Prenatal Care – Antenatal Care – Care During Pregnancy

ANTENATAL CARE, also known as Prenatal Care, is a type of preventive healthcare.

Prenatal Care or in simple language Care During Pregnancy is the most crucial period for pregnant women, her family as well as for the health services provider.

The Antenatal period / Prenatal period can have a positive impact on the health of both the mother and her child.

In this post you will get everything you want to know about Prenatal Care / Antenatal Care / Care During Pregnancy.

Prenatal Care – Antenatal care – Care During Pregnancy Introduction:-

It includes Essential

• obstetric care,
• Detailed history at the first visit,
• Schedule of Examination,
• Examination at the antenatal clinic,
• Investigations,
• Examination, and action to be taken during ANC check-up,
• Fundal Examination,
• Education and counseling regarding care during pregnancy,
• Identify high-risk mothers,
• Actions suggested for some high-risk indicators,
• Calculation of EDD + EPD,
• Triage birth companion,
• Counseling of PPIUCD & Contraception,
• Assessment of fetal wellbeing,
• Exercise for participants.

What is prenatal care?

Definition of prenatal care – Antenatal Care – Care During Pregnancy –

Antenatal care is the care of the woman during pregnancy.

Definition of prenatal care – Antenatal Care – Care During Pregnancy

The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby.

Ideally this care should begin soon after conception and continue throughout pregnancy.

Objectives of Prenatal Care – Antenatal Care – Care During Pregnancy:-

At the end of the session you will be able to –

• Provide quality antenatal care to the mother and
• ensure delivery of a healthy baby.
• Early detection of High-risk pregnancy and its complications and refer to the appropriate health facilities.
• Identify the place of delivery and ensure that delivery is attended by Obstratisian.

Essential obstetric care to every pregnant woman:-

Registration of all pregnant women at Prenatal Care centre before 12 weeks

Importance of Prenatal care:-

Proper prenatal care results in a healthy mother and a healthy baby. The main Importance of Prenatal care is as follow –

why is prenatal care important ?

• Any pregnant woman can have complications that can lead to maternal morbidity and mortality.
• Accurate prediction about which woman will develop complications is not possible.
• Make sure that referral services are available to manage obstetric emergencies.

Detailed history at first visit:-

when to visit doctor to confirm pregnancy?

first prenatal visit at 6 weeks or before 12 weeks

Menstrual history:-

• The regularity of Menstrual cycles,
• Date of LMP,
• Calculate EDD + EPD by Naegele’s rule and
• Record on Mother-Child Protection (MCP) card

Obstetric history:-

1. Number of prior pregnancies and outcome of each pregnancy (full-term birth, preterm birth, abortion),
   
2. place and mode of delivery,
3. The weight of baby,
4. Live birth/stillbirth,
5. Complications during after delivery
   (PPH, Retained Placenta, Infection)

Past history:-

• Hypertension,
• Diabetes Mellitus,
• Tuberculosis,
• Asthma,
• Heart disease, any other,
• Surgical procedures are undergone,
• Medications are taken during the preconception period,
• History of bleeding

H/O current symptoms:-

Perception of fetal movements if pregnancy > 10 weeks

Pregnancy Appointments Timeline:-

Pregnancy Check up Schedule –

For a healthy pregnancy, your doctor will probably recommend the following schedule of prenatal visits:-

• 4 to 28 Weeks : 1 prenatal visit a month.
• 28 to 36 Weeks : 1 prenatal visit every 2 weeks.
• 36 to 40 Weeks : 1 prenatal visit every week.

Schedule of Prenatal Care Examination:-

As per WHO guidelines every woman in her Prenatal Care must have at list a minimum of 4 visits.

4 antenatal care visits schedule :-

1st visit:–

1st Prenatal Care visit Within 12 weeks-preferably as soon as pregnancy is suspected for registration of pregnancy and first antenatal check-up.

The first prenatal visit at 12 weeks or before must be the first check-up when pregnant.

2nd visit:-
2nd Prenatal Care visit is planed Between 14 and 26 weeks of gestation.

3rd visit:-
3rd Prenatal Care visit is planed Between 28 and 34 weeks of gestation.

4th visit:-

4th Prenatal Care visit is planed Between 36 weeks of gestation and at term.

Schedule of antenatal visit:-

Visit	Weeks for an antenatal visit
1st visit	within 12 weeks, preferably as soon as the pregnancy is suspected, for registration of pregnancy and first antenatal check-up.
2nd visit	between 14 and 26 weeks
3rd visit	between 28 and 34 weeks
4th visit	between 36 weeks and term.

Examination at Prenatal / antenatal clinic:-

Examination at antenatal clinic –

• Height -145cm minimum.
• Breast examination for a lump, normal anatomy.
• Weight: Compare with the previous visit ( weight gain min 9- 12 kg )
• Calculate BMI in first-trimester
• POLÍC-Pallor, Lymphadenopathy, icterus, cyanosis and clubbing.
• Edema over feet, hands, face
• Blood pressure
• Systemic examination: Auscultate chest
• P/A:- Fundal height & its correlation with the period of amenorrhea (POA)
• Fetal presentation & position after 32 weeks.
• Fetal heart rate.

High-risk Pregnancy:-

The last two visits are important as many of the pregnancy complications
are detected during the last trimester. These are known as High-risk Pregnancy.

For ‘high risk’ mothers more frequent examinations will be required.

A medical officer should perform at least one check-up during the third trimester and auscultate her chest to
rule out any systemic abnormality.

Investigations during Prenatal care –

Routine Tests during Pregnancy:-

• VDRL Hemoglobin estimation
• Urine Analysis Routine /microscopic: Protein
• Voluntary HIV testing,
• Thyroid and sugar,
• Bile salt, bile pigment.
• Blood grouping, Rh typing
• Hepatitis B surface antigen (HsAg)

investigation Test for sickling in selected tribal area Blood sugar testing

Ultrasonography during Pregnancy –

what weeks do you get ultrasounds during pregnancy ?

first ultrasound during pregnancy –

1st- trimester USG under 12 weeks and

Second ultrasound during pregnancy –

2nd USG in 16 to 18 weeks
be taken during ANC check-up.

Prenatal Examination and Action:-

Examination	Action
Edema	• Examine whether the edema is on one leg or both legs and is it pitting. Look edema over face, hands, and abdomen. Check for proteinuria ar hypertension. • High blood pressure and albuminuria, refer to a specialist as she has pre-eclampsia. Edema History of kidney disease, if yes refer to a specialist. • If edema is on one leg, refer to a specialist. • If bilateral pedal edema without albuminuria and normal BP: Reassure mother, check for anemia, and give IFA tablets as required.
Weight Gain	• Record monthly weight on MCP card of a mother, calculate weight gain since the previous visit Weight gain. • Weight gain more than 3 kg. in a month: Suspect pre-eclampsia. • Weight gain less than 1 kg in a month: Suspect fetal growth retardation, Missed abortion, IUGR, and Oligohydramnios.
Blood Pressure	• If 140 / 90 mm Hg or more, advise the mother to rest for half-hour and then repeat the BP recording. Check for proteinuria. • If systolic between 140-160 and /or diastolic 90 or above: advice extra rest and refer to MO PHC • If systolic 160 or more or diastolic > 100 refer to a specialist.
Fundal Height	• Examine fungal height in weeks and • compare it with the calculated duration of pregnancy as per LMP. If it is greater or lesser refer to a specialist. • Causes of fundal height less or more than expected are given in the table below
Fetal Presentation	• Fetal Noncephalic (correction can be attempted at 36 weeks in suitable cases) by Obs/Gyn specialist.
Fetal Heart Rate	• Fetal Heart FHR < 120 or > 160 /minute : Refer to specialist
Hemoglobin %	• Hb 11 gm% or more: IFA 100 tablets • Hb between 7-11 gram%: Start IFA double dose and reexamine after one month – If the improvement of Hb by more than 1gm%, continue IFA. Give tab Albendazole (during the second trimester) • Hb < 7 gm % – Refer anemia treatment guidelines.
Proteinuria	• If proteinuria presents suspect pre-eclampsia and refers to a specialist.
Risk factors	• All high-risk pregnancies should be checked by MO and then referred to a specialist if necessary for further, check-up or during delivery depending on Risk factors upon the risk factor.

Fundal Examination Antenatal Examination FUNDAL HEIGHT:-

Fundal Examination Preliminaries:-

• Respect woman’s rights.
• Explain the procedure and ensure privacy.
• Ensure bladder is empty.
• Examiner stands on the right side.
• Abdomen is fully exposed from xiphisternum to pubic symphysis.
• Keep woman’s legs straight

• Centralise uterus

How to Measure Fundal Height ?

Fundal Examination Steps:-

1. Correct dextrorotation.
2. Ulnar border of the left hand is placed on the uppermost level of the fundus and marked with pen Measure.
3. Distance between the upper border of the pubic symphysis and marked point.

Fundal Examination GRIPS / Obstetrical GRIPS:-

Legs are slightly flexed and separated for obstetrical grips

1. Fundal Grip
2. Lateral Grip
3. First Palvie Grip (Pawlik’s Grip)
4. Second Pelvic Grip
5. Fetal heart sound is usually located along the lines as shown in the image.

Fundal Height:-

Weeks of Pregnancy	At the Level of
1) 12 Weeks	Pubis Symphysis
2) 16 Weeks	At the midpoint Between Pubic Symphysis and Umbilicus.
3) 20 Weeks	At the midpoint Between 16 Weeks and 24 Weeks
4) 24 Weeks	At the Level of Umbilicus
5) 28 Weeks	At the midpoint Between 24 Weeks and 32 Weeks
6) 32 Weeks	At the midpoint Between Umbalius and Xiphisternum
7) 36 Weeks	At the Level of Xiphisternum
8) 40 Weeks	Below the Xiphisternum ( In Between 32 wks and 40 wks)

Small or Big Belly in Pregnancy Causes:-

Fundal height< Period of Amenorrhea & weight gain less than 9 Kg	Fundal height > Period of Amenorrhea
Wrong LMP date	Wrong LMP date
Missed Abortion	Poly hydramnios
Infrequent periods prior to conception	Twins
Intrauterine Growth retardation(IUGR)	Big baby
Oligohydramnios	Hydatidiform mole
Intrauterine fetal death.	Uterine fibroids

Education and counseling regarding care during pregnancy First and second trimester:-

First Trimester, Second Trimester prenatal care guidelines:-

Diet:-

More than one meal a day and evening snacks (most important), the inclusion of sprouted legumes, pulses, green leafy and other vegetables, seasonal fruits.

Rest:-

2 Hours in the afternoon and 8 hours at night in the lateral position.

Exercise:-

Walking for 30 minutes daily, Yoga, Pranayama, Swimming with consultation, and advised by Your Healthcare Provider.

Habits:-

Avoid tobacco in any form, avoid alcohol.

Sex in Pregnancy:-

Avoid sex during First and Third Trimester.

Iron Supplement for pregnancy –

• Consumption of iron folic acid 100 tablets for anemia prophylaxis.

Tetanus Toxoid Injection in Pregnancy:-

Tetanus Toxoid 2 doses/booster dose must be taken by every pregnant woman.

Calcium supplements in Pregnancy:-

Calcium through diet and Calcium carbonate tablets 1.2 Gm daily.

Self-reporting of danger sign, Danger Signs in Pregnancy:-

If pregnant women have the following danger signs or symptoms she must visit the doctor as soon as possible.

Danger Signs in Pregnancy –

• Abdominal pain,
• severe headache,
• giddiness, palpitations,
• easy fatigability,
• breathlessness,
• fever,
• generalized edema,
• vaginal bleeding;
• watery discharge per vaginum,
• blurred vision,
• excessive vomiting
• reduced fetal movements

Education and counseling regarding care during pregnancy Third trimester:-

• Avoid heavy work and jerky travel on bad roads.
• Importance of institutional delivery, safe delivery, inform TOLL-free No. 102 and 108 for free ambulance service, JSY, JSSK, and other benefits, Plan for a place of delivery, preparation for delivery.
• Importance of early initiation of colostrum feeding within Half an hour of birth & exclusive breastfeeding for 6 months, child immunization, and contraception especially PPIUCD.
• Ask about the birth companion.

High-Risk Pregnancy, Identify high-risk mothers:-

Risk factors detectable during first check up:-

• Age: Teenage/ elderly primi, Para 4 and above. high-risk pregnancy age.
• Short stature, limping gait, vertebral spine abnormalities
• Bad obstetric history: H/O stillbirth, neonatal death, LBW baby, recurrent abortions of membranes Previous Caesarean delivery
• H/O PE/eclampsia, PPH, retained placenta during Previous Pregnancies.
• Preexisting medical conditions: Heart disease, diabetes mellitus, renal disease.
• HIV VDRL positive gravida.
• Rh-negative gravida.

Complications during pregnancy:-

• Anemia
• Hypertension, proteinuria
• Vaginal bleeding during pregnancy Premature rupture (PROM)
• Gestational diabetes mellitus (GDM)
• Fundal height < POA or > POA
• Uterus over distension: Twins, Polyhydramnios Fetal malpresentation persisting near term Pregnancy > 41 Weeks.
• Reduced fetal movements pregnancies.

Normal weight gain in Pregnancy:-

A guide for average weight gain in each trimester:–

1st Trimester:-

900 grams to 1.8 kilograms weight gained by mother

2nd Trimester:-

500 grams/week from 4-6 months to a total of 5-6 kilograms.

3rd Trimester:-

Around 500 grams/week to at total of 3-5 kilograms.

In the total period of Pregnancy pregnant women normally gain 9 to 11 kg of weight.

Summary:-

Antenatal care is the care of the woman during pregnancy. The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby.

Ideally this prenatal care should begin soon after conception and continue throughout the pregnancy.

In some countries, notification of pregnancy is required to bring the mother in the “mother and child health care system” as early as possible.