antenatalcarebabicopy-2 10112151807.pptx

Anushree Bhunia
Assistat professor

DEFINITION
Systematic supervision (examination and
advice) of a woman during pregnancy is called
antenatal (prenatal) care. It starts before pregnancy
and ends at delivery and the postpartum period.
• ANTENATAL CARE COMPRISES OF:
 Careful history taking and examinations (general
and obstetrical).
 Advice given to the pregnant woman.

AIMS
1. To promote, protect and maintain the health of the
mother during pregnancy
2. To screen the ‘high risk’ cases.
3. To prevent or to detect and treat complications at the
earliest.
4. To reduce maternal and infant mortality and morbidity.
5. To ensure continued risk assessment and to provide
ongoing primary preventive health care.

6. To educate the mother about the physiology of pregnancy
and labor, so that fear is removed and psychology is
improved.
7. To discuss with the couple about the place, time and mode
of delivery, and care of the newborn.
8. To motivate the couple about the need of family planning
and also appropriate advice to couple seeking medical
termination of pregnancy.
9. To attend to the under-fives accompanying the mother.

OBJECTIVE
 To ensure a normal pregnancy with
delivery of a healthy baby from a
healthy mother.
The criteria of a normal pregnancy
are:-
Delivery of a single baby in good
condition at term (between 38–42), with
fetal weight of 2.5 kg or more and with no
maternal complication.

ANTENATAL CARE COMPRISES
1. Registration of pregnancy
2. History taking
3. Antenatal examinations [general and obstetrical]
4. Laboratory investigations
5. Health education

FREQUENCY OF ANTENATAL VISITS
• At the interval of 4 weeks up to 28 weeks
• At interval of 2 weeks up to 36 weeks and
• Thereafter weekly till delivery.
• THE FIRST VISIT
OBJECTIVES
(1) To assess the health status of the mother and
fetus.
(2) To assess the fetal gestational age and to
obtain baseline investigations.
(3) To organize continued obstetric care and risk
assessment.

SECOND TRIMESTER VISIT-OBJECTIVES
(A)To assess
(1) Fetal well being.
(2) Lie, presentation, position and number of fetuses.
(3) Anemia, pre-eclampsia, amniotic fluid volume and fetal
growth.
(4) To organize specialist antenatal clinics for patients with
problems like cardiac disease and diabetes.
(B) To select, time for
(1) Ultrasonography.
(2) Amniocentesis or chorion villus biopsy if needed.

REGISTRATION OF PREGNANCY
The registration of pregnancy must
be done in an antenatal clinic within 12
weeks.

1. Vital statistics
 Name: ........................................................
 Date of first examination: ..................................
 Address: ....................................................................
2. Age:
Elderly primi gravida (age over 30 yrs)
( FIGO- 35 yrs)
Teenage pregnancy

3. Obstetrical score:-GPLA
Gravida (G) : Gravida denotes a pregnant state both present and
past, irrespective of the period of gestation.
Parity (P) : Parity denotes a state of previous pregnancy beyond the
period of viability.
Live (L) : Number of live birth
Abortion (A) : Number of abortions

 A nulligravida
 is one who is not now and never has been
pregnant.
• Primigravida
• A primigravida is one who is pregnant for the first
time.
• multigravida is one who has previously been
pregnant.
She may have aborted or have delivered a viable baby.
Terminology

 A nullipara
 is one who has never completed a pregnancy to
the stage of viability. She may or may not have
aborted previously.
 A primipara
 is one who has delivered one viable child.
Parity is not increased even if the fetuses are
many (twins, triplets).
 Multipara
is one who has completed two or more
pregnancies to the stage of viability or more.

 Grand multipara
is a pregnant woman with a previous
history of four births or more.
 A parturient is a women in labor.
 A puerpera is a woman who has just given birth

4. Duration of marriage
5. Religion
6. Occupation
7. Occupation of the husband
8. Period of gestation - in terms of completed weeks

In calculating the weeks of gestation in early
part of pregnancy, counting is to be done from the
first day of last normal menstrual period (LMP).
and in later months of pregnancy, counting is to be
done from expected date of delivery (EDD).

Naegele’s formula
EDD is calculated by adding 9 calendar months and 7 days
to the first day of the last normal (28 day cycle) period.
EDD = LMP + 9 months + 7 days
Alternatively, one can count back 3 calendar months from
the first day of the last period and then add 7 days to get
the EDD. Correct for year if necessary.
EDD = LMP – (3 MON) + 7 days

Naegele's rule
The result is approximately 280 days (40 weeks) from the start
of the last menstrual period.
Example:
LMP :- 20 September 2013(20/10/2013)
+ 9 months = 20 June 2014
+ 7 days = 27 June 2014
EDD = 27 June 2014(27/07/2014)
LMP=24/02/2020 EDC= 1/12/2020
LMP=12/04/2020 EDC=19/01/2020
LMP=25/07/2020
LMP=20/05/2020
Example:
LMP = 8 /05/2009
−3 months = 02
+7 days = 15
So EDD=15/02/2010
LMP=22/01/2020
LMP=27/08/2020

McDonald’s rule
Height of fundus (cm) X 2/7 = gestation in lunar
months
28cmX2/7=8months
Height of fundus (cm) x 8/7 = gestation of
pregnancy in weeks
28cmX8/7=32weeks

9. Chief Complaints
10. Present obstetric history
11. Past Obstetric history

Present obstetric history
• Date of Registration
• No of antenatal visits
FIRST TRIMESTER
 Ask about nausea, vomiting or any other symptoms such as fever
 Abdominal/pelvic/back pain, burning micturition
 Vaginal discharge or Bleeding per vagina
 Use of folic acid tablets (small yellow colored pills)
 Was an ultrasound done at 6 or 7wks (Dating scan)
 Tetanus Vaccination

SECOND TRIMESTER
 Ask about regular use of folic acid, iron and calcium
supplements .
 Ultrasound at 18-22wks (Anomaly scan) .
 Quickening: first fetal movements(felt around 20 weeks)
 Fever, rash, abdominal pain
 Tetanus Vaccination (BOOSTER DOSE)

THIRD TRIMESTER
 Weight gain
 Regular doctor checkups
 Ultrasound

No Year
and
date
Pregnancy
events
Labor
events
Methods of
delivery
Puerperi
um
Baby
• Weight and Sex
• Condition at birth (Apgar
score)
• Breast feeding
• Immunization
1 2004
May
Well covered
antenatally.
Uneventful
Uneventful Spontaneo
us vaginal
Uneventf
ul
Baby-boy, weight 2.6 kg
Cried at birth. Breastfed (6
months), alive and well.
2 2009
Jun
Miscarriage
at 8 weeks
Evacuation
done
Uneventf
ul
11. Past Obstetric history

13. Family history
14. Past medical history
15. Past surgical history
16. Personal history
17.Menstrual history

Marital history
Contraceptive history
Psychosocial history

History on subsequent visits
To note:-
(a)Appearance of any new symptoms (headache,
dysuria).
(b)Date of quickening.

EXAMINATION
•General
• Systemic
•Obstetrical examination = abdominal &
vaginal

EXAMINATION
General Physical Examination
 Build: Obese/Average/Thin.
 Nutrition: Good/Average/Poor.
 Height: Short stature is likely to be associated with a small pelvis.
 Weight:
- First trimester = 1 kg
- Second trimester = 5 kg
- Third trimester = 5 kg

Head to foot examination
Pallor
Jaundice
Tongue, teeth, gums and tonsils
Neck
Edema of legs

 Systemic examination:-
Heart, Lungs, Liver and Spleen.
Obstetrical examination:-
:- Abdominal
:- Vaginal

RELATION BETWEEN
FETUS & PELVIS

LIE:-
The lie refers to the relationship of the
long axis of the fetus to the long axis of the
centralized uterus or maternal spine.
LONGITUDINAL LIE ( 99.5%)
TRANSVERSE LIE
OBLIQUE LIE

PRESENTATION:
The part of the fetus which occupies the
lower pole of the uterus (pelvic brim) is called
the presentation of the fetus. It may be,
 Cephalic (96.5%)
 Breech / Podalic (3%)
 Shoulder and other (0.5%).

Cephalic Presentation Podalic Presentation
Shoulder Presentation

when more than one part of fetus present
at the lower pole of the uterus it is called
compound presentation

PRESENTING PARTS
The presenting part is defined as the part of the
presentation which overlies the internal os & is felt by the
examining finger through the cervical opening.
In cephalic presentation depending upon degree of flexion, the
presenting part may be
- Vertex
- Sinciput
- Brow
- Face

In Breech or Podalic presentation

ATTITUDE
The relation of the different parts of the
fetus to one another is called attitude of the fetus. The
universal attitude is that of flexion.

Attitude Presenting part
Complete flexion vertex (occipitoanterior)
Incomplete flexion Vertex (occipitoposterior)
Deflexion Vertex (occipitoposterior)
Extension Brow
Complete extension face

DENOMINATOR
It is the bony fixed point on the
presenting part which comes in relation
with the various quadrants of the maternal
pelvis.

The denominators of the different presentations: —
Occiput in vertex
Mentum (chin) in face
Frontal eminence in brow
Sacrum in breech
 Acromion in shoulder.

POSITION
It is the relation of the denominator to the
different quadrants of the pelvis.
Pelvis is divided into equal segments of 45 degree
to place the denominator in each segment. So
there are 8 positions with each presenting part.

Anterior , Posterior , right or left position is
referred in relation to the maternal pelvis, with
the mother in erect position.

Preliminaries
 Verbal consent should be taken.
 The patient is asked to evacuate the bladder.
 Give dorsal position with the thighs slightly flexed .
 Abdomen is fully exposed.
 The examiner stands on the right side of the patient.

STEPS
1.Inspection
2.Palpation
3.Auscultation

Inspection:-
(1)Whether the uterine ovoid is longitudinal or transverse
or oblique.
(2)Contour of the uterus—fundal notching, convex or
flattened anterior wall
(3)cylindrical or spherical shape.
(4)Size of the uterus .
(5)Skin condition of abdomen.
(6)Any incisional scar mark on the abdomen.

Palpation
 Warm hands before palpation.
 Should not be done with uterine contractions
 Conduct with utmost gentleness to avoid undue
uterine irritability
 Abdominal girth:-
Measure around abdomen at the level
of umbilicus

Significance of abdominal girth
Girth increases by about 2.5 cm per
week beyond 30 weeks & at term
measures about 95 cm – 100 cm

Palpation
Height of the uterus: ( symphysio fundal height)
The uterus is to be centralized if it is deviated. The
ulnar border of the left hand is placed on the upper most
level of the fundus and an approximate duration of
pregnancy is ascertained in terms of weeks of gestation.

Calculation of gestation using fundal height
 Measure from symphysis pubis to top of
fundus in cm. After 24 weeks distance in cm
corresponds to gestation in weeks. A
variation of 1 – 2 cm is acceptable.

Condition Where SFH Is Higher
Than Normal
Condition Where SFH Is
Lower Than Normal
• Mistaken date of LMP
• Twins
• Polyhydramnios
• Big baby
• Pelvic tumours
• Hydatidiform Mole
• Concealed accidental
hemorrhage
• Mistaken date of LMP
• Scanty liquor Amnii
• Fetal growth
retardation
• Intra uterine fetal death

Obstetric grips (Leopold maneuvers)
(i) Fundal grip (First Leopold)
(ii) Lateral or umbilical grip ( II Leopold)
(iii) Pawlik’s grip (Third Leopold)
(iv) Pelvic grip (Fourth Leopold)

LATERAL GRIP
The palpation is done facing the patient’s face.
The hands are to be placed flat on either side of
the umbilicus to palpate one after the other, the
sides and front of the uterus
to find out the position of the back, limbs and
the anterior shoulder.

Where is the fetal back, limbs &
anterior shoulder?

Pelvic grip (Fourth Leopold):
face the patient’s feet.
Four fingers of both the hands are placed on either
side of the midline in the lower pole of the uterus and
parallel to the inguinal ligament.
fingers are pressed downwards and backwards in a
manner of approximation of finger tips to know the
presentation

the characteristics to note are:
(1) precise presenting Part -cephalic prominence is
carefully palpated and its relation to the limbs and
back is noted. The cephalic prominence, being the
sinciput, is placed on the same side towards which
limbs lie
(2) attitude - noting the relative position of the
sincipital and occipital poles

ATTITUDE A- WELL FLEXED
b- DEFLEXED
In well flexed head, the sincipital pole is placed at a higher level but in
deflexed state, both the poles remain at a same level

engagement - noting the presence or absence of
the sincipital and occipital poles or whether there
is convergence or divergence of the finger tips

Pawlik’s grip (Third Leopold)
face towards the patient’s face.
overstretched thumb and four fingers of the right hand are placed over
the lower pole of the uterus keeping the ulnar border of the palm on
the upper border of the symphysis pubis. When the fingers and the
thumb are approximated, the presenting part is grasped distinctly (if not
engaged) and also the mobility from side to side is tested.

Auscultation
Auscultation of distinct fetal heart sounds
(FHS) not only helps in the diagnosis of a live baby
but its location of maximum intensity can resolve
doubt about the presentation of the fetus

auscultation
The fetal heart sounds are best audible through the
back (left scapular region) in vertex and breech
presentation where the convex portion of the back is
in contact with the uterine wall.
In face presentation, the heart sounds are heard
through the fetal chest.
the maximum intensity of the FHS is below the
umbilicus in cephalic presentation and around the
umbilicus in breech.

In occipitoanterior position, the FHS is
located in the middle of the spinoumbilical
line of the same side.
 In occipitolateral position, it is heard more
laterally
In occipitoposterior position, well back
towards the mother’s flank on the same side.

inferences
Lie: The longitudinal lie is evident from:
1)Longitudinal uterine ovoid on inspection
2) The poles of the fetal ovoid—cephalic and podalic
are placed, one at the lower and the other at the
upper part of the uterine cavity, as evident from
the fundal and first pelvic grips.

presentation
The cephalic presentation is evident from the first
pelvic grip—smooth, hard and globular mass.
ATTITUDE: From the first pelvic grip, the relative
positions of the sincipital and occipital poles are
determined.

PRESENTING PART: Vertex is diagnosed from the
first pelvic grip
POSITION: The occipitoanterior position is
diagnosed by:
(1) Inspection—convexity of the uterine contour.
(2) Lateral grip— (a) The back is placed not far from
the midline to the same side of the occiput
(b) The anterior shoulder is near the midline

3) Auscultation—maximum intensity of the FHS is
close to the spino-umbilical line on the same side
of the back.
Right or left position is to be determined by
(1) Position of the back
(2) Position of the occiput and
(3) Location of the FHS.

ENGAGEMENT
When the greatest horizontal plane, the biparietal, has
passed the plane of the pelvic brim, the head is said to be
engaged.
FIRST PELVIC GRIP: (1) Both the poles (sinciput and occiput)
are not felt per abdomen.
(2) Divergence of the examining fingers of both the hands
SECOND PELVIC GRIP : non mobile head indicate engaged
head

Descend of head by abdominal
assessment

FIRST TRIMESTER
Done for first time before 12 weeks
Purposes
To diagnose the pregnancy
Corroborate the size of uterus with period of
amenorrhoea
Exclude any pelvic pathology
Contraindications
Previous history of abortion
Occassional vaginal bleeding in present pregnancy

steps
Explain procedure
Empty bladder
Dorsal position with thighs flexed & buttocks
placed on the foot end of the table
Drape patient
Handwashing & wear surgical gloves(right hand)

inspection
Separate labia using thumb & index finger &
assess character of vaginal discharge
Assess cystocele, uterine prolapse by asking to do
bear down as if she has bowel movements
Palpate bartholin gland for any infection

Speculum examination
Bivalve speculum is used
Inspect cervix for position ( normally – Center) ,
Colour ,lesions, ulceration, discharge etc.
Pap smear is taken in case of discharge
Cervical os nulligravida – Round & Small
 multiparous – Slit like appearence

Bimanual examination
Introduce index & middle finger of right hand is introduced in
to Vagina
Left hand is placed suprapubically
Note : a) cervix – Consistency , direction & pathology
b) uterus – size, shape, position & consistency
c ) adnexae – any mass felt through the fornix include
ovarian cysts, enlarged fallopian tube, hegars sign

Late pregnancy
Objective
to assess the pelvis
Timing
Any time beyond 37th week. informative only
if done with the beginning of labour or just
before induction of labour

Bi manual examination
To note
State of cervix
Station of presenting part in relation to ischial spine
Test for cephalopelvic disproportion in nonengaged
head
Note the elasticity of perineal muscle

Sacrum - The sacrum is smooth, well curved and usually
inaccessible beyond lower three pieces
Sacrosciatic notch — The notch is sufficiently wide so that two
fingers can be easily placed over the sacrospinous ligament
covering the notch.
Ischial spines — Spines are usually smooth (everted) and
difficult to palpate
Ilio-pectineal lines — To note for any beaking suggestive of
narrow fore pelvis

Sidewalls — Normally they are not easily palpable
by the sweeping fingers unless convergent
Posterior surface of the symphysis pubis — It
normally forms a smooth rounded curve. Presence
of angulation or beaking suggests abnormality
Sacrococcygeal joint — Its mobility and presence
of hooked coccyx, if any, are noted.

Pubic arch — Normally, the pubic arch is rounded
and should accommodate the palmar aspect of
two fingers.
Diagonal conjugate - It is the distance between the
lower border of symphysis pubis to the midpoint
on the sacral promontory.
For practical purpose, if the middle finger fails to
reach the promontory or touches it with difficulty,
the conjugate is adequate

Transverse diameter of the outlet (TDO) — It is measured by
placing knuckles of the clinched fist between the ischial
tuberosities
Pubic angle: In female the angle roughly corresponds to the
fully abducted thumb and index fingers. In narrow angle, it
roughly corresponds to the fully abducted middle and index
fingers
AP Diameter of the outlet—The distance between the inferior
margin of the symphysis pubis and the skin over the
sacrococcygeal joint can be measured

 Laboratory investigations:-
o Blood grouping, Rh typing.
o Haemoglobin.
o Toxoplasma and / or VDRL if needed.
o Urine analysis particularly for albumin and
sugar & pus cells
0 cervical cytological study

Special investigations
Serological tests for rubella, hepatitis B virus and HIV—
antibodies to detect rubella immunity and
screening for hepatitis B virus and HIV
Genetic Screen: Maternal Serum Alpha Feto Protein
(MSAFP), triple test at 15–18 weeks for mother at risk

Ultrasound examination:
Repetition of the investigations: (1)
Hemoglobin estimation is repeated at 28th
and 36th week (2) Urine is tested (dipstick)
for protein and sugar at every antenatal
visit.

PRINCIPLES:
1. To counsel the women about the importance of
regular check up.
2. To maintain or improve, the health status of the
woman to the optimum till delivery.
3. To improve the psychology and to remove the
fear of the unknown by counseling the woman.

DIET
The diet during pregnancy should be adequate to provide:-
1. Good maternal health
2. Optimum fetal growth
3. The strength and vitality required during labor and
4. Successful lactation.

 The pregnancy diet should be light, nutritious and
easily digestible.
 It should be rich in protein, minerals vitamins and
fibres and of the required calories.
 Dietary advice should be given with due consideration
to the socio-economic condition, food habits and taste
of the individual.
 Supplementary iron therapy is needed for all pregnant
mothers from 12 weeks onwards.

Energy (kcal) 2500 kcal (+300)
Protein 60 gm
Iron 40 mg
Calcium 1000 mg
Zinc 15 mg
Iodine 175 µg
Vitamin A 6000 IU
Vitamin D 400 IU

PERSONAL HYGIENE
 Daily all over wash is necessary because it is
stimulating, refreshing, and relaxing.
 Warm bath. shower or sponge baths is better than tub
 Hot bath should be avoided because they may cause
fatigue & fainting
 Regular washing for genital area, axilla, and breast due
to increased discharge and sweating.
 Vaginal douches should avoided except in case of
excessive secretion or infection.

BREAST CARE
 Wash breasts with clean tap water.
 It is not recommended to massage the breast, this may
stimulate oxytocin hormone secretion and possibly
lead to contraction.
 Advise the mother to be mentally prepared for breast
feeding.
 Breast engorgement may cause discomfort during late
pregnancy. A well-fitting brassiere can give relief

DENTAL CARE
 The teeth should be brushed carefully in the
morning and after every meal.
 Encourage the woman the to see her Dentist
regularly for routine examination & cleaning.
 A tooth can be extracted during pregnancy, but
local anesthesia is recommended & can do
preferably 0n 2 nd trimester.

DRESSING
 Woman should avoid wearing tight cloths such as belt
or constricting bans on the legs, because these could
impede lower extremity circulation.
 Suggest wearing shoes with a moderate to low heel to
minimize pelvic tilt & possible backache.
 Loose, and light clothes are the most comfortable.

TRAVEL
 Travel by vehicles having jerks to be avoided especially in 1st
trimester and the last 6 weeks.
 Late in pregnancy, travel plans should take into consideration
the possibility of early labor.
 Long distance travel better to be avoided. Rail route is
preferable.
 Travel in pressurized aircraft is safe up to 36 weeks.
 Prolonged sitting should be avoided due to the risk of venous
stasis and thromboembolism.
 Seat belt should be under the abdomen.

COITUS
 It is not restricted during pregnancy.
 Release of prostaglandins and oxytocin with coitus
may cause uterine contractions.
 Women with increased risk of miscarriage or preterm
labor should avoid coitus if they feel such increased
uterine activity.

REST AND SLEEP
 The woman may continue her usual activities
throughout pregnancy.
 Hard and strenuous work should be avoided.
 On an average, a patient should have 10 hours
of sleep (8 hours at night and 2 hours at noon)

BOWEL
 As there is a tendency of constipation during
pregnancy, regular bowel movement may be
facilitated by regulation of diet taking plenty of
fluids, vegetables and milk.

SMOKING AND ALCOHOL
 Heavy smokers have smaller
babies and there is also more
chance of abortion.
 Alcohol consumption can lead to
fetal mal-development or growth
restriction & FAS.

IMMUNIZATION
 Live virus vaccines (rubella, measles, mumps,
yellow fever) are contraindicated.
 Tetanus: Immunization against tetanus not
only protects the mother but also the neonates.

DRUGS
 The pregnant women should avoid over-the
counter drugs.
 The drugs may have teratogenic effects on the
growing fetus especially during the first
trimester.

DANGER SIGNS OF PREGNANCY
 Vaginal bleeding including spotting.
 Persistent abdominal pain.
 Sever & persistent vomiting.
 Sudden gush of fluid from vagina.
 Absence or decrease fetal movement.
 Sever headache.
 Edema of hands, face, legs & feet.
 Fever above 100 F( greater than 37.7°C).
 Dizziness, blurred vision, double vision & spots before eyes.
 Painful urination.

antenatalcarebabicopy-2 10112151807.pptx

antenatalcarebabicopy-2 10112151807.pptx

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