Comprehensive description of antenatal care, and different objectives and elements of care

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ANTENATAL CARE
Learning objectives:
After reading this chapter students will be able to learn:
1) Definition of antenatal care and its objectives
2) Essential antenatal care services
3) Physical examination and history taking in obstetrics and gyneacology
4) Health education of pregnant women
Definition: Antenatal care is the care given during the period of gestation.
It is essential even for a normal and healthy, pregnant women for her own well- being and
that of the baby to beborn because no pregnancy and child birth is free from risk for both mother
and baby. Ideally the care should start immediately after conception but practically as early as
possible during the first trimester and should continue throught the second and third trimesters.
Objectives of Antenatal Care:
1) To promote, protect and maintain the health of the mother during pregnancy.
2) To detect “high risk” cases and give them special attention.
3) To foresee complications and prevent them.
4) To remove anxiety and dread associated with delivery.
5) To reduce maternal and infant mortality and morbidity.
6) To teach the mother elements of child care, nutrition, personal hygiene, and environmental
sanitation.
To sensitize the mother to the need for family planning,
including advice tocases seeking medical termination of
pregnancy.
7) To detect and treat any abnormality found in pregnancy as early as possible.
Essential Antenatal Care Services:
The essential components of services during pregnancy include are:-
1) Registration of Pregnant Women
2) Antenatal Visits and Antenatal Care
3) Immunization Against Tetanus
4) Iron and Folic Acid and Vitamin A and D Supplementation
5) Health education / prenatal advice during Pregnancy
1) REGISTRATION OF THE PREGNANT WOMEN: Care during pregnancy should
be started as early as possible. The mother must be registered within 20 weeks of
pregnancy either at health centre/ antenatal clinicor at home by a nurse/health visitor/
female health worker (ANM) or trained person. hrough physical and obstetrical check up
should be done to screen for risk factors, make assessment and give appropriate care for
prevention and control of various health problems and complications.
2) ANTENATAL VISITS AND ANTENATAL CARE: Idealy ANC visits include
 First 28 weeks: Once a month
 Upto 36 weeks: Twice a month (Every 15 days)

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 There after weekly till delivery
Minimum Visits includes:
 1st
visit: Around 16 weeks
 2nd
visit: Between 24 weeks and 28 weeks
 3rd
visit: At 32 weeks
 4th
visit: At 36 weeks
Further visits may be made if justified by the condition of the mother. The main purpose
of contact duringantenatal period is to make observations and assess general health,
obstetrical health status, identify risk factors and provide appropriate care.
The preventive services for mothers in the prenatal period are as follows:-The first visit
irrespective of when itoccurs should include:-
1) Taking Health History:
It includes recording history of menstruation, medical history, obstetrical history, socioeconomic
history.
2) Physical Examination:
It includes recording of height, weight, blood pressure, temperature, pulse etc. general
observations from head totoe.
3) Obstetrical Examination:
It includes general observations, examination of breasts, abdominal measurement,
palpation and inspection,vaginal examination if necessary.
4) Laboratory
Investigation
s
• Complete urine
analysis
• Stool examination
• Complete blood count including Hbg estimation.
• Serological examination.
• Blood grouping and Rh determination.
• Chest X- ray, if needed
• Gonorrhea test, if needed
5) On subsequent visits:
• Physical examination including weight and blood pressure
• Laboratory tests including urine examination and hemoglobin estimation
• Iron and folic acid supplementation and medications as needed.
• Immunization against tetanus
• Group or individual teaching on nutrition, self care, family planning, delivery and parenthood
• Home visiting by a female health worker or trained person (trained traditional birth attendant)
• Referral services, when necessary
Risk Approach:
While continuing to provide appropriate care for all mothers, ‘high risk’
cases must be identified as early as possible and arrangements to be made
for skilled care. These casescomprise the following:-
 Women below 18 years of age or over 35 years in primigravida.
 Women who have had four or more pregnancies and deliveries.
 Short structured primigravida

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 Those who have practiced less than 2 years or more than 10 years of birth spacing.
 Those with cephalopelvic disproportion (CPD), genital prolapse.
 Malpresentations, e.g. breech, transverse lie etc.
 Antepartum hemorrhage, threatened abortion
 Preeclampsia and eclampsia
 Anemia
 Twins, hydramnios
 Previous stillbirth, intrauterine death, manual removal of placenta
 elderly grandmultipara
 Those mother with blood Rh negative.
 Those with obesity and malnutrition.
 Prolonged pregnancy ( 14 days beyond expected date of delivery) Previous cesarean or instrumental
delivery
 Pregnancy associated with medical conditions, e.g.
cardiovascular disease, kidneydisease, diabetes, tuberculosis,
liver disease etc.
The purpose of risk approach is to provide maximum services to all pregnant women with
attention to those who needthem most. Maximum utilization of all resources, including human
resources is involved in such care. Services of traditional birth attendants, community health
workers and women’s groups are utilized. The risk strategy is expected to lead to improvements
in both the quality and coverage of health care at all levels, particularly at primary health care
level.
Prevention:
• Administration of folic acid 5mg daily months before conception.
• By improving pre- pregnancy health of woman.
• Providing quality antenatal care.
• Screening all pregnancies for high risk.
• Provide appropriate clinical and technological care by specialist on time.
• Prevent all kinds of infection.
• Early diagnosis of malformation and termination.
• Avoidance of medication (without physician’s prescription).
• Health education on MCH and FP care.
Maintenance of Records:
The antenatal card is prepared at the first examination. It is generally made of thick paper to
facilitate filing. Itcontains a registration number, identifying data, previous health history, and
main health events.
3) IMMUNIZATION AGAINST TETANUS: A pregnant woman must get two injections
of Tetanus Toxoid during the period between 16 – 36 weeks, at one month interval. These
protect the mother and baby both fromthe risk of tetanus. The 2nd injection should
preferably be given at least at one month before delivery. If a woman is registered late
then in that case even one injection
will do. If the woman is immunized earlier within three years of the pregnancy, then one

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booster dose will beenough.
Vaccination schedule in pregnancy:
Vaccine Minimum interval Duration of protection
TT1 As early as possible during pregnancy None
TT2 After 4 weeks 3 years of protection for mother
TT3 After 6 months 5 years of protection
TT4 After 1 year 10 years of protection
TT5 After 1 year Lifetime
4) IRON AND FOLIC ACID AND VITAMIN A AND D SUPPLEMENTATION: It is
being found that 50- 60 percent of pregnant women are anaemic due to iron deficiencies.
Anaemia is also aggravated in pregnancy.
It is therefore important to take one tablet containing 60 mg of elemental iron and 500
mg of folic acid threetimes daily after third month of pregnancy till 3 months after child
birth if the mother is found
having anaemia.
During pregnancy, the mother requires extra iron and folic acid due to changes taking
place in the body and growth of fetus in the womb. Therefore each mother is given one
tablet of iron and folic acid twice a dayfor at least 100 days to prevent anaemia in mother
and to promote proper growth of fetus.
Anemia is common in pregnancy and low – income group. It is a major cause of maternal and
fetal mortality.
5) HEALTH EDUCATION / PRENATAL ADVICE DURING PREGNANCY:
A major component of antenatal care is health education and prenatal advice. The
mother is more receptive to advice concerning herself and her baby at this time than any
other time. A woman during pregnancy needs to know about her nutrition, personal
hygiene, rest and sleep, exercise, use of drugs, warningsigns etc.
Pregnancy can be both an exciting and worrying time for the mother and her
partner. Part of the role ofthe health care professionals (usually fulfilled by the
community midwife and general practitioner) caring forthe mother is the provision of
information about everyday activities that may or may not be affected by or have an
effect on the
pregnancy.
1) DIET DURING PREGNANCY: Supplementary iron therapy is needed for all the pregnant
mothers till 20 weeksof gestation. Additionally daily required amount of carbohydrates,
proteins and fats should also be maintained.
2) PERSONAL HYGIENE: Daily bath is recommended as it is refreshing, relaxing and
prevents from number ofdiseases.
3) REST AND SLEEP: Eight hour sleep in night and at least 2 hour sleep after mid day meal.
4) PHYSICAL WORK: Hard strenous work is avoided in 1st
trimester and last 4 weeks.
5) EXERCISE: Walk in moderation, avoid lifting heavy things; avoid long time standing,
Avoid sitting with crosslegs.
6) COMFORTABLE CLOTHING AND SHOES: Tight belts and clothes are avoided; the
patient should wearloose but comfortable dresses. High heel shoes are better avoided.
7) SMOKING AND DRUGS: Alcohol, smoking and drugs should be avoided as they can

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effect the fetal wellbeing
8) BREAST CARE: Wash the breast regularly with clean tap water
9) PROTECTIONS FROM INFECTIONS AND ILLNESSES: an expectant mother must be
instructed to protectagainst especially measles, syphilis because these infections can cause
spontaneous abortion, malformation, mental retardation,
10) SEXUAL ACTIVITIES: Coitus should be avoided in 1st
trimester and last 6 weeks
11) BOWEL CARE: As there is increase chances of constipation, regular bowel movements
12) TRAVEL: avoid travel during the 1st
three and last 2 months,
13) REPORTING OF UNTOWARDS SIGNS AND SYMPTOMS: Patient must report to
the physician if any ofthe following symptoms develop:
 Fever
 Headache
 Blurring of vision
 Convulsion
 Vaginal bleeding
 Abnormal vaginal discharge
14) CHILD CARE: the mother should be educated regarding the various aspects of child care.
Important aspects ofchild care include breast feeding, child bearing, care during minor
ailments, growth and development, clothing, clothing, immunization and family planning