ANTENATAL

CARE
Sindhu Sebastian
Lecturer
Fmcon

Periodic and regular supervision including

examination and advice of a woman
during pregnancy is called Antenatal
care.

The supervision should be of a regular

and periodic nature in accordance with
the need of the individual.
The aims are-

To screen the high risk cases

To prevent or detect or treat at the any

earliest complication

To ensure continued medical surveillance

and prophylaxis

To educate the mother about the physiology

of pregnancy and labour by demonstrations,
charts and diagrams so that fear is removed
and psychology is improved

To discuss with the couple about the

place, time and mode of the delivery,
provisionally and care of the newborn

To motivate the couple about the need of

family planning

To advice the mother about breast-

feeding, post-natal care and
immunization
To ensure a normal pregnancy
with delivery of a healthy baby
from a healthy mother
Delivery of a single baby in
good condition at term with
no maternal complication
As per !" recommendation at least # visit-

$
st
visit around $% weeks

&
nd
visit between &#-&' weeks

(
rd
visit at (& weeks

#
th
visit at (% weeks
)enerally-

At interval of # weeks up to &' weeks

At interval of & weeks up to (% weeks

At weekly interval up to *++

,ullipara - is one who has never completed a
pregnancy to the stage of viability.
Primiparous- is one who has delivered one viable
child
.ultigravida is one who has previously been
pregnant. /he may have aborted or have
delivered viable baby.
Parturient- is a woman in labour.
,ulligravida is one who is not now and never has
been pregnant.
Primigravida- is one who is pregnant for the 0rst
time
.ultipara- is one who has delivered two or more
children

1areful history taking and examination

and investigation

Advice given to the pregnant woman

!istory taking

*xamination

2nvestigation
$. Particulars of the patient
&. 1hief complaints with duration
(. Past history
#. "bstetric history
3. .enstrual history
%. 4amily history
5. +rug !istory
'. !istory of immunization
6. /ocio-economic history
$7. 1ontraceptive history
$$. !istory of allergy
$.,ame
&.Age
(.Address
#..arital status
3.+ate of Admission
%.+ate of *xamination
$. Period of amenorrhea
&. ,ausea 8 vomiting, vertigo
(. 2ncreased fre9uency of micturition
#. 1onstipation
3. !eaviness of breast
%. :ise of temperature
5. *dema
'. Pain in the abdomen
6. ;ackache
$7. <aginal bleeding
$.!T,
&.+.
(.;A
#.:enal +isease
3.Psychiatric illness
%.2!+
5.Any previous operation

+uration of marriage

)ravida

Para

A=1

Antenatal history - 2
trimester
22
trimester
222
trimester

Past obstetrical history

1
st
Trimester

Ask about nausea, vomiting

ther associated s!m"toms such as #ever

Abdominal$"elvic$back "ain, burning micturition

%aginal discharge

&leeding "er vagina

'se o# #olic acid tablets (small !ello) colored

"ills*

+as an ultrasound done at , or -)ks (.ating

scan*
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/
nd
Trimester

Ask about regular use o# #olic acid, iron and calcium su""lements

'ltrasound at 101//)ks (Anomal! scan*

2uickening3 #etal movements (normall! #elt around /4 )eeks

gestation*

Fever, rash, abdominal "ain

5
rd
Trimester

Tetanus to6oid vaccine at /0 )ks 7 5/ )ks

Regular doctor checku"s

'ltrasound
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Age of menarche

.enstrual period

.enstrual cycle

=.P

*++
a?!T,
b?+.
c?.ultiple pregnancy

Antihypertensive

!ypoglycemic

Antidepressant

1orticosteroid

Anticoagulant

)eneral examination

Abdominal examination

Obtain consent to examine patient

Inform and explain to the patient what you intend to do

Warn patient to inform you if the examination becomes

uncomfortable at any time.

Always look at the patients face during the examination to

identify any signs of pain or discomfort elicited during the
examination.

Make sure that the patient has recently emptied her

bladder.
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As"ects o# Antenatal Assessment

!ead to toe examination

;reast examination

Abdominal palpation

Pelis

!enitalia
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GENERAL ASSESSMENT

!"#"$A% APP"A$A#&"

'"I!'(
R: Maternal height and labour outcome. ) Obstet
!ynaecol. *++* ,ep-**./01/234/
(here was a statistically significant positie correlation
between height and birth weight and a negatie association
between height and incidence of caesarean sections.

W"I!'(

5MI

6I(A% ,I!#,
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'AI$1 7ryness 8 poor nutrition

"9",1 "dema with swollen optic disk 8 PI'

#O,"1 #asal congestion

"A$,1 7ampening of sound

MO:(';(""(' A#7 ('$OA(1

&racked corner of mouth4 itamin A deficiency

Pin point lesions with an erythematous base4 herpes

infection
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7ental caries1
R: Maternal dental caries and pre4term birth
Acta Odontol ,cand. *+22 )ul-<=.>01*>?4/<.
NECK: slight (hyroid enlargement
LYMPHNODES:
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Inspection1

,ymmetry

Primary areola

,econdary areola

Montgomerys

#ipple retracted @flat @erectile@

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Palpation1 lumps@ axillary lymph node

6A$IO:, M"('O7,

&ircular techniAue

Wedge (echniAue .Wheel ,poke0

6ertical strip

"xpression of colostrum1
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Abdominal palpation
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*nsure the patient has emptied her bladder

before examining her abdomen.

Patient should lie in the supine position with a

pillow under the head and arms by her side.

/he is slightly rolled to the left side to prevent

compression of the inferior vena cava by the
enlarged uterus @inferior venacaval syndrome
or supine hypotensive syndrome?.

Ask for any tender area before palpating the

abdomen.
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/he is made to Aex her knees while

doing pelvic palpation.

*xamination is performed by fully

exposing the abdomen.

*xaminer stands on right side of mother.

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2nspection

Palpation

Auscultation
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INSPECTION

,iBe

,hape

,kin changes

,car marks

Cetal moements

Clanks

:mbilicus
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"void in primigravid woman

.ultiparous woman B pendulous

abdomen in which uterus sags forward.
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-
+escribe the abdominal
distension @pyriform?.
-
Previousoperative@1aesare
an?scars
-
=inea nigra
-
/triae gravidarum or
stretch marks
-
<isible foetal movements.
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Cundal height

Abdominal girth

Cundal grip .I
%eopold0 -4etal
poles

%ateral grip .II

%eopold; :mbilical
grip0 4Cetal lie

Pelic grip .I6

%eopold0
1Fetal Attitude
and
engagement

Pawliks grip .III

%eopold0
18resenting "art
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arm hands before palpation

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1entralize uterus,
place ulnar border of
left hand on upper
most level of fundus
and measure till
symphysis pubis with
help of an inch tape.

4undal height-CCcm
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.easure around abdomen at the level of
umbilicus

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Leo"old9s :aneuversare a common

and systematic way to determine the
position of afetusinside the
womanEsuterusF they are named after
the gynecologistChristian ;erhard
Leo"old.

are a common and

systematic way to determine
the position of afetusinside
the womanEsuterusF they are
named after the
gynecologistChristian
;erhard Leo"old.

The uterine
fundus is
palpated to
determine
which fetal
part occupies
the fundus.
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1;oth hands placed over the
fundus and the contents
of the fundus determined.
1A hard smooth, round pole
indicates a fetal head.
-A softer triangular pole
continuous with the fetal
body is the fetal
buttocks@breech?.
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F'N.AL
8AL8AT<N3

The uterine fundus is

palpated to
determine which
fetal part occupies
the fundus.
-.ove both hands in
a downward
direction from the
fundus along the
sides of the uterus
to determine the
GlieG of the foetus.
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*ach side of the

maternal abdomen is
palpated to
determine which side
is the fetal spine and
which is the
extremities.

/pine - smooth
curved and resistent
feel

=imbs - small knob

like irregular parts
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+etermine which
side the foetal back
is situated by
feeling the 0rm
regular surface of
the foetal back on
one side and the
irregular.
foetal limbs

=umpy surface as
the on the other
side.
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=ieG is the relationship
btw the longitudinal
axis of the foetus and
the longitudinal axis of
the mother.

longitudinal

aby is lying length-

wise in the same
direction as
motherEs
longitudinal axis.
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Transverse lie
@fetus lies across
the long. axis of
mother? and
"bli9ue lie @foetus lies
at an obli9ue angle
to the motherEs
long. axis?.
-
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LATERAL 8AL8AT<N3

*ach side of the

maternal abdomen is
palpated to determine
which side is the fetal
spine and which is the
extremities.

/pine - smooth curved

and resistent feel

=imbs - small knob like

irregular parts
"ne hand applies pressure
on the fundus while The
thumb and middle 0ngers
of the right hand are
placed wide apart over
the suprapubic area to
determine the presenting
part to con0rm
presentation and
engagement.
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Presenting part of
fetus is the lowest
most part of the
fetus at the inlet of
the pelvis@the lower
fetal pole as
opposed to the
fetal pole in the
fundus?.

1ephalic or breech
presentation
distinguished from
each other
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"ne hand applies

pressure on the
fundus while the
index 0nger and
thumb of the other
hand palpate the
presenting part to
con0rm
presentation and
engagement.

The area above the

symphysis pubis is
palpated to locate the
fetal presenting part and
thus determine how far
the fetus has descended
and whether the fetus is
engaged. 2f hands are
converging indicates
unengagement F
diverging indicates
engagement of head.
-The examiner turns around
to face patients feet.
-*ach hand placed on either
side of the fetal trunk
lower down.
-The hands moved
downwards towards the
fetal head.
-,ote made as to which
hand 0rst touches the
fetal head @This point
called cephalic
prominence?.
-
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The area above the

symphysis pubis is
palpated to locate the
fetal presenting part
and thus determine
how far the fetus has
descended and
whether the fetus is
engaged. 2f hands are
converging indicates
unengagement F
diverging indicates
engagement of head.
1*The attitude o# the #etal
head3
-The examiner turns around to
face patients feet.
-*ach hand placed on either
side of the fetal trunk lower
down.
-The hands moved downwards
towards the fetal head.
-,ote made as to which hand
0rst touches the fetal head
@This point called cephalic
prominence?.
-
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1ephalic prominence helps determine the
attitude @i.e. Aexion, deAexed or extended? of
fetal head.
-2f cephalic prominence is on the opposite side of
fetal back, fetal head is well Aexed @normal
position?.
-2f cephalic prominence on the same side as fetal
back, fetal head is extended @abnormal
position?.
-2f examiners hands reach the fetal head e9ually
on both sides, fetal head is deAexed @E.ilitary
position, indicating mal-position?
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PALPATION

Cundal height

Abdominal girth

Cundal grip .I %eopold0

%ateral grip .II %eopold; :mbilical grip0

Pelic grip .I6 %eopold0

Pawliks grip .III %eopold0

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-+uring the examination note any foetal
movements @kicks and rolling motions?.
-!ealthy foetuses move, sick or sleepy
foetuses donEt move.
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-
Auscultated with a foetal
stethoscope@ PinardEs
foetal stethoscope? or
with a doptone machine.
-
;est place to listen is
over the foetal back,
closer to the cephalic
pole.
-
The normal foetal heart
rate is btw $$7 to $%7
beats per minute.
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,ormal 4!: is $&7-$%7 b>m

1auses of foetal tachycardia

@H$%7 b>m?

1auses of foetal bradycardia

@I$&7 b>m?
&#
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PELVIC EXAMINATION

Diagona con!"gate
no#$a % & '()* c$

Isc+ia t",e#osit- .ia$ete#

no#$a % '/0'' c$
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EXTREMITIES

"dema of the legs 8

Medial malleolus and anterior surface of the lower
2@3 of the tibia.
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8erineum

"edema of vulva

+ischarge

/oreness of vulva

<aginal bleeding

;artholinJs cyst

Perineal hygiene
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Name First done Re"eated <nter"retation
$. !b, P1< ;ooking "nce every
trimester
I$7 g>d= or I $$ g>d=
@!"? consider as
anemia
&. ;lood group 8
:h typing
;ooking --- 2f :h Bve, husbandJs
group 8 21T
(. !bsAg, !2<,
<+:=
;ooking --- 2f Kve, refer for
counselling 8 PPT1T
#. Lrine routine
examination
;ooking *very visit Pus cellsH 3, do a
culture
AlbK or H, consider
pre-eclampsia
3. )1T &#-#' weeks --- $(7 mg>d= or more, do
a )TT

1;1

;lood grouping 8 :h typing

Lrine :>*

:;/

<+:=

!;/ Ag

Lltrasound
early pregnancy @preferably at $7-$( weeks?
to-

+etermine gestational age

+etect multiple pregnancies

!elp with later screening for +ownEs

syndrome
At $$-$# weeks-
oMer nuchal translucency screening for
+ownEs syndrome, with other tests if
available.
At $'-&7 weeks-
oMer screening with ultrasound for
congenital anomalies.
At (% weeks-
for foetal maturity, placenta praevia.

Patient complains

)eneral examination

)estational age to be calculated

2denti0cation of problem

4oetal movement

/4! measurement

!ealth education

Prophylaxis 8 treatment of anemia

+eveloping individualized birth plan

/4! measurement

To detect .ultiple pregnancy

/creen for-
$.Preeclampsia
&..ultiple pregnancy
(.anemia
#.2L):

2denti0cation of foetal
$. =ie
&. Presentation
(. Position

Lpdate birth plan

Principles-
$.To impress the patient about the importance of
regular check up
&.To maintain or improve the health status of the
woman to the optimum till delivery by Nudicious
advice regarding diet, drugs and hygiene
(.To improve and tone up the psychology and ot
remove the fear of pregnancy by talking
sympathetically to the patient and explaining
the principle changes and events likely to occur
during pregnancy

+iet

:est 8 sleep

;owel

Personal cleanliness

1lothing, shoes 8
belt

+ental care

1are of breast

1oitus

Travelling

/moking 8
alcohol

2mmunization

+rug

.ental
preparation

*xercise

1hild care

;irth plan

arning sign

4amily planning
4ollowing advices are to be given-
+iet should be-
$.nutritious
&.balanced
(.light
#.easily digestible
3.rich in protein, mineral and
vitamin
%.with womanJs choice
Food element "regnanc!
Oilocalories &377
Protein %7 gm.
2ron #7 mg
4olic acid
#77 g
1alcium $777 mg
<itamin A %777 2.L.
*arly morning-

Tea or coMee B $ cup

;iscuit B & pcs

;reakfast-

1hapatties B & pcs

*gg B $ poached or boiled

<egetable B $ cup
.idmorning-

.ilk B &37 ml or $ glass

;iscuit B & pcs

Apple or orange B $ pc
=unch-
$.1ooked rice B # cup
&..eat or 0sh B ( pcs or $&7 gm.
(.1ooked +al B & cups
#.<egetable B $ cup
3.=eafy vegetable B P cup
%./alad B tomato, carrot, cucumber
*vening-

;iscuits B & pcs

4ruits B on choice
+inner-

1ooked rice B ( cup

.eat or 0sh B ( pcs or $&7 gm.

1ooked +al B & cups

<egetable B $ cup
;ed time- one glass of milk
*arly morning-

Tea or coMee B $ cup @without sugar?

/alted ;iscuit B & pcs

;reakfast-

1hapatties B & pcs > Atta B %7 gm.

*gg B $ poached or boiled

<egetable B P cup

.ilk B $37 ml or $ cup

.idmorning- apple or sweet lime
=unch-
$.1ooked rice B $.3 cup > rice B %7 gm.
&..eat or 0sh B $ pcs or #7 gm.
(.1ooked +al B $ cup
#.=eafy vegetable B P cup
3./alad B tomato, carrot, cucumber
*vening- @# pm?

/alted ;iscuits B & pcs

.ilk B $37 ml or $ cup

+inner-

1hapatties B ( pcs > Atta B 67 gm.

.eat or 0sh B $ pcs or #7 gm.

1ooked +al B $ cup

<egetable B P cup
;ed time- one cup of milk
:estricted food-

sugar

.olasses

!oney

Qam > Nelly

/weet

1hocolate

2ce-cream

Nuice

' hour sleep at night

At least & hour sleep

after mid-day meal

!ard strenuous work

should be avoided in
0rst trimester and last
# weeks

:egular bowel movement may be

facilitated by regulation of diet, taking
plenty Auid, vegetable and milk
Coitus
/hould be avoided in

$
st
trimester

last % weeks
/hould be avoided in

$
st
trimester

last % weeks
Air travelling is contraindicated in

Placenta praevia

Preeclampsia

/evere anemia

Tetanus toxoid B safe8 mandatory

$
st
dose- at booking visit 8 then % weeks later

2f already takes within last ( years, booster at (% weeks

'suall! others not given
Sa#e nl! in
e"idemics
C.<
Tetanus Typhoid :ubella
!epatits 1holera ..:
:abies <aricella
;1)
Rellow
fever
1ontraindicated-

=ive virus vaccine @rubella measles, mums,

varicella?

Tetanus toxoid B safe8 mandatory

$
st
dose- at booking visit 8 then % weeks later

2f already takes within last ( years, booster at (% weeks

'suall! others not given
$. 4olic acid B 3mg during $
st
trimester @ if
not begun preconceptionally?
&. 4e 8 1a started at $( wks
continued for ( months after
pregnancy
4e- $77mg 1a- $mg>day

*xercise should be simple.

alking is ideal, but long period of walking

should be avoided.

The pregnant woman should avoid lifting

heavy weights such as- mattresses furniture,
as it may lead to abortion.

/he should avoid long period of standing

because it predisposes her to varicose vein.S
/he should avoid setting with legs crossed
because it will impede circulation.
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$. To develop a good posture.
&. To reduce constipation 8 insomnia.
(. To alleviate discomfortable, postural back
ache8 fatigue.
#. To ensure good muscles tone8 strength
pelvic supports.S
3.To develop good breathing habits, ensure
good oxygen supply to the fetus.

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%.To prevent circulatory stasis in lower
extremities, promote circulation, lessen
the possibility of venous thrombosis
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$. !eadache
&. ;lurring of vision
(. 1onvulsion
#. <aginal bleeding
3. 4ever

,ausea 8 vomiting

;ackache

<aricose veins

!emorrhoids

<aginal discharge

Acidity 8 heart burn

1onstipation
Thank =ou>..
1. ;eneral advice #or all )omen3

Preconceptional folate

:ubella 8 !ep ; vaccine

eight reduction in obesity

1essation of smoking > alcohol

Advice regarding drug intake

:ule out /T+s, 8 !2<

counseling

Avoid teratogens
/. :edical disorders

Preconceptional glycemic control in diabetes

:emission in chronic diseases like /=* 8

chronic renal disease

1ardiac surgery prior to pregnancy

Avoiding pregnancy in certain cardiac

diseases

1hanging teratogenic drugs as in epilepsy

5. Recurrent "regnanc! loss

1hecking for antiphospholipid antibody syndrome

1orrection of uterine septum by hysteroscopic

septal resection

?. ;enetic "roblems

Parental karyotyping

1arrier screening based on ethnicity or family

history

+ietary advice in POL

Preconceptional care is the one step

ahead of antenatal care.

hen a couple is seen and counseled

about pregnancy, its course and outcome
before the time of actual conception, is
called Preconceptional care.

"bNective- to ensure that, a woman

enters pregnancy with an optimal state of
health which would be safe both to
herself and the fetus.

2denti0cation of high risk factor

;asal level health status including ;P

recording

:ubella 8 !epatitis immunization

4olic acid supplementation

.aternal health is optimized

preconceptionally such as overweight
anemia

Patient with medical disease like

hypertension, diabetes are stabilized in an
optimal state by intervention

+rugs used before pregnancy are veri0ed and

changed if re9uired to prevent any adverse
eMect of the fetusF e.g., warfarin is replaced
with heparin, oral anti-diabetic drug with insulin

Advise to stop smoking, alcohol and drug abuse

Proper counseling to those with history of

recurrent foetal loss or family history of
congenital abnormalities

1ounseling regarding health care cost

4ind out supporting or helping people to help

the mother and care of the new born