem

69. ● Subsequent visits : 4 weekly till 28 weeks, then 2 weekly until
36 weeks, then weekly till delivery
A. Maternal health - weight, BP, pallor, symptom analysis, any
complaint
- identification of high risk factor
B. Fetal health - fetal growth, fundal height, fetal heart rate,
amniotic fluid volume, presentation, fetal movements
● Couple education, counselling and advice
● Preparation for childbirth

70. VALUES OF ANTENATAL CARE
.
� Antenatal care is said to be the strategy; the intranatal care is
the tactic in obstetrics
� Net effect is marked reduction in maternal mortality and
morbidity and significant reduction in perinatal mortality and
morbidity

71. DRAWBACKS
� Simple abnormality may be exaggerated
� Unless quality of care is maintained in the antenatal clinic, the
benefits of antenatal care are not obtained.
� Good antenatal care only cannot reduce maternal and
neonatal mortality and morbidity unless the woman gets good
care during labor and postnatal period.
.

72. LIMITATIONS:
Many complications in obstetrics often
arise as emergency and without any
warning.

73. Antenatal care programs in india
 JANANI SHISHU SURAKSHA KARYAKRAM
 PRADHAN MANTRI SURAKSHIT MATRUTVA ABHIYAN
 NATIONAL NUTRITIONAL ANEMIA PROPHYLAXIS
PROGRAM
 PRADHAN MANTRI MATRU VANDANA YOJANA

74. THANK YOU