October/ 2019

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for

ANTE-NATAL MANAGEMENT OF NORMAL PREGNANCY
FIRST VISIT (PREFERABLY IN FIRST TRIMESTER)
ASK EXAMINE INVESTIGATIONS DO
• Age • Height, weight ESSENTIAL TESTS • UPT if in doubt
• LMP • Calculate BMI • Hemoglobin • Fill up MCH
• Parity & obstetric history • Pallor, Jaundice, Pedal edema • Urine R & M protection card or
• Any complaints especially excessive • Pulse, BP, RR, temperature • ABO & Rh grouping ANC card, make entry
nausea & vomiting/ bleeding PV • Thyroid DESIRABLE TESTS on RCH portal &
• H/o medical illness : diabetes, • Breast • VDRL/ RPR generate RCH
hypertension, cardiac problem, • Respiratory and CVS exam- • HIV number (in public
epilepsy or any other chronic illness ination • HBsAg sector)
• Consanguinity, multiple pregnancy • P/A examination, P/S and P/V • DIPSI test/ WHO OGTT for diagnosis of • Give filled MCH
• H/o blood transfusion and H/o prior examination GDM protection card & safe
surgical intervention # If woman presents with • TSH in high risk cases (BOH, goiter, obesity motherhood booklet
• Personal history : tobacco/ alcohol bleeding per vaginum do P/A or residing in iodine deficiency prone to woman
intake & P/S to confirm amount of areas) • Give Tab Folic Acid
• Family history : diabetes, hypertension, bleeding & rule out local OPTIONAL TESTS* daily
genetic disorders/ congenital causes. All such cases to be Aneuploidy screen* by USG & double • Give first dose of
problems, multiple pregnancy, referred to CHC or higher marker tetanus toxoid
infections including tuberculosis centre

SECOND VISIT (SECOND TRIMESTER)

ASK EXAMINE INVESTIGATIONS DO
ESSENTIAL TESTS • IFA tablet one (if Hb >11g%) or twice ( if Hb

.in
• Any com- • Weight • Hemoglobin <11g%) daily with water or lemon juice
plaints since • Pallor • Urine albumin • Calcium carbonate 500 mg with vitamin D
last visit • Pedal edema DESIRABLE TESTS 250 mcg tablet twice daily with meals.
• Quickening • Pulse, BP in • USG ( Level II between 18-20 weeks for gross congenital • Calcium Carbonate and IFA not to be given
and/ or fetal sitting malformations) together
movements position • DIPSI/ WHO OGTT if >24weeks & at least 4 weeks have • Single dose of Albendazole 400mg
• Adherence to • P/A elapsed after 1st test • Ensure compliance for investigations and
medications examination OPTIONAL TESTS* treatment
for fundal
rg
Quadruple test as per availability • Discuss birth preparedness
height • Give second dose Tetanus Toxoid at least four
*Should be performed only if adequate counselling facilities are available weeks after first dose

THIRD (28 – 34 WEEKS) AND FOURTH VISIT (36 - 40 WEEKS)

r.o
ASK EXAMINE INVESTIGATIONS DO
• Same as above • Continue IFA and calcium tablets and ensure compliance
Same as • Hemoglobin
• Auscultate FHS • If non compliant or Hb < 9g% give parenteral iron sucrose therapy (not > 200mg
above • Urine albumin
• Measurement of at one time & not > 3 times a week) and refer patient with Hb < 7g% to higher
abdominal girth • Optional USG for fetal centre
and Symphysiofundal growth and liquor • Refer to higher centre if any discrepancy between fundal height and period of
Height gestation

DANGER SIGNALS FOR PATIENT TO REPORT TO HEALTH HIGH RISK PREGNANCY

m

FACILITY • Any H/o medical illness, previous caesarean section, past obstetric
• Fever mishap or congenital malformation
• Persistent vomiting • Past H/o PPH
• Abnormal vaginal discharge • Age > 35 years or < 19 years or parity > 4
• Palpitations, easy fatigability and breathlessness at rest and/ or on • Malnourished (BMI < 18.5 kg/m2 or > 30 kg/m 2)
mild exertion.
.ic

• Hemoglobin < 7g%

• BP > 140/90mm Hg on 2 occasions 6 hours apart
• Vaginal bleeding • APH
• Decreased or absent fetal movements at > 28 weeks gestation • Discrepancy between fundal height and period of gestation > 4 weeks
• Leaking of watery fluid per vaginum (P/V) • GDM/ overt DM
• Severe headache/ blurring of vision/ convulsion • Multiple pregnancy * High risk pregnancy to be
• Passing lesser amounts of urine and/ or burning sensation during • Malpresentation at term delivered at district
micturition • Previous uterine surgery hospital/medical college
w

• Itching all over the body * Preferably to have antenatal

care also at these centres

COUNSELLING AT ALL LEVELS FOR : BIRTH PREPAREDNESS MUST INCLUDE

• Timing and place of next ANC visit based on presence or absence of risk factor IDENTIFICATION OF THE FOLLOWING :
st

• Rest, nutrition, balanced diet and exercise

• Counselling for HIV testing • Facility for delivery
• Danger signs • Support persons
• Birth companion
∙ Institutional delivery • Means of transport in emergency
∙ Birth preparedness • Blood donors (if required in emergency)
• Early & exclusive breastfeeding for six months

ASSESSMENT OF FUNDAL HEIGHT & ITS CORRELATION WITH

GESTATIONAL AGE

At 12th week : Just palpable above the symphysis pubis

At 16th week : At lower one-third of the distance between the symphysis pubis and
umbilicus

At 20th week : At two-thirds of the distance between symphysis pubis and umbilicus

At 24th week : At the level of umbilicus

At 28th week : At lower one-third of the distance between the umbilicus and • UMBILICUS
xiphisternum

At 32nd week : At two-thirds of the distance between the umbilicus and xiphisternum

At 36th week : At the level of xiphisternum

At 40th week : Sinks back to the level of the 32nd week, but the flanks are full, unlike
that in the 32nd week

COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.