Antenatal care

Antenatal care

1. ANTENATAL
CARE
Prepared by,
PinkiSah
Lecturer
BHC

3. 
Systematicsupervision(examinationandadvice)ofawoman
duringpregnancyiscalledantenatal(prenatal)care.The
supervisionshouldberegularandperiodicinnatureaccordingto
theneedoftheindividual.

Actuallyprenatalcareisthecareincontinuumthatstartsbefore
pregnancyandendsatdeliveryandthepostpartumperiod.

4. A
IMS

toscreenthe“highrisk”cases

topreventortodetectandtreatattheearliestanycomplication,

toensurecontinuedriskassessmentandtoprovideongoingprimary
preventivehealthcare,

toeducatethemotheraboutthephysiologyofpregnancyandlaborby
demonstrations,chartsanddiagrams(mothercraftclasses),sothatfearis
removedandpsychologyisimproved,

5. 
todiscusswiththecoupleabouttheplace,timeandmodeof
delivery,provisionallyandcareofthenewborn,

tomotivatethecoupleabouttheneedoffamilyplanningandalso
appropriateadvicetocoupleseekingmedicalterminationof
pregnancy.

6. O
BJECTIVE

Theobjectiveistoensureanormalpregnancywithdeliveryofa
healthybabyfromahealthymother.

7. C
OMPONENTOFANTENATALCARE

Registration

Historytaking

Antenatalexamination(GeneralandObstetricalexamination)

Laboratoryinvestigations

Healtheducation

Immunization

8. F
IRSTVISIT

Historytaking

Examination

Investigations

9. H
ISTORYTAKING
Vitalstatistics

Name

Dateoffirstexamination

Address

Age

Gravidaandparity

Durationofmarriage

Religion

Durationofmarriage

Religion

Occupation

Occupationofhusband

Periodofgestation

10. Complaints:Categorically,thegenesisofthecomplaintsistobe
noted.Evenifthereisnocomplaint,enquiryistobemadeaboutthe
sleep,appetite,bowelhabitandurination.
Historyofpresentillness:Elaborationofthechiefcomplaintsas
regardtheironset,duration,severity,useofmedicationsandprogress
istobemade.

11. Historyofpresentpregnancy:Theimportantcomplicationsindifferent
trimestersofthepresentpregnancyaretobenotedcarefully.

Thesearehyperemesisandthreatenedabortioninfirsttrimester,featuresof
pyelitisinsecondtrimesterandanemia,preeclampsiaandantepartum
hemorrhageinthelasttrimester.

Numberofpreviousantenatalvisits(bookingstatus),immunizationstatus,
hastobenoted.

12. 
Anymedicationorradiationexposureinearlypregnancyor
medical-surgicaleventsduringpregnancyshouldbeenquired.

13. Obstetrichistory:Thisisonlyrelatedwithmultigravida.Statusofgravida,
parity,numberofdeliveries(term,preterm),miscarriage,pregnancy
termination(MTP)andlivingissue[e.g.Mrs.R.L,(P2+0+1+2)G4,P2,
miscarriage1,living2at36weeksofpresentpregnancy].

Anunduelonggapbetweenthelastandthepresentpregnancyrequires
carefulsupervisionduringpregnancyandlabor.Theminimumspacing
betweenfirstbirthandsubsequentpregnancyshouldbe2years.

15. Menstrualhistory:Cycle,duration,amountofbloodflowandfirstdayof
thelastnormalmenstrualperiod(LNMP)aretobenoted (spontaneous).
FromtheLNMP,theexpecteddateofdelivery(EDD)hastobecalculated.

16. 
Calculationoftheexpecteddateofdelivery(EDD):Thisisdone
accordingtoNaegele’sformula(1812)byadding9calendar
monthsand7daystothefirstdayofthelastnormal(28days
cycle)period.Alternatively,onecancountback3calendarmonths
fromthefirstdayofthelastperiodandthenadd7daystogetthe
expecteddateofdelivery;theformermethodiscommonly
employed.

17. Pastmedicalhistory:Relevanthistoryofpastmedicalillnesses(urinary
tractinfections,tuberculosis)istobeelicited.
Pastsurgicalhistory:Previoussurgery—generalorgynecological,ifany,is
tobeenquired.
Familyhistory:Familyhistoryofhypertension,diabetes,tuberculosis,blood
dyscrasia,knownhereditarydisease,ifany,ortwinningistobeenquired.

18. Personalhistory:Contraceptivepracticepriortopregnancy,smokingoralcoholhabits
aretobeenquired.

LMPmaybeawithdrawalbleedfollowingpillusage.

Thefirstovulationmaybedelayedfor4–6weeks(seep.108).

Smokingoralcoholabusehasgotsomerelationwithlowbirthweightofthebaby.

Previoushistoryofbloodtransfusion,corticosteroidtherapy,anydrugallergyand
immunizationagainsttetanusorprophylacticadministrationofanti-Dimmunoglobulin
aretobeenquired.

19. E
XAMINATION

20. P
HYSICALEXAMINATION

Build:obese/Average/Thin

Height:Average/Shortstature/tallstature.Shortstatureislikelytobe
associatedwithasmallpelvis

Weight:Weightcheckingshouldbedoneateachvisit.

Thetotalweightgainduringpregnancyisapproximately11kg.

weightshouldbetakentoassessoverweightorthin/underweight.

21. 
Bloodpressure:Bloodpressureshouldberecordedduringeachvisit.
Anyreadingabove140/90shouldbereported.

Anemia:presentorabsent-mild,moderateandsevere.Theprimarysite
toseeis:

Lowerpalpebralconjunctiva-Retractedboththelowereyelidsatatime
andtellthepatienttolookupwards

22. 
Othersites:

Dorsumandtipsofthetongue

Softpalate

Nailbeds

Palmandsoles

skin

23. 
Cyanosis:Absent/present.Types:peripheral/central
Sitestodetectcyanosis:
Peripheral-

Tipofnose

Earlobe

24. 
Outersurfaceoflips,cheekandchin

Tipsoffingersandnose

Nailbeds

25. Central-

Tongue

Innersurfaceoflips

Gum,softpalate,cheeks

Allsitesofperipheralcyanosis

26. 
Jaundice:Expressedaspresent/absent
Sitetodetect:

Upperbulbarconjunctiva-Thepatientisaskedtolookdownwardsandupper
eyelidsareretractedtoseethebulbarconjunctivawell

Undersurfaceoftongue

Softpalate

Soleandpalm

Skin
Jaundiceisalwayscheckedinsunlightnearanopenwindow

27. 
Tongue,teeth,gumandtonsils:Writehealthyoranyspecificlesion
present.Themouthisexaminedforfeaturesofmalnutritionlikeglossitis,
stomatitis,presenceofanysepticfocusliketonsillitisandcariesteeth

Neckveins:Generallyexaminedtoseewhethertheseareengorgedornot

NeckGlands:Theneckisexaminedforpresenceofanyenlargedgland.
Thyroidglandisalsoinspectedandpalpatedforanyenlargementorany
otherpathology.

28. 
Edemaoflegs:Boththelegsaretobeexamined.Thesitesforevidenceof
edemaareoverthemedialmalleolusandanteriorsurfaceofthelowerone-
thirdofthetibia.Theareaistobepressedwiththethumbforatleast5
seconds.Varicosityinthelegs,ifany,istobenoted.

Causesofedemainpregnancy:(1)Physiological(2)Preeclampsia(3)
AnemiaandHypoproteinemia(4)Cardiacfailure(5)Nephroticsyndrome.

29. 
Cardiovascularsystem:palpationandauscultationofheartare
done.

Palpation:Noabnormality

Auscultation:Normalheartsounds,ifanyabnormalityisdetected
orsuspecteddetailedexaminationisdoneandnoted

30. 
Respiratorysystem:

Positionoftrachea

Palpation,percussionandauscultationdoneonbothsides

G.I.System:Liverandspleenarepalpatedroutinelyforany
enlargementandtenderness

31. 
Othersystems:
Neurologicalsystems-

Higherfunction

Cranialnerves

Sensoryfunction
Urinarysystem:

Kidney

Renalangletenderness

32. 
Legveins:Notethepresenceoftortuositiesofveinsvaricoseveinorpresenceof
anypigmentationorulcer

Pulse:rate,volume,rhythmanyspecialcharacter,otherpulsesandanydifferent
ofdifferentpulses

Respiration:rate,rhythm,anyspecialvariety

Temperature:writebodytemperature

BloodPressure:writeBloodpressure

33. 
Examinationofbreast:Examinationofbreastshelpstonotethepresence
ofpregnancychangesandalsonotethenipples(crackedordepressed)and
skinconditionoftheareola.Thepurposeistocorrecttheabnormality,if
any,sothattherewillbenodifficultyinbreastfeedingimmediately
followingdelivery

34. BREAST CHANGES

Normalchangesduringpregnancy.
•
3-4wks-prickingandtinglingsensation.
•
6wks-enlarged,tense,painful.
•
8wks-Bluishsurface,veinsvisible.
•
8-12wks-Montgomeryglandsbecomeprominentontheareola.
•
16wks-colostrumcanbeexpressed.

35. TERMINOLOGY

LIE:Theliereferstotherelationshipofthelongaxisofthefetustothelongaxis
ofthecentralizeduterusormaternalspine ,themostcommonliebeing
longitudinal(99.5%).Theliemaybetransverseoroblique;sometimesthelieis
unstableuntillaborsetsin,whenitbecomeseitherlongitudinalortransverse.

PRESENTATION:Thepartofthefetuswhichoccupiesthelowerpoleofthe
uterus(pelvicbrim)iscalledthepresentationofthefetus.Accordingly,the
presentationmaybecephalic(96.5%),podalic(3%)orshoulderandother(0.5%).
Whenmorethanonepartofthefetuspresent,itiscalledcompoundpresentation.

36. 
PRESENTINGPART: Thepresentingpartisdefinedasthepartofthe
presentationwhichoverliestheinternalosandisfeltbytheexamining
fingerthroughthecervicalopening.

ATTITUDE:Therelationofthedifferentpartsofthefetustooneanotheris
calledattitudeofthefetus.Theuniversalattitudeisthatofflexion.Duringthe
latermonths,thehead,trunkandlimbsofthefetusmaintaintheattitudeof
flexiononalljointsandformanovoidmassthatcorrespondsapproximatelyto
theshapeofuterineovoid.

38. A
BDOMINALEXAMINATION
Abdominal examination can reasonably diagnose the lie, presentation,
position, and attitude of the fetus. Before abdominal examination the
following preparatory procedures are done:

Verbal consent for examination is taken

Ask the patient to evacuate her bladder

Always keep one female attendant

Stand on right side of the patient

39. 
Explainthepatientwhatyouaregoingtodo

Makedorsalposition-thighsandkneesbothpartiallyflexed

Abdominalisexposedfullyandotherpartsarecoveredwell

40. INSPECTION
Tonote

Whethertheuterineovoidislongitudinalortransverseoroblique

Undueenlargementoftheuterus

Skinconditionofabdomenforevidenceofringwormorscabiesand

Anyincisionscarmarkontheabdomen

Lneanigra,striagravidarum,fetalmovement

41. Scabies
Ringworm

42. P
ALPATION
Generalprinciples:

Palpateshouldbedoneverygently.

Don’ttrytopalpateduringcontraction.Itisdoneinrelaxedphaseof
uterus.

Allgripsarepalpatedfacingtowardsthemother’sfaceexceptthepelvic
gripwhichisdonefacingtowardsthepatient’slegs.

43. MEASUREMENT OF THE HEIGHT OF THE
FUNDUS:

Theuterusistobecentralizedifitisdeviated.

Theulnarborderofthelefthandisplaceontheuppermostlevel
ofthefundusandanapproximatedurationofpregnancyis
ascertainedintermsofweeksofgestation.

45. 
Normally,heightofthefundusat24weeksliesatthelevelofumbilicus.

Thelevelofjunctionbetweenthelowerthirdandmiddlethirdofthe
distancebetweenumbilicusandensiformcartilage(Xiphoidprocess).
correspondsto28
th
weekofpregnancy,thejunctionofmiddlethirdand
upperthirdto32
nd
weekandatthelevelofensiformcartilagepregnancy
correspondsto36
th
week.At40
th
weekfundalheightdropsdownagainto
thelevelof32
nd
week

47. SYMPHYSIO-FUNDAL HEIGHT (SFH)

MeasuretheSymphysio-fundalheight(SFH)withameasuring
tape.

SFHisthedistancebetweentheupperborderofsymphysispubis
tohighestleveloffundusasdetectedbyulnarborderoflefthand.

Bladdershouldbeempty30minutesbeforeexamination.

48. 
SFHismeasuredinsupinepositionwithlegsextended.

Zeromarkofthetapeisplacedovertheuppermostborderof
symphysispubis.

Tapeisrunalongthemidlineofthewomen’sabdomenuptothe
fundusincmapproximatesthefetalgestationalageuntil36weeks
ofpregnancy.

50. Finger methods to measure fundal height

51. Obstetric grips (Leopold Manoeuvers):
Therearefourgripswhichwillbeperformedsequentially.
A.
Fundalgrip(FirstLeopold)
B.
Lateralgrip(SecondLeopold)
C.
Pawlik’sgrip(ThirdLeopold)
D.
Pelvicgrip(FourthLeopold)

52. A. Fundal grip (First Leopold):

Thepalpationisdonefacingthepatient’sface.

Thewholeofthefundusareaispalpatedusingbothhandslaidflat
onittofindoutwhichpoleofthefetusislyinginthefundus

Broad,softandirregularmasssuggestiveofbreechor

Smooth,hardandglobularmasssuggestiveofhead.Intransverse
lie,neitherofthefetalpolesarepalpatedinthefundalarea.

54. B. Lateral grip or umbilical grip (Second
Leopold)

Thepalpationisdonefacingthepatient’sface.

Thehandsaretobeplacedflatoneithersideoftheumbilicustopalpate
oneaftertheother,thesidesandfrontoftheuterustofindoutthe
positionoftheback,limbsandtheanteriorshoulder.

Thebackissuggestedbysmoothcurvedandresistantfeel.Thelimbside
iscomparativelyemptyandtherearesmallknoblikeirregularparts.

56. C. Pawlik’sgrip ( third Leopold):

Theexaminationisdonefacingtowardsthepatient’sface.

Theoverstretchedthumbandfourfingersofthehandareplacedoverthe
lowerpoleoftheuteruskeepingtheulnarboarderofthepalmontheupper
boarderofthesymphysispubis.

whenthefingersandthethumbareapproximated,thepresentingpartis
graspedwhenitisnotengagedandmobilityistestedfromsidetoside

58. D. Pelvic grip (fourth Leopold):

Theexaminationisdonefacingthepatient’sfeet.

Fourfingersofbothhandareplacedoneithersideofthemidlineinthelower
poleoftheuterusandparalleltobeinguinalligament.

Thefingersarepresseddownwardsandbackwardsinamannerof
approximationoffingertipstopalpatethepartoccupyingthelowerpoleofthe
uterus.

Ifitishead,characteristicstonoteare:presentingarea,attitudeandengagement

59. Pelvic grip

60. Auscultation
Preparatoryprocedures-

Askthepatienttoevacuateherbladder

Dorsalposition-thighandkneeflexed

Abdomenisexposed

Standonrightsideofthepatient

61. Procedures:

Bylateralgripthebackofthefetusislocated

Diaphragmisplacedoverthefetalbackofthestethoscope.
Alternatively,Pinard’sfetoscopecanalsobeused

FHSisheardwherethereismaximumintensity

62. 
Thefetalheartsoundsarebestaudiblethroughtheback(left
scapularregion)invertexandbreechpresentationwherethe
convexportionofthebackisincontactwiththeuterinewall.
However,infacepresentation,theheartsoundsareheardthrough
thefetalchest

63. V
AGINALEXAMINATION

Examinationisdoneintheantenatalclinicwhenthepatientattendstheclinic
forthefirsttimebefore12weeks.Itisdone:
(1)
todiagnosethepregnancy,
(2)
tocorroboratethesizeoftheuteruswiththeperiodofamenorrheaand
(3)
toexcludeanypelvicpathology.Internalexaminationis,however,omittedin
caseswithprevioushistoryofmiscarriage,occasionalvaginalbleedingin
presentpregnancy.

64. 
Ultrasoundexamination hasreplacedroutineinternal
examination.Itismoreinformativeandwithoutanyknown
adverseeffect.
Speculumexamination
Bimanualexamination

65. I
NVESTIGATION
Routineinvestigation:

Blood:Hemoglobin,hematocrit,ABO,Rhgrouping,bloodglucoseand
VDRLaredone.Serology(antibody)screeningisdoneinselectedcases

Urine:Protein,sugarandpuscells.

CervicalcytologystudybyPapanicolaoustainhasbecomearoutinein
manyclinics.

66. Specialinvestigations:

Serologicaltestsforrubella,hepatitisBvirusandHIV:

Geneticscreen:Maternalserumalpha-fetoprotein(MSAFP),
tripletestat15–18weeksformotheratriskofcarryingafetuswith
neuraltubedefects,Down’ssyndromeorotherchromosomal
anomaly.

67. 
Ultrasoundexamination:Firsttrimesterscan either
transabdominal(TAS)ortransvaginal(TVS)helpstodetect:
(i)
earlypregnancy,
(ii)
accuratedating,
(iii)
numberoffetuses,

69. (i)
grossfetalanomalies,
(ii)
anyuterineoradnexalpathology.Useofultrasoundshouldbe
selectiveratherthanaroutine.

Ultrasoundexaminationisperformedasaroutineat18–20weeks
thoughdoubtremainsaboutitsabsolutebenefit

70. Repetitionoftheinvestigations:(1)Hemoglobinestimationis
repeatedat28thand36thweek.(2)Urineistested(dipstick)for
proteinandsugarateveryantenatalvisit.

71. P
ROCEDUREATSUBSEQUENTVISITS

Generally,checkupisdoneatintervalof4weeksupto28weeks ;at
intervalof2weeksupto36weeksandthereafterweeklytilldelivery.

Ideally,thisshouldbemoreflexibledependingontheneedandthe
convenienceofpatient.

Inthedevelopingcountries,asperWHOrecommendation,thevisitmaybe
curtailedtoatleast4;firstinsecondtrimesteraround16weeks,second
between24and28weeks,thethirdvisitat32weeksandthefourthvisitat
36weeks.

72. I
NSUBSEQUENTVISIT

Patientcomplains

Generalexamination

Gestationalagetobecalculated

Identificationofproblem

Fetalmovement

SFHmeasurement

Healtheducation

Prophylaxis&treatmentof
anemia

Developingindividualizedbirth
plan

73. O
BJECTIVES
(A)Toassess:(1)fetalwell-being,(2)lie,presentation,positionand
numberoffetuses,(3)anemia,preeclampsia,amnioticfluidvolumeand
fetalgrowth,(4)toorganizespecialistantenatalclinicsforpatientswith
problemslikecardiacdiseaseanddiabetes.
(B)Toselect,timeforultrasonography,amniocentesisorchorionvillus
biopsywhenindicated.

74. History:Tonote:(1)appearanceofanynewsymptom(headache,dysuria),(2)dateof
quickening.
Examination:

General:Ineachvisit,thefollowingarecheckedandrecorded:
(1)
weight,
(2)
pallor,
(3)
edemalegs,
(4)
bloodpressure.

75. Abdominalexamination:

Inspection:Abdominalenlargement,pregnancymarks—linea
nigra,striae,surgicalscars(midlineorsuprapubic).

76. 
Palpation:
(a)
Tonotetheheightofthefundusabovethesymphysispubis.
(b)
Inthesecondtrimester,toidentifythefetusbyexternal
ballottement,fetalmovements,palpationoffetalpartsand
auscultationoffetalheartsounds.

77. c)
Inthethirdtrimester,abdominalpalpationwillhelptoidentifyfetal
lie,presentation,position,growthpattern,volumeofliquorandalso
anyabnormality.Examinationalsohelpstodetectwhetherthe
presentingpartisengagedornot.Girthofabdomenismeasuredatthe
levelofumbilicus.Thegirthincreasesbyabout2.5cmperweek
beyond30weeksandatterm,measuresabout95–100cm.
d)
Others—anyuterinemass(fibroid)ortenderness.Fetalactivity
(movements)isalsorecorded.

78. 
Vaginalexamination:Vaginalexaminationinthelatermonths
ofpregnancy(beyond37weeks)withanideatoassessthepelvis
isnotinformative.Pelvicassessmentisbestdonewiththeonsetof
labororjustbeforeinductionoflabor.Anyhistoryofvaginal
bleedingcontraindicatesvaginalexamination.

79. 
Ongoingassessmentandcounselingisimportantasprenatalcare
hasaneducationalopportunity.Thewomanshouldbeinformed
aboutthelistofwarningsignssothatshecancontactthehospital
oravailthenearbyhealth-carefacilitiesintime

80. ANTENATAL ADVICE

Principles:
•
Tocounselthewomenaboutimportanceofregularcheck-up.
•
Tomaintainorimprovethehealthstatusofthewomentotheoptimum
tillthedeliverybyjudiciousadviceregardingdiet,drugsandhygiene.
•
Toimprovethepsychologyandtoremovethefearoftheunknownby
counsellingthewomen.

81. DIET

Thedietduringpregnancyshouldbeadequatetoprovide-
•
Goodmaternalhealth
•
Optimumfetalgrowth
•
Thestrengthandvitalityrequiredduringlaborand
•
Successfullactation.

82. 
During pregnancy, there is increased calorie requirement due to increased
growth of the maternal tissues, fetus, placenta and increased basal
metabolic rate.

The increased calorie requirement is to the extent of 300 over the non-
pregnancy state during second half of pregnancy.

Generally, the diet in pregnancy should be with women’s choice as regard
the quantity and the type.

83. 
WomenwithnormalBMIshouldeatadequatelysoasgaintheoptimum
weight(11kg).

Thepregnancydietideallyshouldbelight,nutritious,easilydigestibleand
richinprotein,mineralsandvitamins.

Dieteticadviceshouldbegivenwithdueconsiderationtothe
socioeconomiccondition,foodhabitsandtasteoftheindividual.

84. SUPPLEMENT NUTRITIONAL THERAPY

Dailyoralironandfolicacidsupplementationwith30mgto
60mgofelementalironand400µg(0.4mg)offolicacidis
recommendedforpregnantwomentopreventmaternalanaemia,
puerperalsepsis,lowbirthweight,andpretermbirth.

85. 
Intermittentoralironandfolicacidsupplementationwith120
mgofelementalironand2800µg(2.8mg)offolicacidonce
weeklyisrecommendedforpregnantwomentoimprovematernal
andneonataloutcomesifdailyironisnotacceptableduetoside-
effects,andinpopulationswithananaemiaprevalenceamong
pregnantwomenoflessthan20%.

86. 
Inpopulationswithlowdietarycalciumintake,dailycalcium
supplementation(1.5–2.0goralelementalcalcium)is
recommendedforpregnantwomentoreducetheriskofpre-
eclampsia.

VitaminAsupplementationisonlyrecommendedforpregnant
womeninareaswherevitaminAdeficiencyisaseverepublic
healthproblem,topreventnightblindness

87. ANTENATAL HYGIENE
RESTANDSLEEP:

Thepregnantwomenmaycontinueherusualactivitiesthroughoutthe
pregnancy.

Excessiveandstrenuousworkshouldbeavoidedespeciallyinthefirst
trimesterandlast4weeks.

Recreationalexercise(prenatalexerciseclass)arepermittedaslongas
shefeelscomfortable.

88. 
Thereisindividualvariationoftheamountofsleeprequired.

Onaverage,thewomenshouldbeinbedforabout10hours
(8hoursatnightand2hoursinday)especiallyinthelast6weeks.

89. BOWEL

Constipationiscommon.itmaycausebackacheandabdominal
discomfort.

Regularbowelmovementmaybefacilitatedbyregulationofdiet
takingplentyoffluids,vegetablesandmilkorprescribingstool
softenersatbedtime.

90. BATHING

Thepatientshouldtakedailybathbutbecarefulagainst
slippinginthebathroomduetoimbalance.

91. CLOTHING, SHOES AND BELT

Thepatientshouldwearloosebutcomfortablegarments.

Highheelshoesshouldbetterbeavoidedinadvancedpregnancy
whenthecenterofbalancealters.

Constrictingbeltshouldbeavoided.

92. DENTAL CARE

Gooddentalcareandoralhygieneshouldbemaintained.

Thedentistshouldbeconsulted,ifnecessary.

Thiswillfacilitateextractionorfillingofthecariestooth,if
required,comfortablyinthe2
nd
trimester.

93. CARE OF THE BREASTS

Breastengorgementmaycausediscomfortduringlate
pregnancy.

Awell-fittingbrassierecangiverelief.

94. COITUS

Generally,coitusisnotrestrictedduringpregnancy.

Releaseofprostaglandinsandoxytocinwithcoitusmaycause
uterinecontractions.

Womenwithincreasedriskofmiscarriageorpretermlabor
shouldavoidcoitusiftheyfeelsuchincreaseduterineactivity.

95. TRAVEL

Travelbyvehicleshavingjerksarebettertoavoidedespeciallyinfirst
trimesterandthelast6weeks.

Thelongjourneyispreferablybelimitedtothesecondstageoflabor.

Airtraveliscontraindicatedincaseswithplacentaprevia,pre-eclampsia,
severeanemiaandsicklecelldisease.

Prolongedsittinginacaroraeroplaneshouldbeavoidedduetoriskof
venousstasisandthromboembolism.

96. SMOKING AND ALCOHOL

Inviewofthefatthatsmokingisinjurioustohealth,itisbettertostop
smokingnotonlyduringpregnancybuteventhereafter.

Heavysmokershavesmallerbabiesandthereisalsomorechanceof
abortion.

Alcoholconsumptionistobedrasticallycurtainedoravoided,soasto
avoided,soastopreventfetalmal-develomentorgrowthrestriction.

97. IMMUNIZATION

TDinjection:
WHOguidelines
•
1
st
dose:assoonaspregnancyknown.
•
Nextdose:onemonthafter1
st
dose

98. DRUGS

Almostallthedrugsgiventomotherwillcrosstheplacentato
reachthefetus.

Possibilitypregnancyshouldbekeptinmindwhileprescribing
drugstoanywomenofreproductiveage.

99. GENERAL ADVICE

Thepatientshouldbepersuadedtoattendforantenatalcheckup
positivelyonthescheduledateofvisit.

Sheisinstructedtoreporttothephysicianevenatanearlydateif
someuntowardsymptomsarisesuchasintenseheadache,disturbed
sleepwithrestlessness,urinarytroubles,epigastricpain,vomiting
andscantyurination.

100. 
Sheisadvisedtocometohospitalforconsiderationofadmissioninthe
followingcircumstances:
•
Painfuluterinecontractionsatintervalofabout10minutesorearlierand
continuedforatleastanhour-suggestiveofonsetoflabor.
•
Suddengushofwateryfluidpervagina-suggestiveofprematurerupture
ofthemembranes.
•
Activevaginalbleeding,howeverslightitmaybe.

101. D
ANGERSIGN
/W
ARNINGSIGN

102. Antenatal care models with a minimum of eight
contacts are recommended

Evidencesupportingimprovedsafetyduringpregnancythrough
increasedfrequencyofmaternalandfetalassessmenttodetect
complications.

Evidencesupportingimprovedhealthsystemcommunicationandsupport
aroundpregnancyforwomenandfamilies.

103. 
Evidenceindicatingthatmorecontactbetweenpregnantwomen
andrespectful,knowledgeablehealthcareworkersismorelikely
toleadtoapositivepregnancyexperience.

104. FOCUS ANTENATAL CARE (FANC)

FANCisprovidinggoalorientedcarethatistimely,friendly,
simple,beneficialandsafetopregnantwomen.Toachieveagood
outcomeforthemotherandbabyandpreventanycomplications
thatmayoccurinpregnancy,labor,deliveryandpostpartum.

105. PURPOSES OF FANC

Promoteandmaintainthephysical,mentalandsocialhealthofmother
andbabybyprovidingeducationonnutrition,rest,sleepandpersonal
hygiene.

Detectandtreatconditionsonnutrition,rest,sleepandpersonalhygiene.

Detectandtreatconditionsassociatedwithcomplicationwhether
medical,surgicalorobstetric.

106. 
Ensurethedeliveryofafull-termhealthybabywithminimalstress
orinjurytomotherandbaby.

Helpandpreparethemothertobreastfeedsuccessfully,experience
normalpuerperiumandtakegoodcareofthechildphysically,
psychologicallyandsocially.

107. ELEMENTS OF FANC

Earlydetectionandmanagementofdisease/abnormality

FocusedANCvisits

108. E
ARLYDETECTIONANDMANAGEMENTOF
DISEASE
/
ABNORMALITY

Counselling on health promotion, Birth preparedness and
Complication readiness, Individual birth plan
Methods used:
-
History taking
-
Physical examination
-
Laboratory test

109. FOCUSED ANC VISITS

Thereshouldbeatleast4thorough,comprehensive,personalizedantenatal
visits,spreadoutduringtheentireuncomplicatedpregnancy(WHO2002).

Thefirstvisit-Assoonaspregnancyisdetected.

Thesecondvisitshouldbeinthe20
th
-24
th
week(5
th
-6
th
month)

Thethirdvisitshouldbein28
th
-32
nd
week(7
th
-8
th
month)

Thefourthvisitshouldtakeplaceinthe36
th
week(9
th
month)

110. 1
ST
ANC VISIT

Screen,detectandtreatsuchconditionasanemia,syphilisand
malaria.

Begintheindividualizedbirthplanandimmunizationschedule.

Issueironandfolicacidwhetheranemicornot.

111. 2
ND
, 3
RD
AND
4
TH
VISITS

Toconfirmlifeoffetus,detecttheexistenceofanyabnormalitiesandfinalizethe
individualbirthplan.

Thesevisitsareaimedatdetectingandmanagingconditionssuchasmultiple
gestation,pre-eclampsia,anemiaandtofurtherdeveloptheindividualizedbirth
plan.
NOTE:ThebasictoolforFANCistheANCcarddesignedtocutacrossallmajor
aspectsofAntenatalcare.

112. F
OURFOCUSEDVISIT

113. 2016 WHO ANC model

114. INVESTIGATION DURING PREGNANCY IN
DHULIKHEL HOSPITAL

Up to 12 weeks: TVS, ANC package, folic acid

After 12 wks: Tab calcium, iron, dental check-up

16weeks: Injection TD 1
st
dose, Albendazole.

20 weeks: Inj. TD 2
nd
dose, USG scan.

24-28weeks: GCT, Repeat Hb, Urine RE/ME

Above 28weeks: RBS if client visit ANC after 28 weeks.

Above 30weeks: Family planning counselling

At 37weeks: Pelvic assessment

Rh-ve: ICT every month.

115. 
ANC package:
PMTCT
HbsAg
VDRL
Hb
Blood sugar
Blood grouping
Urine RE/ME

116. Anomalies scan:
-Gestational age
-Cervical length
-Fetal weight
-Fetal well being

117. OBS Scan
-AFI (Amniotic Fluid Index)
-EFW (Estimated Fetal Weight)
-Gestational age
-Placental age
-Presentation