Prenatal care involves monitoring the health of the mother and fetus during pregnancy. It was introduced in the US in the early 20th century by social reformers and nurses to improve maternal and infant health outcomes. Prenatal care consists of risk assessment, health promotion, and medical and psychosocial interventions. Regular checkups allow doctors to monitor the growth and development of the fetus and spot any issues. The goals of prenatal care are to define the health status of the mother and fetus, estimate gestational age, and establish a plan for ongoing care.

1. Prenatal care
By
Connie Sussan Austen.

2. What is pre-natal care.
Prenatal care is defined as the care given to a woman
during her stages of pregnancy, to monitor the mother
and her fetus.
Largely social reformers and nurses introduced and
organized prenatal care in the United States.
Whitridge Williams reviewed 10,000 consecutive
deliveries at Johns Hopkins Hospital and concluded that
40 percent of 705 perinatal deaths could have been
prevented by prenatal care. In 1954, Nicholas J.
Eastman credited organized prenatal care with having
“done more to save mothers’ lives in our time than any
other single factor” (Speert, 1980).
Historically,the first focus of prenatal care was to
improve maternal safety. The accepted plan of visits,
consisting of monthly visits in early pregnancy,
becoming more frequent in the mid trimester, then
weekly in the last month, was an attempt to detect the
most common serious illness of women in pregnancy –
pre-eclampsia.
Epidemiologicstudies support the benefit of this
approach, as they appear to demonstrate lower
maternal and perinatal mortality for women who
receive prenatal care (Greenberg, 1983).

3. Prenatal care is a comprehensive program which
consist from:
(1) Preconceptionalcare.
(2) Prompt diagnosis of pregnancy.
(3) Initial prenatal evaluation.
Preconcepttionalcare:
Because health during pregnancy depends on health
before pregnancy, preconceptional care should logically
be an integral prelude to prenatal care.
Comprehensive preconceptionalcare program has the
potential to assist womenby reducing risks, promoting
healthy lifestyles, and improving readiness for
pregnancny.
Prompt diagnosis of pregnancy:
The diagnosis of pregnancy usually begins when a
woman presents with symptoms, and possibly a
positive home urine pregnancy test result.
Clinicalfindings and symptoms may indicate an early
pregnancy:
 The abrupt cessation of menstruation in a healthy
reproductive-aged woman who previously has
experienced spontaneous, cyclical,predictable
menses is highly suggestive of pregnancy.
Amenorrhea is not a reliable indicationof
pregnancy until 10 days or more after expected

4. menses onset. When a second menstrual period is
missed, the probability of pregnancy is much
greater.
Uterine bleeding somewhat suggestive of
menstruation occurs occasionallyafter conception.
 Nausea and vomiting.
Nausea occurs in 80% of nulliparous and 60% of
multiparous women. For many pregnant women
this is the first sign of pregnancy with the
symptoms occurring even before the first period is
missed.
The nausea and vomiting usually disappears by
16 weeks gestation and lessens in severity after
about 12 weeks.
 Change in cervicalmucus:
Dried cervicalmucus examined microscopically
has characteristicpatterns dependent on the stage
of the ovariancycle and the presence or absence of
pregnancy. Mucus crystallizationnecessary for the
production of the fern pattern is dependent on an
increased sodium chloride concentration. Cervical
mucus is relativelyrich in sodium chloride when
estrogen, but not progesterone, is being produced.
Thus, from approximately the 7th to the 18th day
of the cycle,a fern like pattern is seen.

5.  Anatomical changes in the breasts that ac-
company pregnancy are characteristicduring a
first pregnancy
 Change in uterus size:
During the first few weeks of pregnancy, the
increase in uterine size is limited principally to the
antero-posterior diameter. By 12 weeks, the body
of the uterus is almost globular with an average
diameter of 8 cm. At 6 to 8 weeks menstrual age, a
firm cervix is felt which contrasts with the now
softer fundus and compressible interposed
softened isthmus—the Hegar sign. The softening at
the isthmus may be so marked that the cervixand
the body of the uterus seem to be separate organs.
Pregnancy test.
 Measument of HCG:
Detection of hCG in maternal blood and urine
provides the basis for endocrine tests of pregnancy.
Human chorionicgonadotropin (hCG) is a
glycoproteinhormone that contains two
carbohydrate side chains: alpha (a) and beta (b).
The a subunit is identical to that of follicle
stimulating hormone (FSH), luteinizing hormone
(LH) and thyrotrophin (TSH). The b subunit is
immunologicallyspecific. HCG is secreted by the
trophoblast cells of the fertilized ovum and later by

6. the definitive placenta.
Trophoblast cells produce hCG in amounts that
increase exponentially following implantation.
With a sensitive test, the hormone can be detected
in maternal plasma or urine by 8 to 9 days after
ovulation.
False-positive hCG test results are rare
(Braunstein, 2002). A few women have circulating
serum factors that may interact with the hCG
antibody.
 Home pregnancy test:
This is a test done at home where the woman
urinates on a pregnancy kit strip. Two main sorts
are available:a double band of blue or a central
spot of pink indicates a positive test while a single
band of blue or absence of a pink spot indicates a
negative pregnancy test.
Bastian and colleagues(1998) evaluated studies
of home pregnancy test kits and found that testing
done by volunteers achieved a mean 91-percent
sensitivity. Importantly, actual patients obtained
only 75-percent sensitivity and a high false-
negative result rate.

7. Initial prenatal evaluation:
Prenatal care should be initiated as soon as there is a
reasonable likelihoodof pregnancy.
The major goals are to:
Define the health status of the mother and
fetus.
Estimate the gestational age.
Initiate a plan for continuing obstetrical care.

8. The three basic components of prenatal care are:
(1) Early and continuing risk assessment.
To reduce the risk of pregnancy complications.
Following a healthy, safe diet; getting regular
exercise as advised by a health care provider; and
avoiding exposure to potentially harmful
substances such as lead and radiationcan help
reduce the risk for problems during pregnancy and
ensure the infant's health and development.
Controlling existing conditions, such as high blood
pressure and diabetes, is important to avoid
serious complications in pregnancy such as
preeclampsia.
Reduce the infant's risk for complications.
Tobacco smoke and alcohol use during pregnancy
have been shown to increase the risk for Sudden
Infant Death Syndrome, alcohol use also increases
the risk for fetal alcoholspectrum disorders, which
can cause a variety of problems such as abnormal
facial features, having a small head, poor
coordination, poor memory, intellectualdisability,
and problems with the heart, kidneys, or bones.
According to one recent study supported by the
NIH, these and other long-term problems can occur
even with low levels of prenatal alcoholexposure.

9. (2) Health promotion.
Health promotion consists of providing
Information on proposed care, enhancing general
knowledge of pregnancy and parenting, and
promoting and supporting healthful behaviors.
(3) Medicaland psychosocial interventions and
follow-up.
Help ensure the medications women take are safe.
Certainmedications, including some acne
treatments and dietary and herbal supplements,
are not safe to take during pregnancy. For example
The acne medicine isotretinoin (such as
Amnesteem and Claravis). This medicine is very
likelyto cause birth defects also some antibiotics,
such as doxycycline and tetracycline.

10. Prenatal check up.
During pregnancy, regular checkups are very
important.
Typically, routine checkups occur:
• Once each month for weeks four through 28
• Twice a month for weeks 28 through 36
• Weekly for weeks 36 to birth
This consistent care can help keep the mother and
baby healthy, spot problems if they occur, and prevent
problems during delivery. Women with high-risk
pregnancies need to see their doctors more often.
The Frist Prenatal Visit:
Provides the opportunity to:
• Obtain general medical history and reproductive
history.
Review outcome of previous pregnancies and
assess pregnancy risk. Obtain previous records if
any abnormal outcome.
Perform genetic history, screening for inherited
illness and malformations.

11. Such reproductive histories as preterm birth, low
birth weight, preeclampsia, stillbirth, congenital
anomalies, and gestational diabetes are important
to obtain because of the substantial risk for
recurrence.
Women with prior cesareandelivery should be
asked about the circumstances of the delivery, and
discussion about options for the mode of delivery
for the current pregnancy should be initiated.
• Conduct physical examination.
Clinicians should be familiarwith physical findings
associated with normal pregnancy, such as systolic
murmurs, exaggeratedsplitting, and S3 during
cardiac auscultation, or spider angiomas, palmar
erythema, linea nigra, and striae gravidarum on
inspection of the skin. During the breast
examination, clinicians should initiate discussion
about breastfeeding.
A pelvic examination should be performed and Pap
smear status documented or obtained, to rule out
infections like chlamydia, syphilis Gonorrhea and
BacteriaVaginitis.

12. Followup visits:
At each return visit, steps are taken to determine the
well-beingof mother and fetus. Certain information is
considered especially important for example
assessment of gestational age and accurate
measurement of blood pressure.
Evaluationtypically includes:
Fetal
• Heart rate(s)
The fetal heart can first be heard in most women
between 16 and 19 weeks when carefully auscultated
with a standard nonamplified stethoscope. By 21
weeks, audible fetal heart sounds were present in 95
percent, and by 22 weeks they were heard in all. The
fetal heart rate now ranges from 110 to 160 bpm.
• Size.
To monitor the growth of the baby.
• Amount of amnionic fluid
The amount of amniotic fluid increases until the
beginning of the third trimester. At the peak of 34 to
36 weeks, may carry about a quart of amniotic fluid.
After that, it gradually decreases until birth.

13. Low levels of amniotic fluid can make complications
during labor more likely.
The main concern is that the fluid levelwill get so
low that the baby's movements or contractions will
compress the umbilicalcord.
• Fetal movements
Fetal movement should be felt 6-10times in two
hours.
Maternal
• Blood pressure.
High blood pressure during pregnancy is defined as a
reading of 140/90 or higher, even if just one of the
numbers is elevated. Severe chronic hypertension is
160/110 or higher.
• Weight.
Monitoring of weight gain can is believed to prevent
gestational hypertension and fetal macrosomia.There is
irrefutable evidence that maternal weight gain during
pregnancy influences birthweight.
• Symptoms—including headache, altered vision,
abdominal pain, nausea and vomiting, bleeding,
vaginal fluid leakage, and dysuria

14. • Height in centimeters of uterine fundus from pubic
symphysis .
Between20 and 34 weeks, the height of the
uterine fundus measured in centimeters correlates
closely with gestational age in weeks. The fundal
height should be measured as the distance over the
abdominal wallfrom the top of the symphysis
pubis to the top of the fundus.
• Vaginal examinationlate in pregnancy to monitor the,
Clinicalestimation of the pelvic capacity and its
general configuration. Also check for Consistency,
effacement, and dilatation of the cervix this is
mostly done from 37-40wks.

15. Pregnancy interventions and continuous test.
• Frist trimester screen
A screening test done at 11 to 14 weeks to detect
higher risk of:
Chromosomal disorders, including Down syndrome
and trisomy 18. It also can reveal multiple births.
• Provide indicated genetic carriertesting, e.g. Tay-
Sachs Disease, Sicklecell disease,
hemoglobinopathies.
 Screen for STDs, including HIV, and counsel about
prevention strategies.
HIV is a virus the attacks the CD4 cells in the body
and can lead to AIDS. Is a mother is infected with HIV
and not taking her anti-retroviral there is high chance
of passing it to the baby, it can be passed through
genital fluid and breast milk in this case. This
medications are mostly prescribed at the second
trimester. After birth for 6weeks the baby will still be
given medications for preventive measures.
• Test urine for protein and glucose at each visit to rule
out diabetes, kidney damage and Pre-eclampsia.
Ketone in the urine is due to decrease in amount of
carbohydrate so the body starts breaking down fat

16. to store as energy.
• Test for triple marker (alpha fetoprotein, BHCG,
estriol) at 15–17 weeks to screen for Down’s
syndrome and neural tube defects.
• Perform mid-trimester genetic amniocentesis for
women over age 35 and others at increased risk.
This test can diagnosis certain birth defects,
including:
Down syndrome: is the most frequent genetic
cause for mild to moderate mental retardation
and related medical problems. It is caused by a
chromosomal abnormality. For an unknown
reason, a change in cell growth results in 47
instead of the usual 46 chromosomes. This
extra chromosome changes the orderly
development of the body and brain.
Cystic fibrosis: one of the most commonserious
genetic (inherited) diseases. One out of every
400 couples is at risk for having childrenwith
CF. CF causes the body to make abnormal
secretions leading to mucous build-up. CF
mucous build-up can impair organs such as the
pancreas, the intestine and the lungs
Spinal bifida: is the most common of all birth

17. defects. Its name means clef spine, or a failure
of a fetal spine to close the right way when it is
developing before birth. It occurs very early in
pregnancy, roughly three to four weeks after
conception, before most women know that they
are pregnant. Any woman can have an affected
pregnancy. Most women who bear a child with
Spinal bifida have no family history of it.
This test is performed at 14 to 20 weeks. It may
be suggested for couples at higher risk for
genetic disorders. It also provides DNA for
paternity testing.
• Perform ultrasound exam at 18–20 weeks to screen
for other anomalies.
Reasons for ultrasound :
 Check for multiple fetus.
In this situation, ultrasonography is
invaluable in determining the number of
fetuses, the chorionicity, fetal
presentations, evidence of growth
retardation and fetal anomaly, the
presence of placenta previa, and any
suggestion of twin-to-twin transfusion.
 Diagnosis and confirmationof early
pregnancy.

18. The gestational sac can be visualized as
early as four and a half weeks of
gestation and the yolk sac at about five
weeks. The embryo can be observed and
measured by about five and a half weeks.
Ultrasound can also very importantly
confirm the site of the pregnancy is
within the cavity of the uterus.
 Asses possible risk of miscarriage,ectopic
pregnancy
 Placentallocalization.
Ultrasonography has become
indispensible in the localizationof the
site of the placenta and determining its
lower edges, thus making a diagnosis or
an exclusion of placenta previa. Other
placental abnormalities in conditions
such as diabetes, fetal hydrops, Rh
isoimmunization and severe intrauterine
growth retardation can also be assessed.
 Fetal malformationeg club foot, spinal
bifida, cleft palate.
 Determine is an intrauterine growth
retardation condition is present ( caused
by decrease in oxygen to the fetus and
mal-nutrition by the mother).

19.  Doppler ultrasound during pregnancy is
to check fetal umbilicalblood flow,
placental blood flow and blood flow in the
heart and brain. Its done at each visit to
monitor the fetal heart beat . Normal
heart rate at 6 weeks is around 90-110
beats per minute (bpm) and at 9 weeks is
140-170 bpm. At 5-8 weeks a bradycardia
(less than 90 bpm) is associated with a
high risk of miscarriage.
• Rescreen for gonorrhea, chlamydia, syphilis, and
group B streptococcus in mid-third trimester.
Gonorrhea and Chlamydia are STD that can lead to
pelvic inflammatory disease if not treated .
Group B streptococcus is a type of bacteria that live
in the vagina and rectum, but it could be passed to
the baby during birth, which can lead to death. GBS
is tested between 35 or 37 weeks, if its high in the
flora of the vagina antibiotics are given to treat it.
• Instruct about the course of normal pregnancy,
warning signs, e.g., decreased fetal movement,
rupture of membranes, bleeding, uterine
contractions.
• Ensure control of blood sugar for womenwith
diabetes mellitus.
Perform glucose load test (50 gram glu, one hour
blood sugar ) at 24-28wks to screen for gestational

20. Diabetes.
• Determine blood type and screen for blood type
antibody (Rh, Kell, other blood group
sensitization).
Rh negative womenwhere the fetus's father is
Rh positive, leading to a Rh positive pregnancy.
During birth, the mother may be exposed to the
infant's blood, and this causes the development of
antibodies, which may affect the health of
subsequent Rh+ pregnancies. In mild cases, the
fetus may have mild anemia with reticulocytosis. In
moderate or severe cases the fetus may have a more
marked anemia and erythroblastosis fetalis
(hemolytic disease of the newborn). When the
disease is very severe it may cause hydrops fetalis
or stillbirth. Rh disease is generally preventable by
treating the mother during pregnancy or soon after
delivery with an intramuscular injection of anti-
RhD immunoglobulin (Rho(D) immune globulin).
Administration of Rh immune globin to Rh negative
mother’s is done at 28wks.
• Determine hemoglobin or hematocrit, diagnose and
treat anemia.
Pregnant womenneed more iron than normal for
the increased amount of blood they produce during
pregnancy. Symptoms of a deficiency in iron

21. include feeling tired or faint, experiencing
shortness of breath, and becoming pale. Because
these symptoms are common for all pregnant
women, health care providers check iron levels
throughout pregnancy.
The ACOG recommends 27 milligrams of iron daily
(found in most prenatal vitamins) to reduce the
risk for iron-deficiency anemia. Some women may
need extra iron through iron supplements.
• Screen for hemoglobinopathy.
This is done at 26-28 weeks, The sicklecell
hemoglobinopathies (HbS S, HbS C, and HbS-Thal)
are hemolytic anemias characterized by recurrent
painful crises, systemic infection, and infarction of
various organ systems. HbS S is the most common,
and affects approximately one in 708 African
Americans. There is increased risk for fetal death,
so care routinely includes ultrasound assessment
of fetal growth and prenatal fetal heart rate
monitoring.
• Screen for tuberculosis; evaluate positives and
treat. ( for examplewomen with HIV have a high
risk of contacting TB)
• Encourage weight gain for very slender women.
Assess maternal weight and adequacy of
nutrition, counsel about diet, obtain additional
food sources if needed

22. • Screen for use of tobacco, alcoholand other drugs
Because they can cause preterm birth and sudden
infant death syndrome.
A brief, five step intervention program, referred to as
the “5 A’s” model, is recommended in clinicalpractice to
help pregnant women quit smoking
(Fiore2008,Melvin2000,ACOG2010).
The 5 A’s include the following:
 Ask about tobacco use.
 Advise to quit.
 Assess willingness to make a quit attempt.
 Assist in quit attempt.
 Arrange follow-up.
 Note: smoking can cause baby to have decrease in
oxygen supply and may lead to early labor, the
 Baby may also develop asthma or bronchitis
• Counsel about avoiding environmental exposure to
volatilehousehold chemical(e.g., paints, oven
cleaners, cleaning Xuid, lead, other heavy metals).
• Counsel about avoiding exposure to sick children
who might have transmissible viral illness
• Determine adequacy of living conditions and seek
improvement if needed.
• Determine if womanis being abused and arrange help
if needed.

23. • Non stress test .
This test is performed after 28 weeks to monitor
baby's health. It can show signs of fetal distress,
such as if the baby does not getting enough oxygen.
• Prescribe folic acid
Folic acid is a B vitamin (B9). It helps produce and
maintain new cells. This is especiallyimportant
during times when the cells are dividing and
growing rapidly such as infancy and pregnancy.
The United States Public Health Service recommends
that all pregnant women and women of childbearing
age [15 to 44 years] in the United States who are
capable of becoming pregnant should consume [a
supplement containing] 0.4 mg of folic acid per day for
the purpose of reducing their risk of having a
pregnancy affected with spinal bifida or other neural
tube defect (NTDs). Although a related form (called
folate) is present in orange juice and leafy, green
vegetables (such as kale and spinach), folate is not
absorbed as wellas folic acid. Most prenatal vitamins
contain the recommended 400 micrograms of folic
acid as well as other vitamins that pregnant women
and their developing fetus need. Folic acid has been
added to foods likecereals, breads, pasta, and other

24. grain-based foods. Studies show that taking folic acid
for 3 months before getting pregnant and 3 months
after conceiving can reduce the risk of NTDs, such as
spinal bifida, by up to 70%. In addition, taking 400
micrograms of folic acid daily reduces the risk for
neural tube defects by 70% also.
 Biophysical profile (BPP)
This test is used in the third trimester to monitor the
overall health of the baby and to help decide if the
baby should be delivered early.

25. High-risk pregnancy
Pregnancies with a greater chance of complications
are called"high-risk." But this doesn't mean there will
be problems.
The following factors may increase the risk of problems
during pregnancy:
• Very young age or older than 35
• Overweight or underweight
• Problems in previous pregnancy
• Health conditions you have before you become
pregnant, such as high blood pressure, diabetes,
autoimmune disorders, cancer, and HIV
• Pregnancy with twins or other multiples
Health problems also may develop during pregnancies
that make it high-risk, such as gestational diabetes or
preeclampsia.
Women with high-risk pregnancies need prenatal care
more often and sometimes from a specially trained
doctor. A maternal-fetal medicine specialist is a medical
doctor that cares for high-risk pregnancies.
In the case of post term pregnancy:
Post term Pregnancy is when gestational age has
passed above 40-42 weeks.

26. Ultrasound is conducted weeklyfor amniotic fluid
volume, fetal heart rate is monitored twice a week and
in most cases induction is advised.
Importance of Prenatal care.
Monitor baby's movement
After 28 weeks, it’s advised to keep track of baby's
movement. This willto notice if the fetus is moving less
than normal, which could be a sign that your fetus is in
distress. Count your baby's movements every day so
you know what is normal for you. If the count is less
than 10 movements within two hours or if you notice
the baby is moving less than normal. If your baby is not
moving at all its advised that the mother should go to
the nearest hospital.
Helps to reduce risk of miscarriages.
Noticed when a fetal heart beat is missing, an
ultrasound is advised to be positive.
Helps to reduce rate of premature birth.
Birth before 37weeks is considered preterm. The U.S
experienced a 20% increase in premature birth from
1990-2006.
Women who have little or no prenatal care or obese
women and those who have had preterm labor before
are at increased risk.
Preterm birth is the leading cause of newborn death
and disability.

27. Babies who survive often have lifetime health
complications for example breathing problems due
incomplete formation of the lungs, Cerebral palsy and
intellectualdisabilities.
Helps in monitoring high risk pregnancies.

28. References .
http://ob-ultrasound.net
Prenaral care Effectiveness and Implementation
Textbook ; Edited by MarieC. McCormick Harvard
School of Public Health, Boston, Massachusetts
www.hsph.harvard.edu/children and Joanna E. Siegel
Arlington Health Foundation, Arlington, Virginia.
https://www.womenshealth.gov/pregnancy/you-are-
pregnant/prenatal-care-tests.html
https://www.nichd.nih.gov/health/topics/preconcepti
oncare/conditioninfo/Pages/before-pregnancy.aspx
AmericanCollegeof Obstetricians and Gynecologists
(ACOG).
23rd Edition Williams Obstetrics