Antenatal Care

ANC is very important sector of government health services

1. Antenatal Care Devender Kumar Maulana Azad Medical College

2. Objectives to achieve History Examination Routine investigations Risk assessment – at first visit, warning signs on subsequent visits Treatment (routine like Fe, folate & calcium and special) Number of visits and steps or “must do” on each visit When to come for next visit / refer / advices

3. INTRODUCTION The systematic supervision of Pregnant women and fetus to ascertain well being of both and healthy outcome of pregnancy To reduce maternal mortality to less than 100 per 100000 births To avoid or minimize maternal morbidity To reduce the perinatal morbidity & mortality

4. MATERNAL MORTALITY MAJOR CAUSES Hemorrhages - Antepartum and Postpartum Hypertension during pregnancy Anemia Obstructed labor Puerperal sepsis

5. Maternal mortality reasons Direct medical causes Indirect medical causes Social determinants Health system-related factors Haemorrhage Sepsis Unsafe abortions Hypertensive disorders Obstructed labour Anaemia Malaria Marriage & childbirth at young age Less spacing between births Low literacy level among women Delay to seek care Delay in reaching the appropriate health facility Delay in receiving quality care in an institution. .

6. Purpose of ANC Diagnose and confirm normal pregnancy Diagnose associated medical or any other disorders and plan its treatment Diagnose pregnancy related disorders like GDM, Gest hypertension, Placental abnormalities To perform basic investigations Supplement iron and folic acid To monitor fetal growth and detect abnormalities earliest

7. Purpose of ANC Counselling of couple regarding contraception and future pregnancies Immunization of the mother and inform about immunization schedule Significance of breast feeding Planning of place / mode of delivery Detect the cases which require referral to tertiary level

8. HISTORY OF PRESENT PREGNANCY Find out the LMP and calculate EDD Identify any current or past medical/surgical or obstetric condition(s) that may complicate the present pregnancy as below- High blood pressure (hypertension) Diabetes Breathlessness on exertion Palpitations (heart disease) Chronic cough, blood in the sputum, prolonged fever (tuberculosis) Renal disease Convulsions (epilepsy) Attacks of breathlessness or asthma Jaundice Malaria Other illnesses, e.g. Reproductive Tract Infections, HIV/AIDS

9. CALCULATION OF EDD Normal pregnancy average duration is counting from first day of last menstrual period is about 280 days and 10 lunar months or 40 weeks. Ovulation delivery interval is 267 days (as ovulation occurs on 13 th or 14 th day in 28 days cycle. If regular Cycles -The EDD is calculated by counting back 3 months and adding 7 days or by counting forward 9 months and 7 days.(NAEGELE’S rule). Cycles > 28 – 30 da ys -Add the extra number of days to arrive at EDD Cycles < 28 days- Subtract the number of days from the EDD.

10. DETAILED PAST OBSTETRIC HISTORY The number of previous pregnancies Confirm whether live births, stillbirth, abortion or any child who died. Ascertain the date and outcome of each event, (birth weight, if known). It is especially important to know about the last pregnancy. Find out if there was any adverse perinatal (period between 7 days before birth and 28 days after birth) outcome. Identify whether there were complications during previous pregnancy that may have a bearing on the present one. Any obstetric complications - Recurrent early abortion, Post-abortion complications, Hypertension, Pre-eclampsia or eclampsia, Ante-Partum Hemorrhage (APH),Breech or transverse presentation, Obstructed labour , including dystocia ,Perineal injuries/tears, Excessive bleeding after delivery, Puerperal sepsis. Ascertain mode of delivery-Simple vaginal delivery or obstetrical operations (caesarean sections/ instrumental delivery/vaginal or breech delivery/manual removal of the placenta). Any history of blood transfusions.

11. FAMILY HISTORY Family history of following is important Hypertension, Diabetes Tuberculosis Thalassemia Twins Birth of malformed baby

12. PERSONAL HISTORY History of drug intake or allergies Any treatment or drugs for infertility(as a higher chance of having twins or multiple pregnancies) History of intake of habit-forming or harmful substances -chewing or smoking tobacco , alcohol, substance abuse.

13. ANTENATAL VISIT FREQUENCY I visit –as soon as the pregnancy is suspected i.e. in first three months Till 28 weeks- 4 weekly 28-36 weeks - 2 weekly >36 weeks - weekly Visits may vary if any high risk factor is present

14. MINIMUM DESIRABLE VISITS I visit –as soon as the pregnancy is suspected i.e. in first three months II visit - Around 26 wks III visit - 32 wks IV visit - 36 wks

15. FIRST VISIT CONFIRM THE PREGNANCY -simplest way to confirm pregnancy in the first trimester is history & clinical examination Pregnancy test kits- ‘ Nischay ’ have also been provided to Accredited Social Health Activists (ASHAs) for use during their community visits. Ensure that the kits are available to them and they report positive results to you.

16. Examination General Examination Temperature, Pallor, Icterus, Edema, Height Thyroid, Breast Pulse , Blood pressure Systemic Examination Respiratory system Cardiovascular system Obstetric Examination

17. Obstetrics Examination Inspection Palpation Percussion Ausculatation Genital Examination

18. ABDOMINAL EXAMINATION Abdominal examination helps in following up fetal growth Fundal height- If any disparity in fundal height –refer Height of the uterus more than period of amenorrhea Wrong date of LMP Full bladder Multiple pregnancy/large baby Polyhydramnios Hydrocephalus Hydatidiform mole Height of the uterus less than period of amenorrhea Wrong date of LMP IUGR Missed abortion Intrauterine Death (IUD) Transverse lie

19. Fetal lie and Presentation- If lie Longitudinal with cephalic presentation –no intervention required Other Longitudinal lie- confirmed by p/v examination-breech,brow,face If Breech, Transverse,Oblique- Before 34 wks-no intervention - After 34 wks –Refer as may need LSCS OTHERWISE - If left undiagnosed- can lead to obstructed labour, Rupture of uterus and even Death of mother Multiple fetal parts felt/large uterus –suspect multiple pregnancy Fetal Heart Sounds(FHS)- heard after 26 wks NORMAL—120-160/min beats Fetal bradycardia - <120/min -refer Fetal Tachycardia - >160/min- refer Irregular fetal heart- refer Foetal movements ( ‘quickening’, begin at around 18–22 weeks ) Felt earlier in a multigravida and later in a primigravida Decreased/Absent movements-an indication of foetal distress.Refer to FRU

20. PER VAGINUM EXAMINATION P/V EXAM I Trimester- To diagnose pregnacy (generally UPT done for very early pregnancy now-a-days) For cervical incompetence if previous history suggestive To rule out any adenexal masses or ectopic pregnancy if indicated’ II trimester Generally not done For cervical incompetence III Trimester- Pelvic assessment Diagnose labour PELVIC ASSESSMENT- to be discussed in section dealing with labour management

21. LABORATORY INVESTIGATIONS Hemoglobin estimation Blood group, including Rh factor VDRL/RPR HBsAg HIV testing Blood sugar testing Urine-Albumin & Sugar Thalessemia screening(Nestroff test) if available is desirable

22. INTERVENTIONS If lady reports in first trimester- start Folic Acid-5 mg/day IFA supplementation- Prophylactic dose: All pregnant women need to be given one tablet of IFA (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days, starting at 14–16 weeks of gestation. Calcium carbonate Tab- Dietary -I ncrease dietary intake of iron-rich foods: green leafy vegetables, whole pulses, jaggery, meat, poultry and fish; high protein diet- black gram, groundnuts, ragi, whole grains, milk, eggs, meat and nuts, Administration of TT injection-GOI recommendation- The first dose of TT should be administered as soon as possible, preferably when the woman registers for ANC. (Ideally not to be given in the first trimester)

23. WHEN TO REFER THE CASES- Symptoms which indicate that a complication may arise--- Fever Vaginal discharge Easy fatiquability , Palpitation,& breathlessness at rest. Generalized swelling of the body, puffiness of face Vaginal bleeding Decrease or absent foetal movements Leaking of watery fluid per vaginum Decrease in urinary output

24. DANGER SIGNS IN ANC Malpresentation Multiple pregnancy Any bleeding P/V during pregnancy (a pad is soaked in less than 5 minutes) Haemoglobin 7– 8g% even after consuming IFA tablets for 30 days Haemoglobin <7 g% Breathlessness at rest or Fast or difficult breathing Excessive vomiting, unable to take anything orally High BP (>140/90 mmHg) with proteins in the urine Severe headache with blurred vision or epigastric pain (With high BP or even without high BP) Convulsions or loss of consciousness Reduced urinary output with high BP Decreased or absent fetal movements FHR >160/minute or <120/minute or irregular Continuous severe abdominal pain Premature rupture of membranes (PROM) before 37 weeks Temperature more than 38°C , with or without abdominal pain Foul smelling discharge before delivery/abortion Ruptured membranes for more than 18 hours

25. Historical perspective - ANC National Family Planning Programme 1952 Family Welfare Programme 1977 National Child Survival And Safe Motherhood Programme 1992 Reproductive and Child Health Programme Phase I - 1997 Phase II - 2005 RMNCH+A approach – Reproductive Maternal Newborn Child + Adolescent Health(12 th Plan)

26. Paradigm shift Item Pervious approach New approach Goal Two child norm Enable clients to meet goals Approach Centralized approach Decentralised, client driven Service Family planning Full range of MCH care Quality Not cared High Quality Attitude to client Motivate persuade Listen, assess, inform, advice Performance monitoring Targets Quality, client satisfaction, coverage measures Accountability To bureaucracy To client & community

27. National Programs Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) envisages to improve the quality and coverage of Antenatal Care (ANC), Diagnostics and Counselling services as part of the Reproductive Maternal Neonatal Child and Adolescent Health (RMNCH+A) Strategy

28. MAA National Breastfeeding Promotion Programme— MAA (mothers’ absolute affection) to ensure adequate awareness is generated among masses, especially mothers, on the benefits of breastfeeding . Around 20% newborn deaths and 13% under-five deaths can be prevented by early initiation of breastfeeding Besides it can also prevent child deaths associated with diarrhoea and pneumonia The goal of the Programme is to enhance optimal breastfeeding practices, which includes initiation of breastfeeding within an hour of birth , exclusive breastfeeding for the first six months, and continued breastfeeding for at least two years.

29. KEY MESSAGES Register every pregnancy within 12 weeks. Ensure four antenatal visits to monitor the progress of pregnancy. This includes the registration and 1st ANC in the first trimester. Give every pregnant woman Tetanus Toxoid (TT) injections and Iron Folic Acid (IFA) supplementation Test for Blood group, Hb,Urine -A/S ,BSR, HIV, VDRL, HBsAg at earliest opportunity Test the blood for hemoglobin, urine for sugar and protein at EVERY VISIT. Record blood pressure and weight at EVERY VISIT. Advise and encourage the woman to opt for institutional delivery. Maintain proper records for better case management and follow up. Do not give a pregnant woman any medication during the first trimester unless advised by a physician. Identify all high risk at earliest and plan management