Care during Pregnancy and Lactation

1. Pregnancy and Lactation
By-
Dr Bhuwnesh Chaudhary
Asst Professor Community Medicine
NIIMS, Gautam Buddha Nagar

2. Introduction
• Pregnancy: It is described as a state in which
a woman carries a fertilized egg inside her
body (uterus) to help it develop and to be
delivered eventually after a certain period.
• Lactation: It describes the secretion of milk
from the mammary glands and the period
of time that a mother lactates to feed her
new borne baby

3. Objectives
• To produce, healthy, normal weight infants while
minimizing health risks to the mother
• To determine appropriate weight gain during
pregnancy for normal, under and overweight
women
• To recognize the additional energy, vitamins and
minerals requirement for women during
pregnancy
• To understand changing nutritional needs during
pregnancy

4. Mother and Child – One Unit
• Foetus obtains all building materials and Oxygen from mother’s blood
through placenta during whole pregnancy (280 days approx.)
• Child’s health is closely related to mother’s health
• Some diseases/conditions in the mother directly affect the foetus e.g.
German measles, Syphilis, Drug intake, smoking etc
• Child is fully dependent on mother for 6-9 months
• Post partum care is not separate from child care
• Mother is the “First Teacher” of her child

5. Maternity Cycle
Stages of the maternity cycle are-
• Fertilization
• Antenatal or prenatal period
• Intra-natal period
• Postnatal period and
• Inter-conceptional period
Maternity

6. Periods of Growth During Pregnancy
Prenatal Periods-
• Ovum stage – 0 to 14 days
• Embryo Stage – 14 days to 9 weeks
• Foetus stage – 9 weeks to birth
• Premature Infant -28 to 37 weeks
• Birth, Full term – 280 days (Average)

7. MCH (Maternal and Child Health) Care
Promotive, preventive, curative and rehabilitative health care for
mothers and child
Sub Areas of MCH Care-
 Maternal health
 Child health
 Family planning
 School health
 Handicapped children health
 Adolescent care
 Health aspects of child care in special settings e.g Day care

8. Problems and objectives of MCH care
Problems of MCH -
• Malnutrition
• Infections
• Uncontrolled reproduction
Objectives of MCH care-
• Reduction of maternal, perinatal, infant and childhood morbidity and
mortality
• Promotion of reproductive health
• Promotion of physical and psychological development of children and
adolescents in the family
• “THE ULTIMATE” objective - Lifelong health

9. Pregnancy Detection
By Urine examination-
• Pregnancy test Kit ( Nischay )
• The test is based on the detection of the chorionic
gonadotropins in the urine during pregnancy
By Ultrasound examination-
• At PHC/FRU

10. Antenatal care (ANC)
Antenatal care is defined as the care provided by the skilled
healthcare professionals to pregnant women and pregnant
adolescents girls in order to ensure the best health conditions
to both mother and baby during pregnancy.
Components of ANC-
• Risk identification
• Prevention and management of pregnancy related or
concurrent diseases
• Health education
• Health promotion

11. Objectives of Antenatal Care
• To promote, protect and maintain the health of the mother during
pregnancy
• To detect “High Risk cases” and give them special care/attention
• Foresee complications and take preventive action
• Remove anxiety and fear of pregnancy
• Reduce maternal and infant mortality and morbidity
• To teach the mother, elements of - child care, nutrition, personal
hygiene and environmental sanitation
• Sensitize the mother about need of family planning and to render
advice to the cases seeking MTP
• To attend the under-5 children arriving with mothers

12. Antenatal Visits
Ideal No of visits to Antenatal clinic by a pregnant mother-
• Once a month for first 7 months
• Twice a month during next month
• Once a week till delivery
Target – minimum four visits during entire pregnancy, as suggested-
• Ist visit – within 12 weeks of pregnancy, preferably as early as possible
• IInd vist – between 14 and 26 weeks
• IIIrd visit – between 28 and 34 weeks (at PHC)
• IV th visit – Between 36 weeks and term
Registration of the pregnancy within 12 weeks is the responsibility of ANM

13. Importance of Early Detection of Pregnancy
• Helps in proper planning and adequate care
• Date of LMP and EDD can be calculated more accurately
• Mothers baseline information of BP, Weight, Hb etc can be
recorded and illness is detected and treated well in time
• Timely detection of any complication
• Confirmation of an unwanted pregnancy and timely safe
abortion service at PHC/FRU
• Good inter-personal relation developed between the care
giver and pregnant mother

14. Pregnancy Tracking and Registration
For better and assured tracking and early registration of the pregnant
women in her AoR, ANM should know estimated number of
pregnancies in that area
Method of calculating Expected No of Pregnancies in an area-
• Expected No of live births (Y)/year in an area
= Birth rate per 1000 population X population of the area
1000
• Apply correction of 10%
• Total No of expected pregnancies = Y+10% of Y

15. Guidelines: Pregnancy Tracking by ANM
• ANM should know the expected pregnancies in her AoR
• ANM should approach community leaders and key persons, if No of
registered pregnancies is less than expected
• Visit of every house by ASHA and link workers
• Register all those taking antenatal care in private health care system
• Keep track of all the pregnant women
• Follow and counsel those missing the visits
• All the components of the missed visit to be included in next visit
• Name based tracking system for the pregnant women and children

16. Antenatal Check Up
On First Visit –
History taking – confirm pregnancy, H/o complications in previous pregnancies,
current medical/surgical /obstetric condition, Record Ist day of LMP and calculate
EDD by adding 9 months and 7 days, record any other symptom, H/O any current
systemic illness, family H/O any systemic illness, drug allergies, H/O drug or Alcohol
intake/smoking.
Physical Examination – Pallor, pulse rate, respiration rate, Oedema
Blood Pressure – Two readings 4 or more hours apart. Maximum Systolic 140 and
Diastolic 90 mm of Hg, Check urine for Albumin if more and refer to MO if Albumin
(++) is with high B.P.
Weight Recording–
• Weight recorded on first visit is the baseline
• Normal weight gain during whole pregnancy is 9-11 kgs at the @ of 2kgs/ month
in first trimester
• Less weight gain leads to IUGR and excessive weight gain (more than 3kgs/month)
may be due to twin/ multiple pregnancy, eclampsia or diabetes
Breast examination – check for size, shape of the nipple, flat and inverted nipple

17. Antenatal Check Up
Abdominal Examination –
The most important part of
the examination-
Fundal Height –
• At 12 weeks – just palpable
per abdomen
• At 20 weeks – Fundus flat at
the lower border of
umbilicus
• At 36 weeks – At the level of
Xiphisternum

18. Antenatal Check Up
• Foetal Heart Sounds – 120 to 140 B.P.M. Heard in midline at
28 weeks
• Foetal movement – Felt at 18-22 weeks
• Foetal parts – 22-28 weeks
• Uterus size – Multiple pregnancy is suspected if uterus is
bigger for gestational age
• Foetal Lie and Presentation – After 32 weeks
• Any scar mark over the abdomen to be noted carefully

19. Gestational Age Assessment
1. LMP Method –
• Add 9 months 7 days to first day of LMP
• Widely used method of calculating EDD
2. Best Obstetric Estimate Method – Abdominal USG corelated with
LMP method
3. Alternative Methods –
• Fundal height method
• Clinical assessment of the newborn after birth
• Birth weight of the new born as a surrogate

20. Antenatal Check Up
Laboratory Investigations-
At Sub Centre Level –
• Pregnancy test, Hb, Urine for Albumin and Sugar and Rapid Malaria
test
At PHC Level –
• Blood grouping including Rh, HIV test, Rapid Malaria test (if not done
at Sub Centre), Blood sugar, HBsAg or hepatitis B

21. Antenatal Check Up
Interventions and Counselling –
• Tetanus immunization
• IFA supplementation
• Advices on – Nutrition, family planning, Self care, Delivery and
parenthood
• Home visits by FHW/ trained Dai
• Referral where necessary
• Information about JSY and other schemes/ incentives by the
government

22. Maintenance of Records and Home Visits
• Mother and Child protection Card to be made
• Card to be handed over to the woman
• This card should be brought by her on every visit
• Home Visits by HW(F) or Public health Nurse are the backbone of
MCH care
• At least one visit to be made even if the pregnant woman is visiting
the clinic regularly
• More visits be made if the delivery is planned at home

23. Antenatal Check Up : Risk Approach
• Elderly primigravida (30 years or more years old)
• Short statured primigravida (Height less than 140 cms)
• Malpresentation (Breech or transverse lie)
• APH or threatened abortion
• Pre-eclampsia or eclampsia
• Anemia with pregnancy
• Twin pregnancy or hydramnios
• Past H/O of stillbirths, IUD or manual removal of placenta
• Elderly grand multipara

24. Antenatal Check Up : Risk Approach
• Prolonged pregnancy (14 days beyond EDD)
• History of previous LSCS or forceps delivery
• Pregnancy with systemic diseases e.g. CVS disease, Diabetes, Renal
disease, Tuberculosis, Liver disease, malaria, convulsions, Ashthma,
HIV, RTI, UTI etc
• History of treatment for infertility
• Three or more consecutive abortions

25. Prenatal Advices
Prenatal advice on all aspects of MCH care is the major component of
Antenatal care and include the following aspects –
• Dietary advice and interventions
• Personal hygiene
• Drug intake
• Radiation exposure
• Warning signs
• Child care

26. Prenatal Advices
Dietary Advice- is based on the following principles-
• On an average 60,000 kcal extra calories are required by a woman for
having a successful pregnancy delivering a healthy newborn
• 500 kcal/day additional calories are required for lactation
• Birth weight of the new born is dependent upon weight gain by the
mother
• On an average 9-11 kgs is the normal weight gain during whole
pregnancy while in women of poor class its only 6.5 kgs
• Extra iron and Folic Acid is required to build up the iron reserve of the
baby
• A balanced and adequate diet is needed

27. Prenatal Advices
Drug Intake –
• Great caution to be exercised in prescribing/taking drugs during
pregnancy
• e.g. Thalidomide disaster-a well documented medical disaster
• Other drugs contraindicated in pregnancy are Streptomycin, iodide
containing drugs, Tetracycline, Corticosteroids, LSD, Anaesthetic
agents including Pethedine etc
• During lactation also caution is needed in drug intake. Drugs being
taken by mother are excreted in her milk.
Radiation-
• Abdominal X-ray during pregnancy to be avoided
• To be done only when indication is inescapable

28. Prenatal Advices
Personal hygiene- includes the following aspects-
• Personal cleanliness- daily bath, clean clothes, Tidy and clean hair
• Rest and sleep -8 hours during night and 2 hours after lunch
• Bowels – to avoid constipation
• Exercise – light house hold work only, Avoid manual physical labour
during last trimester
• Smoking – Cut down to minimum, rather stop
• Alcohol – Intake may cause IUGR, abortion and developmental delay
• Dental care – should be regular and adequate
• Sexual activity to be avoided in late pregnancy

29. Prenatal Advices
Warning Signs- mother be educated about the following warning signs
and be advised to report to the PHC/FRU if noticed-
• SHwelling of the feet
• Convulsions
• eadache
• Blurring of vision
• Bleeding/discharge PV
• Any other unusual symptoms

30. Prenatal Advices
Child Care – “Mother- Craft” education to a mother includes-
• Nutrition education
• Hygiene and child rearing
• Meal cooking demonstration
• Family planning
• Family budgeting

31. Specific Health Protection
MCH care should focus on providing protection to every pregnant woman
against the following diseases/ailments -
• Anemia
• Other nutritional deficiencies
• Asymptomatic bacteriuria
• Gestational Diabetes
• Toxemia of pregnancy
• Tetanus
• Syphilis
• German Measles
• Rh Status
• HIV Infection
• Hepatitis B infection
• Chromosomal/ Genetic defects

32. Intranatal Care
Aims of Good Intranatal care-
• Thorough asepsis
• Delivery with minimum injury to mother and newborn
• Readiness to deal with complications such as- prolonged and
difficult labour, APH, Convulsions, malpresentations, Cord
prolapse etc
• Care of the baby at delivery – resuscitation, care of the cord, care
of the eyes etc

33. Domiciliary V/S Institutional Care
• A vast majority of the deliveries in Indian rural area (more than 70%) will
have to be done at homes
• HW (F) or Trained Dai provide domiciliary midwifery service and conduct
deliveries at home
• Institutional care is recommended to all High Risk Pregnancy cases and
when home conditions are not suitable
• In institutional normal delivery a woman is allowed to be up next day and
discharged after 48 hours lying-in period
• Rooming-in of the baby i.e. keeping baby’s crib next to mother’s bed done
at the earliest
• This gives mother opportunity to know, connect with and feed the baby
• Mother’s fears are also allayed

34. Domiciliary Care
Advantages -
• Familiar surroundings
• Less chances of cross infection
• Mother able to keep an eye on other children also
Disadvantages-
• Less medical and nursing supervision
• Less rest to mother
• Domestic duties resumption too soon
• Diet may be neglected

35. Danger Signals During Delivery
• Sluggish or no pains after rupture of membrane
• Pains good but no progress even after one hour
• Prolapse of cord or hand
• Meconium stained liquor or slow irregular/fast FHS
• Excessive show or bleeding
• Collapse during labour
• Placenta not separated within half an hour
• PPH or collapse
• Temp of 38 degree C or more during labour

36. Postnatal care
Objectives of Postpartal Care-
• Prevent complications of the postpartal period
• Provide care for the rapid restoration of mother to optimum health
• Check adequacy of breast feeding
• Provide family planning services
• Provide basic health education to the mother
Complications of the Postpartal Period-
• Puerperal sepsis
• Thrombophlebitis
• Secondary hemorrhage
• Others – UTI, Mastitis

37. Restoration of Mother to Optimum Health
PHYSICAL-
1. Postnatal examinations
2. Treatment of Anemia
3. Nutritional care and breast feeding
4. Postnatal exercises
PSYCHOLOGICAL-
1. Ignorance
2. Fear and insecurity
SOCIAL-
1. Family support
2. Sex of the child