The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation
The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation
it will help the general public regarding the basic aspect of the antenatal care. it will also help to nursing and para medical educator to teach their students. it also create awareness about it.
Antenatal care is the routine health control of presumed healthy pregnant women without symptoms (screening), in order to diagnose diseases or complicating obstetric conditions without symptoms and to provide information about lifestyle, pregnancy and delivery.
it will help the general public regarding the basic aspect of the antenatal care. it will also help to nursing and para medical educator to teach their students. it also create awareness about it.
Antenatal care is the routine health control of presumed healthy pregnant women without symptoms (screening), in order to diagnose diseases or complicating obstetric conditions without symptoms and to provide information about lifestyle, pregnancy and delivery.
Obsterics and Gynaecology-
introduction-Preventive obstetrics is the concept of prevention or early detection of particular health deviations through routine periodic examinations and screening .
The concept of preventive obstetrics concerns with the concepts of the health & wellbeing of the mother her baby during the antenatal,intranatal & postnatal period.
The goal of the preventive obstetrics is the delivery of a healthy infant by a healthy mother at the end of a healthy pregnancy.
Pregnancy & child birth normal physiological
process that change from conception to
delivery.
Objectives
To promote , protect and maintain the health of the mother during pregnancy.
To detect “high risk” cases and give them special attention
To foresee complications and prevent them.
To remove anxiety and dread associated with delivery
Introduction
Screening of high risk cases
High risk cases (according to WHO)
Management of high risk cases
Risk approach (according to WHO)
Interventions to reduce maternal mortality
High risk approach in maternal and child healthShrooti Shah
High risk pregnancy is defined as one which is complicated by factor or factors that adversely affects the pregnancy outcome –maternal or perinatal or both.The risk factors may be pre-existing prior to or at the time of first antenatal visit or may develop subsequently in the ongoing pregnancy labour or puerperium.
Over 50 percent of all maternal complications and 60 percent of all primary caesarean sections arise from the high risk group of cases.
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CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
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Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
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2. INTRODUCTION
• The goal of prenatal care is to ensure the birth of a
healthy baby with minimal risk for the mother.
• Antenatal care represents a series of assessments and
interventions over time. It is not a single interventio
3. AIM OF ANTENATAL CARE
• To provide advice, reassurance, education and
support for woman and family.
• To treat associated minor symptoms.
• To provide an ongoing screening program to
confirm that pregnancy continues to be low risk.
• To identify high risk pregnancies so that
appropriate, timely management is provided to
prevent or minimize morbidity & mortality
4. TIMING of ANC
IDEALLY
Prenatal care should be initiated in the first
trimester and should provide comprehensive
medical care in second and third trimester.
BUT-Less than 50 percent of women in developing
regions receive early antenatal care
So second trimester care is important, even after
the initial prenatal assessment and patient
counseling
5. ANTENATAL CARE IN SECOND TRIMESTER
Second Trimester is from 14 to <28 weeks of gestation
Antenatal care in second Trimester is directed at
• Early, accurate estimation of gestational age
• Ongoing evaluation of the health status of both mother and fetus
• Anticipation of problems and intervention.
6. FREQUENCY OF VISITS
ACOG
RECOMMENDATIONS
• NULLIPAROUS WOMEN WITH
UNCOMPLICATED PREGNANCIES
(16 VISITS) :-
1. Every 4 weeks tilL 28 weeks
2. Every 2 weeks from 28 -36
weeks
3. Weekly until delivery
• PAROUS WOMEN WITH
UNCOMPLICATED MEDICAL AND
OBSTETRICAL HISTORIES=less
frequently.
• WOMEN WITH PROBLEMS are
seen more frequently, depending
on the nature of the problems.
NICE GUIDELINES
• 10 appointments
for nulliparous
women
• 7 appointments
for parous women
• Each visit should
have a specific
purpose/goal
•Minimum of eight antenatal
visits for all women, regardless
of parity
•One visit in the first trimester
•Two in the second trimester
•Five in the third trimester.
•High risk pregnancies need
additional care
WHO GUIDELINES 2016
7. CARE PROVIDER ?
Standard one-on-one care
by midwives, obstetrician-
gynecologists, family
medicine clinicians, and
maternal-fetal medicine
(MFM) subspecialists.
Group prenatal care
• Participants with the same
month of expected delivery
receive the majority of their
care in a group setting.
• The only private time
between patient and
clinician is during the initial
prenatal assessment, when
health concerns involving
need for privacy arise, and
during cervical assessment
late in pregnancy.
• Majority of the visit, which
may last two hours, involves
facilitated group discussion,
education, and skills building
to address explicit learning
objectives in prenatal care,
childbirth preparation, and
postpartum and parenting
roles.
Subspecialty obstetrical care
Referral to a MFM subspecialist
• chronic health conditions
• pregnancy complications in the past
• develop complications during their
current pregnancy
Multidisciplinary care
Women with medical comorbidities:
collaborative multidisciplinary care by a
team including obstetric provider and
appropriate medical or surgical
subspecialists, specialists in genetics,
anesthesia and pediatrics.
8. INITIAL EVALUATION IF FIRST
VISIT IN SECOND TRIMESTER
• - Medical/Obstetrical history
• - Psychosocial history
• - Correct estimation of period of gestation.
Examination
General Physical Exam : Resp /cardiac system
Obstetric Examination
History
9. INITIAL EVALUATION IF FIRST VISIT IN
SECOND TRIMESTER
Standard panel
• Rhesus type and antibody screen
• Hematocrit or hemoglobin and mean
corpuscular volume
• Rubella immunity and varicella
• Qualitative assessment of Urine
protein
• Urine culture
• Cervical cancer screening acc to
standard guidelines
• Human immunodeficiency virus
• Syphilis
• Hepatitis B virus
Selective screening
Thyroid function
Type 2 diabetes
Infection
• - Gonorrhea
• - Hepatitis C
• - Tuberculosis
• - Toxoplasmosis
• - Bacterial vaginosis
• - Trichomonas vaginalis
- Herpes simplex virus
- Cytomegaloviru
- Zika
- Chagas disease
Laboratory tests
10. Ongoing Assessments
Screening and diagnostic testing if not performed at the first prenatal
visit or later in the first trimester are done now :
●Red cell antibodies (Rh Negative Prge)
●Current or past infection (sexually transmitted diseases, bacteriuria,
rubella immunity)
●Inherited disorders (eg, cystic fibrosis, fragile X, spinal muscular
atrophy, hemoglobinopathy)
●Fetal aneuploidy (eg, trisomy 21) screening
●Thyroid disease
11. INITIAL EVALUATION IF FIRST VISIT IN
SECOND TRIMESTER
Ultrasound examination
Discussion of screening and testing for
genetic abnormalities in offspring
Aneuploidy
Carrier screening= ethnic-specific, panethnic, and
expanded carrier screening acceptable strategies
12. SONOGRAPHY : SECOND TRIMESTER
Fetal number
Fetal presentation
Placental localization
AFI
Fetal biometry and EFW
To r/o CMF
To evaluate maternal pelvic masses
13. 15 to 24 weeks of Gestation:Screening
• Neural tube defects — maternal serum alpha-fetoprotein
and ultrasound are both effective methods.
• Trisomy 21 — Quadruple test= level of alpha-fetoprotein
(AFP), unconjugated estriol (uE3), hCG, and inhibin A in
maternal serum between 15 and 22 weeks of gestation.
• Fetal anomalies — ultrasound screening for fetal structural
anomalies, is optimally performed in the second trimester,
between 18 and 22 weeks of gestation
• Cervical length — Transvaginal ultrasound measurement of
short cervical length between 16 and 28 weeks of gestation
is associated with an increased risk of spontaneous preterm
birth <35 weeks. It can be measured when the patient
undergoes ultrasound examination for fetal anomalies.
14.
15. 24 to 28 weeks of Gestation: Screening
• Gestational diabetes — Universal screening for
gestational diabetes is recommended at First visit, and
repeated at 24 to 28 weeks of gestation.
• RBC antibodies — In Rh(D)-negative women, red cell
(RBC) antibody screening is repeated at 28 weeks of
gestation and anti-D immune globulin is administered.
• Hemoglobin or hematocrit — The hemoglobin or
hematocrit should be rechecked to assess for anemia.
16. SCREENING FOR DEPRESSION
• Pregnant women should be assessed AT
LEAST ONCE during pregnancy or the
postpartum period for depression and
anxiety symptoms using a` validated
screening tool
• The Edinburgh Postnatal Depression Scale is
commonly used
• No consensus for optimal time
• Women who screen positive referred for
further evaluation and counseling
17. FOLLOW-UP VISITS
Ongoing Assessments
• Measurement of blood pressure
• Measurement of weight
• Urine dipstick for protein, although the value of
this test is questionable in women with normal
blood pressure
• Assess fetal growth either through measurement
of fundal height or by ultrasound evaluation for
women with risk factors for intrauterine growth
restriction.
• Assessment of maternal perception of fetal
activity
• Assessment of significant events since prior visit,
such as recent travel, illness, stressors, or
exposure to infection (eg, Zika virus) etc.
18. FOLLOW UP VISITS-Periodic assessments
Prenatal screening should be performed early WITHIN
RECOMMENDED INTERVALS to allow adequate time for:-
• Follow-up of screening tests
• Performance of diagnostic tests
• Counseling about test results
• Discussion of management options, including
termination of pregnancy if the patient chooses this
approach.
19. MANAGEMENT OF PREGNANCY
COMPLICATIONS -Risk approach
• Risk is the possibility of coming to harm
• Vulnerability is the degree to which one would be
adversely impacted by the risk
• Vulnerability is a parameter which we
can influence
20.
21. Management of common discomforts
- Nausea and vomiting
- Gastroesophageal reflux disease
- Constipation
- Hemorrhoids
- Rhinitis and epistaxis
- Gingivitis
- Difficulty sleeping
- Headache
- Back pain and sciatica
- Leg cramps
- Peripheral edema
- Varicose veins
- Diarrhea
- Urinary frequency and nocturia
22. NAUSEA & VOMITING
Nausea is the most common GI symptoms during pregnancy
(80-85%) during 1st trimester
Nausea + vomiting - 52%
Nausea & vomiting of pregnancy manifests before 9 wks of
POG & subsides by 16-20 wks of pregnancy.
Treatment – reassurance
Dietary modifications
Ginger 250 mg thrice/day
Acupressure
Pharmacological t/t
23. BACKACHE
• Low backache – 70% of pregnant ladies
• Causes –
• excessive straining / fatigue
• excessive bending, lifting, walking
• acute strain / fibrositis
• Reduced by preventing bending, sitting with
back support
• Avoid high healed shoes
• severe backache – orthopaedic consultation
24. PAIN ABDOMEN
• Pain abd results from 3
sources
• Physiological effects of
pregnancy
• pathological causes during
pregnancy
• pathological causes unrelated
to pregnancy
• Physiological conditions
causing pain abd
• Round ligament pain
• Braxton hicks contractions
• Misc – heart burn, excessive
vomiting, constipation
•
RL pain BH
contractions
Misc (heart
burn,
contipation)
pain cramping/stabbing
agg by movement
irregular
tightening
mild/varied
prev
anomaly
- - fibroid
urine - - -
trimester late 1st / 2nd late 2nd /3rd 3rd
tenderness over the area of RL irregular
contraction
-
inv normal normal normal
t/t
(exclude
pathologic
al causes)
reassurance
reduce physical
activity
observation
, rule out
true labour
25. VAGINAL DISCHARGE
• Pregnant women usually produce more vaginal
discharge due to increased mucus secretion in response
to hyperestrogenemia.
• Troublesome & copious vaginal discharge may indicate
infection & a per speculum exam should be done.
• Fishy –smelling discharge
• Curdy white discharge
• Foamy greenish discharge
26. HEART BURN
• Reflux of gastric contents in lower oesophagus
• Occurs in late trimester
• Due to upward displacement & compression of
stomach by uterus & relaxation of lower
oesophageal sphincter
• Management :-
• Dietary modification
• Lying propped up
• Antacids
• Sodium Alginate
27. CONSTIPATION
• Common during pregnancy
• Caused by increased bowel transit time & large bowel compression by
enlarged uterus or by presenting head
• May be ass with pain & bleeding during daefecation
• Management :-
• High fiber diet
• Plenty of fluids
• Laxatives
• Stool softener
28. VARICOSITIES
• Pooling of blood in surface veins as a resulting of
inefficient valves
• Congenital predisposition
• Exaggerated by prolonged standing , pregnancy &
advancing age
• Become prominent as pregnancy advances & weight
increases
• Management :-
• Bed rest
• Leg elevation
• External pneumatic intermittent compressio
29. HAEMORHOIDS
• Exacerbated by pregnancy
• Caused by
• Obstruction of venous return by enlarged uterus
• Constipation during pregnancy
• Symptoms :-
• bleeding per rectum
• pain (thrombosis)
• Management :-
• High fiber diet
• Stool softener
• Local anesthetic agents
30. Assessment of Fetal Well Being at ANC
• Progressive Fundal height growth as per expectation
• Adequate maternal perception of fetal movements
• Ultrasonographic fetal assessment esp. for anomalies
31. Counseling
Counseling about Diet, Exercise, Rest, Immunisation,weight gain ,
Alcohol, Smoking, Dress, Personal hygiene and warning symptoms
32. SECOND TRIMESTER WORK UP
(14-28 Weeks)
Ongoing Preg in Second trimesterInitial Booking in first trimester
Recommended
Wt, BP, Hb
Blood group and
Rh (Both
partners
Urine — R/M,
VDRL, HpB, HIV,
TSH; DIPSI
Dating Scan +NT
+ Dual marker +
Cervical length
Preferable
BMI, MAP, CBC,
(Peripheral) smear,
electrophoresisHPLC
MSU + Culture HCV,
Rubella IgG
Recommended
Repeat blood tests
Hemoglobin
TSH
Urine dipstick DPISI
Quadruple/triple
marker Anomaly scan
Cervical length
Preferable
NIPT
Uterine artery
Doppler 2D-4D scan
Fetal
echocardiography
IDENTIFY HIGH RISK CASES
AND
INDIVIDUUALIZE MANAGEMENT
History & Examination
• Medical/obstetrical history
• Psychosocial history
• Estimation of gestational age
33. SECOND TRIMESTER WORK UP
(14-28 Weeks)
Initial Booking in Second trimester
Rcommended
Wt, BP, Hb
Blood group and Rh (Both
partners
Urine — R/M, VDRL, Hepatitis
B, HIV, TSH; DIPSI
Quadruple/triple marker
Anomaly scan
Cervical length
Preferable
BMI, MAP, CBC,
(Peripheral) smear,
electrophoresis HPLC
MSU + Culture HCV,
Rubella IgG
NIPT
Uterine artery Doppler
2D-4D scan
Fetal echocardiography
History & Examination
• Medical/obstetrical history
• Psychosocial history
• Estimation of gestational age
IDENTIFY HIGH RISK CASES
AND
INDIVIDUUALIZE MANAGEMENT
37. NUTRITION
CALORIE REQUIREMENTS
• Pregnant women of normal weight with a singleton
pregnancy need to increase daily caloric intake by
340 and 450 additional kcal/day in the second and
third trimesters, respectively, for appropriate weight
gain
• Recommended daily allowance (RDA) for an Indian
reference woman ( 20 – 29 yrs, weighing 50 kg)
•
particulars Kcal/da
y
protein (g/d) fat (g/d)
nonpregnant 2200 50 20
pregnant +300 +15 30
lactating +550
+400
+25
+18
45
38. NUTRITION AND
MICRONUTRIENTS
• Balanced Diet (ICMR)
• Carbohydrate – 50-70%
• Protein – 15 – 20%
• Fat – 20 – 30% ( essential fatty acid – 50%)
• Micronutrients
• The Institute of Medicine and the Centers for
Disease Control and Prevention recommend
multiple-micronutrient supplements (commonly
called multivitamin supplements) for pregnant
women who do not consume an adequate diet or
may have malabsorption.
• Well-nourished women may not need multiple-
micronutrient supplements
39.
40. NUTRITION
FOOD HYGIENE
Practice good personal hygiene (frequent hand washing)
●Consume only meats, fish, and poultry (including eggs) that are
fully cooked
●Avoid unpasteurized dairy products and fruit/vegetable juices
●Thoroughly rinse fresh fruits and vegetables under running water
(about 30 seconds) before eating
●Avoid eating raw sprouts (including alfalfa, clover, radish, and
mung bean). Bacteria can get into sprout seeds through cracks in
the shell; these bacteria are nearly impossible to wash out.
●Wash hands, food preparation surfaces, cutting boards, dishes,
and utensils that come in contact with raw meat, poultry, or fish
with hot, soapy water. Countertops can be sanitized by wiping with
a solution of one teaspoon liquid chlorine bleach per quart of
water and leaving to dry over 10 minutes.
41. EXERCISE DURING PREGNANCY
RECOMMENDATIONS
• Physical activity in pregnancy has minimal risks and
benefits most women, but some modification to exercise
routines may be necessary because of normal anatomic
and physiologic changes and fetal requirements.
• Before recommending an exercise program, a thorough
clinical evaluation should be done to ensure that the
patient does not have a medical reason to avoid exercise.
• Women with uncomplicated pregnancies should be
encouraged to engage in aerobic and strength conditioning
exercises before, during, and after pregnancy.
• Bed rest, although frequently prescribed in the past (for
prevention of second-trimester loss, preterm birth, and
other conditions) is rarely indicated and, in most cases,
allowing ambulation such as walking should be considere
42. EXERCISE DURING PREGNANCY
ACOG(2015)
A thorough clinical exams mandatory before recommending
an exercise program.
In the absence of C/I –regular, moderate intensity physical
activity for 30 min/day is recommended for pregnant women
Activities with a high risk of falling, abdominal trauma/ scuba
diving (increase fetal risk of decompression sickness) should be
avoided.
43. TRAVEL
CONSIDER SEVERAL ISSUES:
● Risk of pregnancy complications away from their usual
source of medical care, as well as the availability of medical
resources and their medical insurance coverage at their
destination.
● Increased risk of venous thromboembolism during
pregnancy and with prolonged immobility during the trip.
●Issues related to air travel (eg, access to medical
providers, lower oxygen environment, restricted
movement).
● Potentially increased risk of exposure to infectious
diseases (eg, travelers' diarrhea, malaria, Zika virus), as
well as prophylaxis, prevention and treatment of these
diseases.
44. TRAVEL:AUTOMOBILE-
Use of seat belts and air bags
• Pregnant women should continue wearing three-point seat
belts during pregnancy.
• The lap belt is placed across the hips and below the uterus;
the shoulder belt goes between breasts and lateral to the
uterus.
• ACOG=pregnant occupants of motor vehicles wear lap and
shoulder seatbelts and should not turn off air bags
45. TRAVEL: AUTOMOBILE
Use of seat belts and air bags
The correct use of seatbelts in pregnancy:
• Above and below the bump, not over it.
• Use three-point seatbelts with the lap strap placed as
low as possible beneath the ‘bump’, lying across the
thighs with the diagonal shoulder strap above the
bump lying between the breasts.
• Adjust the fit to be as snug as comfortably possible
46. TRAVEL:AIR TRAVEL
• Most airlines allow women to fly up to 37 weeks POG.
• Commercial airline travel is generally safe for women with uncomplicated
pregnancies ;Fetal heart rate is not affected during flight if the mother
and fetus are healthy
• Women with complicated pregnancies that may be exacerbated by flight
conditions or require emergency care should avoid air travel.
• All airline travelers should maintain hydration and periodically move their
lower extremities to minimize stasis and reduce the risk of venous
thrombosis; use of compression stockings and avoidance of restrictive
clothing may also be helpful. Seat belts should be worn continuously to
protect against injury from unexpected turbulence.
• Supplemental oxygen should be administered to pregnant women (eg,
women with sickle cell disease, severe anemia [hemoglobin <8 g/dL], or
cyanotic heart disease) who must travel and may not tolerate the
relatively hypoxic environment of high altitude flying, even in pressurized
aircraft.
47. Hair dyes and Cosmetic products
• Exposure to hair dyes or hair grooming/styling products results in
very limited systemic absorption, unless the integrity of scalp skin is
compromised by disease.
• Therefore, these chemicals are unlikely to cause adverse fetal effects
in women with a normal scalp
• Plant-based hair dyes are probably safe and there is no information
on whether non-ammonia versus ammonia-based products are safer.
• Avoid ammonia- and peroxide-based products, given the wide
availability of non-ammonia-based products.
• Use these products in a well-ventilated area since women with
asthma/allergies may be more sensitive to the scents during
pregnancy.
• Avoid new products since skin sensitivity is more common in
pregnancy.
• limited data on the safety of cosmetics. Skin may be more sensitive in
pregnancy. Some nail polishes have toludene, formaldehyde, and
dibutyl phthalate; these toxins may be inhaled when applied or
absorbed from the nail bed, so it is prudent to apply nail polish in a
well ventilated place.
48. Sexual intercourse in pregnancy
PREGNANT WOMAN SHOULD BE INFORMED THAT
SEXUAL INTERCOURSE IN PREGNANCY IS NOT
KNOWN TO BE ASSOCIATED WITH ANY ADVERSE
OUTCOMES.
• In the absence of pregnancy complications (eg,
vaginal bleeding, ruptured membranes), there is
insufficient evidence to recommend against sexual
intercourse during pregnancy.
• Whenever abortion or preterm labour is a threat,
coitus should be avoided. Otherwise it is allowed
with less frequency and violence.
• Abstinence in the last 4 weeks of pregnancy for fear
of ascending infection may be considered
49. IRON SUPPLEMENTATION
WHO
iron 60mg + folic acid 400μg/day
• supplementation starting in second trimester &
continuing for the rest of pregnancy & 3 mths
postpartum
Anaemia Prophylaxis MOHFW INDIA Six months in
pregnancy and six months after delivery
• Nonanaemic preg women – 100mg elemental iron &
500μg of FA daily
• Anaemic pregnant women – 200mg elemental iron &
1 mg FA/day
51. IMMUNISATION
Tetanus toxoid. 2 doses or one dose of T Dap
Tetanus Toxoid
1st dose: Between 16–20 weeks, 2nd dose: After 4–6 weeks
after the 1st dose.
Tdap
• Can replace TT (wherever available)
• Single dose replaces both doses of TT
• Administered 28–36 weeks, if previously immunized
• If not Immunized then Two doses of TT and 1 dose of T dap
Influenza:
Infuenza vaccine
(during flu season) Intramuscular after first trimester .(FOGSI Recomm
2017)
53. IMMUNISATION
Recommended vaccines under “Special Situations”
• Rabies: Where the benefits outweigh the risks involved
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
54. Prevention of infection {ACOG}
Women should be offered routine screening for asymptomatic
bacteriuria by midstream urine culture early {12 and 16 wks} in
pregnancy, Identification and treatment of asymptomatic bacteriuria
reduces the risk of pyelonephritis.
Routine screening for bacterial vaginosis should not be offered because
evidence suggests that : identification and treatment of asymptomatic
bacterial vaginosis does not lower the risk for preterm birth and other
adverse reproductive outcomes.
Chlamydia screening should not be offered as part of routine antenatal
care.
Serological screening for hepatitis B virus has to be done to provide
effective postnatal intervention to decrease the risk of mother-to child
transmission
55. Screening for syphilis has to be done in all pregnant women at first
prenatal visit. Repeat serologic testing at 28 wks and delivery is
recommended in women at increased risk.
Rubella susceptibility screening should be done early in antenatal
period to identify women, at risk of contracting rubella infection and
to enable vaccination in the postnatal period for the protection of
future pregnancies.
Pregnant women may not be offered routine screening for hepatitis
C virus as there is insufficient evidence to support its effectiveness
and cost-effectiveness.
Prevention of infection {ACOG}
56. Routine antenatal serological screening for toxoplasmosis is not required
as risks of screening may outweigh the potential benefits.
Pregnant women should be informed of primary prevention measures
to avoid toxoplasmosis infection such as:
• Washing hands before handling food
• Thoroughly washing all fruit and vegetables, including ready-prepared
salads, before eating
• Thoroughly cooking raw meats and ready-prepared chilled meals
• Wearing gloves and thoroughly washing hands after handling soil and
gardening
• Avoiding cat faeces in cat litter or in soil
Prevention of infection {ACOG}
57. Group B streptococcal {GBS} screening can be offered in all women
by vaginorectal culture at 35 to 37 wks as recommended by ACOG.
All pregnant women should be asked about h/o chickenpox. Women
with no h/o varicella should have serologic testing for VZV IgG to
determine immunity {80-90 % are found to be immune}.
Prevention of infection {ACOG}
58. Exposure of high dose ionizing radiation in pregnancy is:
• Lethal------------ preimplantation stage
• Teratogenic----- organogenesis
• Growth restriction & CNS effects---- fetal period
No increased risk of malformations, growth restriction
or
abortion from a radiation dose of <5 rad.
RADIATION
59. Employment
• Physically demanding work - increase preterm birth ,IUGR
&PIH (Mozurlumich,2000 - 1,60,000 pregnant
women)
• Occupation “Fatigue index” incorporates 5 sources of
occupation hazard.
• Posture
• Type of work
• Physical exertion
• Mental stress
• Situational factors or environmental hazards (e.g. noise,heat)
• Strong relation b/w adverse pregnancy outcome & fatigue
index
• Recommendation for pregnant women ACOG 2002
• Any occupation causing severe physical strain should be avoided
• No work should be continued to the extent that undue fatigue develops
• Adequate periods of rest in b/w work
• Women with prev preg. complication (IUGR, preterm delivery) should
minimize physical work
• Women with uncomplicated preg. can continue work till onset of labour
60. BATHING
• Early pregnancy exposure to hot tub/Jacuzzi at 1000F
or higher -increases incidence of miscarriage & NTDs.
• Late pregnancy - (heavy uterus can upset the balance
of pregnant woman) - increase likelihood of slipping/
falling in bath tub.
61. CLOTHING
• Preferably comfortable +non-contricting
• Proper breast support (increase mass of breast may make them pendulous &
painful)
62. SHOES
• Wear low-heeled (but not flat) shoes with good arch
support
• High - heeled shoes should be discouraged as they
increase lumbar lordosis, back strain and risk of falling.
63. ALCOHOL INTAKE
●Alcohol consumption =negative effects throughout pregnancy
●No exact dose-response relationship between the amount of
alcohol consumed and the extent of damage caused by alcohol in
the infant.
Abstinence IS RECOMMENDED from alcohol at conception and
during pregnancy (Grade 1C).
●Identification and counseling of women who use alcohol can
decrease intake during pregnancy.
●The T-ACE, TWEAK, or AUDIT-C screening tool can be used to
identify women who may be at risk for prenatal alcohol use.
●For pregnant women who consume alcohol but are not heavy
drinkers, recommend a brief intervention (eg, educational
session(s), motivational counseling) rather than no intervention or
more extensive alcohol cessation programs (Grade 1A).
● Women with heavy drinking patterns who are unlikely to reduce
their consumption should be referred to professional alcohol
treatment.
64. CIGARETTE SMOKING
NOT RECOMMENDED
Women who smoke/exposed to secondhand smoke during
pregnancy are at greater risk for spontaneous pregnancy
losses, preterm delivery, low birth weight (LBW), preterm
premature rupture of membranes (PPROM), placenta previa,
abruptio placentae, and stillbirth. Most of these risks are
reduced by smoking cessation
Quitting at any time during pregnancy can have some
beneficial effects. Women are more likely to be successful if
encouraged to quit, rather than cut down.
The five A's (ask, advise, assess, assist, and arrange) provide a
general approach to helping patients stop smoking
For women who are heavy smokers and are unable to quit on
their own, pharmacotherapy is advised(Grade 2B). Nicotine
replacement therapy and bupropion are reasonable first-line
drug options.
65. SIGNS AND SYMPTOMS THAT SHOULD BE
REPORTED TO THE HEALTH CARE PROVIDER
OBSTETRIC
●Vaginal bleeding
●Leakage of fluid per vagina
●Decreased fetal activity
●Signs of preterm labor (eg, low backache; increased
uterine activity compared to previous patterns;
menstrual-like cramps; diarrhea; increased pelvic
pressure; vaginal leaking of clear fluid, spotting or
bleeding, contractions)
●Signs of preeclampsia (eg, headache not responsive to
acetaminophen, visual changes that do not resolve after a
few minutes, persistent right upper quadrant abdominal
pain)
● Signs or symptoms suggestive of a MEDICAL
OR SURGICAL DISORDER