Ante natal clinic - protocol

1. ANTENATAL CLINIC PROTOCOL Prof . M.C. Bansal MBBS.,MS. FICOG ., MICOG. Ex . Principal & controller Jhalawar Medical College & Hospital & M.G.M.C & Hospital . Sitapura ., Jaipur .

2. Ante Natal Clinic-- Protocol 1 . It helps in early identification of complications of pregnancy in time and their management. 2. Ensures healthy outcomes for the mother and her baby. 3. P rovides opportunity to council regarding immunization, diet supplementation during pregnancy and lactating period, motivation for breast feeding and contraception , patient education about mother craft.

3. When and how frequent patient should come for check up? Registration: - As early as pregnancy is suspected /diagnosed. At least 4 Antenatal Visits during all 3 trimesters. 1 st ANC ---in first trimester i.e. first 12 weeks of pregnancy. 2 nd ANC –between 14-26 weeks. 3 rd ANC –between 28 and 34 weeks . 4 th ANC—between 36 weeks and term. Ideally ANC visit once a month till 28 weeks , then every fortnight in 28-34 weeks and once a week after wards till delivery.

4. First ANC Visit Pregnancy Detection by clinical examination /urinary pregnancy test. ANC Registration ,filling the ANC card and safe motherhood booklet of every pregnant women after patient interrogation , detailed menstrual , LMP , Obstetrical , personal, family history & any pre-existing medical/surgical diseases and their drug therapy.

5. First Visit- Clinical Examination- General Examination- Height, weight , calculate BMI , pallor, edema, B.P., jaundice , lymph node enlargement , cyanosis , clubbing or koilonychia etc. Systemic - CVS , Respiratory , locomotive Obstetrical---Per abdominal if gravid uterus is palpable above symphysis pubis , PS & PV when indicated.

6. First visit- Investigations- Hb gm % CVC Urine Examination—Albumin ,Sugar , Microscopic. ABO Rh Grouping—if Rh negative  husband’s ABO Rh grouping . VDRL HIV counseling and screening. HBsAg Random Blood Glucose. USG / TVS Not as routine but only when indicate on obstetrical grounds.

7. Information for Pregnant woman and her family Encourage institutional delivery ,Ensure delivery by qualified , trained ,experienced labour room nurse or resident doctor. Explain entitlement under JSY. Identify nearest PHC / FRU for delivery. Early identification of high risk / BOH pregnancy to be attended in district hospital or medical college hospital. Pre-identification of referral , transport and blood donor. Insist upon regular ANC visits.

8. Therapeutic --Advise Tab. Folic Acid 5mg once a day. Inj. T. T0x0id 0.5ml –1 st dose ; 2 nd dose to be repeated after 6 weeks, Avoid self medication. For any illness / symptom consult your obstetrician before exposing yourself to any scanning , drugs, chemicals. Eat small amount of food at 4-6 times. Avoid preserved food, synthetic drinks, smoking , alcohol. Consume plenty of fresh fruits and vegetables. Take rest in left lateral side for 2hrs after mid day meal and 8 hrs at night. For troublesome nausea & vomiting -Take anti emetic tab as per advise of the obstetrician.

9. Decide to continue / discontinue any medication which patient is taking for pre pregnancy diseases like asthma , epilepsy , heart disease, renal hypertension, obesity , liver disease. cancer etc. Stress to maintain dental , oral , whole body & private parts hygiene. Avoid taking Pica- like clay , lime , chalk etc. Avoid exposure to insecticides , fertilizers & industrial chemical fumes at the work site.

10. Subsequent visits On every visit -  Ask for any complain. Record all findings of physical examination- Weight , anemia ,edema, B.P. Abdominal Examination---Height of uterus , do all grips and note down Presentation , Position, Free floating /Fixed or engaged presenting part , f oetal movements ,foetal heart ( rate and rhythm ) any uterine irritability , uterine tenseness , tenderness , any over distension of uterus to early detection of pleural pregnancy / poly hydramnios. Do Breast examination. Correlate and compare your physical findings with previous records and reports.

11. Fundal height at different gestational period

12. Measurement of distance between upper limit of uterus and superior border of symphysis pubis

13. Fundal grip

14. Umbilical grip

15. Obstetrical grips

16. Location of fetal heart in different presentations

17. Different fetal presentations

18. Subsequent Visits- Investigations-  Repeat Hb ., Urine –albumin and sugar. Blood Sugar at 28 and 34-36 weeks to diagnose gestational / pre diabetic mother. USG---- 18weeks to rule out / confirm any congenital anomaly. Correlate its findings with physical examination and previous USG. Repeat USG as and when indicated or at 34-36 weeks. Color Doppler as and when required .

19. Subsequent Visits- 2nd dose of T. Toxoid. Start Iron 100 mg + folic acid tab every day after 14 weeks or when nausea & vomiting stops , continue till term . Tab. Calcium Citrate 1200 mg / day. Protein supplementation

20. Subsequent Visit- When to report to hospital- Any Bleeding PV, watery discharge PV , pain abdomen, fever , unable to feel fetal movements , yellow coloration of eyes or urine , swelling of feet, headache, pain in epigastrium , fits , unconsciousness , fainting attacks , excessive vomits or loose motions etc.

21. Maternal Risk Factors Detected during ANC (USA 2001) Risk Factor Births Percent Total live births 4,025,933 100 Gestational hypertension 150,329 3.7 Diabetes 124,242 3.1 Anemia 99,558 2.5

22. Maternal Risk Factors Detected During ANC ( USA 2001) Cardiac Disease 20,698 0.5 Renal Disease 12,251 0,3 Incompetent Os 11.251 0,3 Hydramnios/oligohydramnios 54,694 1.4 Lung disease 48,246 1.2 Genital herpes 33,560 0.8 Chronic hypertension 32,232 0.8 D (Rh) sensitization 26,933 0.7

23. Thank You