ANTE NATAL CARE

For undergraduate Medical Student

1. Principles of
Antenatal Care
Assistant Professor
Chittagong Medical College
Email: [email protected]
Fahmida Rashid Swati

2. Systematic supervision of a woman
[examination and Advice]
during pregnancy is called
antenatal care.
Written

3. It includes:
•Registration.
•Detailed history taking and examination, both
general and obstetrical
•To carry out relevant investigations.
•Risk assessment
•Adviceis given to pregnant women
•Appropriate treatment is given when indicated.

4. Todiscusssubsequentfamily
planning
Written
To identify any risk
factors and high-risk
pregnancies.
TheAimandobjective:
To prevent, detect, and treat at the
earliest any complication.
To educate mothers
about the physiology of
pregnancy and
childbirth.
To maintain or improve the health
of the mother
Toimprovethepsychologyand
removethefearofunknownevents
thatmightoccurduringpregnancy
andchildbirth
To discuss birth plan,
place, time, and mode of
delivery with the
couple.

5. •Finally, to ensure a normal pregnancy and to
get a healthy baby from a healthy mother.
•The net result is reduction of maternal and
peri-natal mortality and morbidity.

6. Case Scenario: Mrs. Rabeyahas come to you with the
complaints of amenorrhoeafor 10 weeks with morning sickness
and vomiting? How will you diagnose the case?
•Detailed history :
•Name:For identification
•Date of examination:
•Age of the patient:
•Duration of marriage :
•Occupation:
•Occupation of husband:Reflects
social class and nutritional status.

7. •Menstrual history:
•Length of menstrual cycle:
•Last menstrual
period(LMP):
•Expected date of delivery
(EDD)
•Contraceptive history:
•Obstetric history:
•Parity:
•Gravidity:
•Period of gestation:
•History of past childbirth:
•Age of last child
•.
Chief complaints:
History of present
illness:
History of medical
diseases and surgical
history:
Family history:
Personal history:
Drug history:
Immunization history:
Rubella, tetanus toxoid
if completed it is to be
noted

8. •Gravida: Denotes pregnant state both present and
past, irrespective of GA.
•Parity: Denotes state of previous pregnancy after the
age of viability.
------Both related to pregnancy not to babies.
•Twin-gravida one and para one.
•P-2+1 ( 2 >age of viability and 1 abortion)
•Grand multi-H/O ≥ 4 birth
•Nullipara-who have not completed pregnancy
beyond viable age .She may have abortion.
•Primipara-Who delivered one viable child.

9. EDD calculation:
•By adding 280 days ( 9 months and 7 days) to
the first day of the last menstrual period
(LMP). or 266 days after conception.
Written

10. •Then patient is to be examined
thoroughly
•General examination:
•Height: Weight: BMI:
•Appearance
•Pulse; Blood pressure
•Temperature
•Anemia
•Jaundice
•Edema:
•Dehydration
•Legs to see any varicose vein
•Heart; Lungs
•Thyroid gland.
•Breast
Abdominal examination:
Inspection: Any incision scar
mark
Palpation: Any abnormality
Uterus becomes palpable
at 12 weeks
Vaginal examination: To
assess size of the uterus and
exclude other pelvic
abnormalities.

11. Edema during Pregnancy:
1.Physiological
2.Preeclampsia &
eclampsia
3.Anemia &
hypoproteinemia
4.Cardiac failure
5.Nephrotic Syndrome
5.DVT
•High risk cases via ANC:
Written

12. Written

13. •After history taking and examination it was found that she is 22 years
old, married for 5years. Her menstrual cycle was regular 28 days; last
menstrual period was on 12.11.18, which is 10 weeks ago. She did not
visit any doctor and did not receive any treatment. Her husband used to
practice barrier method of contraception and stopped 1 year back. She
has no history of any childbirth or any conception. She has no family or
personal history of any medical or obstetrical problem. She is a school
teacher and has no habit of smoking or alcoholism.
•On examination her pulse, BP, heart, lungs are normal and no anemia,
oedemanoted. Abdominal examination reveals no abnormality.
•Vaginal examination was done with aseptic precaution and found uterus
is soft and 10 weeks size, anteverted.
•On this ground what is your provisional diagnosis and what
investigations do you like to do?

14. •She is a case of 10 weeks pregnancy.
•Following investigations are to be done
•Ultrasonogram(USG) of lower abdomen -For
confirmation of pregnancy and gestational age
•Blood for CBC
•Grouping and Rhtyping
•Sugar fasting and 2 hours after 75 gm glucose
•HbsAg
•VDRL
•TSH
•Urine for routine and microscopic examination
Written

15. Importance of USG in 1s trimester
Written
To detect-
1.Early pregnancy
2.Acurate dating
3.Number of fetus
4.Gross fetal anomalies
5.Any uterine and adnexal
pathology

16. Her blood group is A +ve and all other investigation reports are within
normal limit. Now what advice will you give her?
•antenatalcheckupafteronemonth.
•Athome-advice.
•Diet:
•balanceddiet.
•Lightnutritious,easilydigestible,richin
protein,mineralsandvitamins
•300Kclmorethannon-pregnantwomen

17. •Supplemental food:
•Iron, vitamin and calcium supplementation
from 12-16 weeks onwards.
•Rest and sleep:
•Strenuous works -avoided.
•Rest at least for 10 hours.
•8 hours at night and 2 hours at day time.
•Lying lateral posture

18. •Clothing and shoes:Loose comfortable
garments High heel shoes -avoided.
•Dental care:Dental and oral hygiene -
maintained.
•Care of breast:
•Cleaning of nipple during bath.
•Wearing well-fitting brassiere.
•Any crack or retracted nipple –taken care from
pregnancy period

19. •Coitus:not restricted, better to avoided during 1
st
and last trimester.
•Travelling:
•Long exhaustive journey and travel by vehicles
that might cause jerks-better to avoided.
•Prolonged sitting in a car or airplane -avoided to
prevent thromboembolism. T
•Travelling by train is safe and comfortable.
•Travelling via pressurized aircraft from 4-6 month.
•Smoking and alcohol:avoided

20. Immunization: Two doses tetanus toxoid
between 16 and 24 weeks.
If she has taken 2 injections of TT in
school or previous pregnancy (within 3
years)-she have to take only 1 injection.

21. •Bowel care:For regular bowel movement
plenty of fluid, vegetables and milk.
•Bathing:Daily bathing encouraged

22. •Awareness about warning
(danger) signs:
•Leakage of the fluid
•Vaginal bleeding
•Abdominal pain
•Headache
•Visual disturbances
•Less or loss of foetalmovement
•Fever, rigor
•Excessive vomiting
Written

23. How frequently she will come for check up?
•Schedule for antenatal check up
•She will be advised to come
•In every month (4 weeks apart) up to 28
weeks
•Then every 2 weeks interval up to 36 weeks
•Then in every week till delivery.

24. •According to WHO (2016) recommendation 8 visit is essential
•2016 WHO ANC model
•First trimester
•Contact 1: up to 12 weeks
•Second trimester
•Contact 2: 20 weeks
•Contact 3: 26 weeks
•Third trimester
•Contact 4: 30 weeks
•Contact 5: 34 weeks
•Contact 6: 36 weeks
•Contact 7: 38 weeks
•Contact 8: 40 weeks
Written

25. •1
st
visit in second trimester around 16 weeks
•2
nd
visit between 24 and 28 weeks
•3
rd
visit at 32 weeks
•4
th
visit between 36 and 38 weeks.
In the developing countries where patients
are reluctant for ANC, visit curtailed to at
least 4 according to WHO recommendation.

26. What are the things you need to do in every visit?
•History:To explore any new complaints -to
identify high risk pregnancies
•Quickening at 20 weeks,
•Foetalmovement in all visits after 20 weeks.
•Examination:
•General examination:any derangement of
normal physiological change.
•Weight, pulse, blood pressure, pallor, jaundice,
edema legs, heart, and lungs are checked.

27. •Obstetrical examination
•Abdominal examination:
a. Inspection:Pigmentation-lineanigra, striae, and any
unusual distension of the abdomen or any abnormality.
b. Palpation:
In 1
st
trimester:At 12 weeks, fundalheight at the level of
the symphysispubis.
In 2
nd
trimester:
•Fundal height whether corresponds to GA or not.
•External ballotment
•Foetalmovement
•Palpation of foetalparts.

28. •In 3
rd
trimester:
•Fundalheight to assess growth of the foetus.
•Foetallie, presentation (exclude
malpresentation), position, engagement etc by
different grips like fundalgrip, lateral grip, 1
st
and
2
nd
pelvic grips.
•Foetalmovement
•Volume of liquor amni
•Uterine irritability is to be noted.
•Girth of the abdomen is measured
•c. Auscultation of FHS

29. •Investigations:
•Hb% :
•at 24-28 weeks,
•32 weeks
•36-38weeks.
•Blood sugar fasting and 2 hours after
75 gm glucose at 24-28 weeks
•Urine R/M/E:
•at 24-28 weeks,
•32 weeks, and
•36-38 weeks
•USG:
•i)Around 20 weeks-Anomaly scan
•ii) Placental localization

30. •Health education, advice and counselling:
•About danger signs,
•diet and nutrition,
•rest, exercise, bowel bladder habit,
•birth preparedness,
•newborn care,
•breastfeeding.

31. Mrs. Rabeyahas come to you at 32 weeks of pregnancy. What
things do you need to do?
•Asked about any new complaints
•Previous records of complaints, findings and
treatment should be looked for.
•General examination:
•Weight, pulse, blood pressure, pallor, edema.

32. •Obstetric examination:
•Abdominal examination:
•verbal consent to be taken.
•Bladder must be evacuated
•Inspection:
•At and after 32 weeks-
•Uterine ovoid whether it is longitudinal or
transverse or oblique.
•Undue enlargement of the uterus.
•Skin pigmentation and any sign of infection

33. •b. Palpation:
•It must be explained before the procedure.
•With due permission and adopting utmost
gentleness systematically abdomen should be
palpated.
•Things to be mentioned
Fundal height: To assess gestational age
•Fundal grip: To identify pole of the foetus
•Auscultation of foetalheart sound and rate

34. •d. Internal Examination:
•Not needed
•e. Ultrasonogram:growth scan
•done to see foetalwellbeing and growth by
observing
•1. Foetalmovement
•2. Foetaltone
•3. Foetalrespiratory movement
•4. Volume of liquor amni
•5. FoetalBPD, HC, FL and weight
•Placental location and placental condition also
can be assessed.

35. •f.Other Investigations: Hb%, blood sugar and
routine urine test.
•g. Treatment:according to patient’s need.
•h.Advice:About danger signs, foetal
movement, diet and drugs

36. What are the minor problems might occur during
pregnancy?
•Nausea and vomiting:
•very common problem 950% of primigravid)
•O ccursin the morning soon after getting out of
bed, and it usually subsides at the end of the first
trimester.
•
•Frequent small meals, non-spicy meals, dry toast,
biscuits, and a protein-rich diet can help to
reduce the symptom. Vitamin B1 and B6 are
helpful.

37. •Backache:
•It is a common problem in pregnancy, and about
50% of patients have complaints of backache.
Due to hormone relaxinand estrogen, ligaments
and joints become relaxed to facilitate the birth
process. Weight gain, hyperlordosis, faulty
posture, high hill shoes, an anterior tilt of the
pelvis, muscular spasm, urinary infection, and
constipation are other contributing factors.

38. •Excessive weight gain should be avoided.
Wearing flat shoes, resting in a hard bed,
maintaining a normal posture, and a pelvic
girdle belt during walking may relieve the
symptoms. Muscle spasm pain can be reduced
by back massaging, pain killers, and rest.

39. •Constipation:
•
•Very common complaints in pregnancy. Due to
muscle relaxing hormone progesterone gut
becomes atonic. So atonicityof gut, reduced
physical activities and pressure of gravid uterus
on the pelvic colon may cause constipation.
•
•Taking plenty of fluid and vegetables and mild
physical activities are helpful for regular bowel
habit.

40. •Acidity and heart burn:
•Very common complaints in pregnancy. Due to
hormonal effect oesophagealsphincter becomes
relaxed, which allows backflow of acidic gastric
contents causing heart burn. Hiatus hernia is also
common in pregnancy causing heart burn.
•
•Frequent small meal is advisable. Avoiding to go to bed
immediately after taking meal, liquid antacid and
sleeping in semi-reclining position relieves the
symptom.
•

41. •Leg cramps:
•
•Baby consumes much calcium for its
development. So, there may be calcium
deficiency. Leg cramp may occur due to
calcium deficiency or elevation of serum
phosphorus.
•
•Supplementary calcium therapy is helpful

42. •Varicose vein:
•
•Due to obstruction of venous return by the
pregnant uterus, there is engorgement of leg
veins and the vulva and rectum veins.
•For leg varicosities, elastic crepe bandage and
elevation of legs during rest can relieve the
symptoms. It usually disappears after delivery.

43. •Hemorrhoids:
•
•Hemorrhoids also occur due to diminished
venous return due to gravid uterus, that may
causes per-rectal bleeding and sometimes getting
prolapsed. The bowel should be kept soft by
using a laxative, and local hydrocortisone can be
applied. Surgery better to be avoided during
pregnancy as, most of the time, it regresses after
delivery.

44. •Ankle edema:
•
•Ankle edema sometimes occurs without any
pathology, and no treatment is required.
Usually subsides with rest. But sometimes,
pedal edema might be a sign of preeclampsia,
which needs to be excluded if there is edema

45. •Is exercise recommended during pregnancy?
•
•Vigorous exercise is not recommended. Regular household
activities can be done which might have low impact
exercise value.
•
•Is there any contra-indication of exercise or limitation of
physical activities?
•
•There are certain conditions where rest is advised, so
physical activities and exercise should be avoided.
•IUGR of foetus
•Maternal cardiac or pulmonary disease
•Cervical incompetence that might leads to preterm labour.
•Antepartumhaemorrhagedue to placenta previa.

46. •Hypertensive disorder in pregnancy
•Presence of risk of preterm labour
•Other less common ailments are Carpel tunnel
syndrome, round ligament pain, ptyalism,
syncope (Supine hypotension syndrome),
vaginal discharge.

47. •The benefit of ANC and advice:
•1. To identify and treat the medical and obstetrical
diseases earlier.
•2. To detect high-risk pregnancy.
•3. To reduce maternal and perinatalmortality and
morbidity.
•
•But despite patient's awareness, maximum effort, and
carefulness of emergency obstetric care services
(EmOC), some unpredictable accidents may not be
avoided, leading to maternal morbidity and mortality.

48. Ref:
DC Dutta