outlines

 Objectives

 Introduction

 The concept of antenatal care.

 Goals & objectives of antenatal care.

 Places of antenatal clinics

 Schedule of antenatal visits.

 Preparation of antenatal rooms.

 The first visit including :
A. Assessment:
 History taking
 Examination

 Investigation

 B. Health teaching
 C. Follow-up visit
 Self care of common discomforts of pregnancy
 General Objectives

 At the end of this chapter each student will be able to

acquire knowledge about antenatal care.
 Specific Objectives:

 At the end of this chapter each student will be able

to:
 Understand the concept of antenatal care.

 Enumerate the goals and the objectives of antenatal care.

 Identify the places where these clinics can be found.

 Explain how to prepare antenatal room.

 Clarify the antenatal schedule visits.

 Discuss the role of the nurse in antenatal clinic.

 Determine the causes of oversized and undersized pregnant
uterus.
 Able to give health instruction for the pregnant women
about:
 Diet , Sleep , Exercises, Traveling, Coitus , Clothing , Care
of the teeth, Breasts, Bowel habits, Bathing, Follow up
schedule.
• Discuss the sell care of common discomforts of
pregnancy.
 :
Introduction

 Every year there are an estimated 200 million

pregnancies in the world. Each of these pregnancies

is at risk for adverse outcome for the women and her
infant. While risks in pregnancy cannot be totally
eliminated, they can be reduced through effective,
accessible and acceptable maternity care.
 The meaning of the antenatal care

 Ante: means before

 Natal: means delivery

 Antenatal: means before delivery

 Antenatal care: comprehensive health supervision

of a pregnant woman from conception till delivery.

 Definition

 It is planned examination ,observation &

guidance given to pregnant women from

conception till the time of labor. It also includes
History taking , Physical examination,
Investigation , Instruction or advice to the
pregnant mother &Reassurance
 GOALS

 To reduce maternal and peri-natal morbidity and

mortality rates.

 To improve the physical and mental health of

women and children

 Objectives

 To ensure that the pregnant woman and her

fetus are in the best possible health.

 To prepare the woman for labor, lactation and

care of her infant.

 To early detect and treat properly complicated

conditions that could in danger the life or impair

the health of the mother or the fetus.
 Factors affecting mother's utilization
of antenatal care

 Factors that influence a pregnant women's decision

about initiation and continuing prenatal care include

1. Demographic and biological factors

2. Socioeconomic

3. Psychological

4. Health services, medical and environmental factors

Ante natal clinics founded at the
following places:

 Maternity hospitals.

 General hospital.

 Maternal and child health centers.

 Private clinics.
 Schedule of antenatal
visits:

1. Every one month for the first six month.

2. Every two weeks for the 7 th and 8 th month.

3. Every one week during the 9 th month.

 Immediately when, she experiences
any of the following (Dangerous signs)
 Sever Vaginal bleeding.
 Swelling of the face or the fingers.
 Severe persistent headache.
 Dimness or blurring of vision.
 Flashes of light or dots infront the eyes.
 Abdominal pain.
 Persistent vomiting.
 Chills and fever.
 Sudden escape of fluid from the vagina.
 Stop fetal movement

Preparation of antenatal rooms:
 Components of antenatal care

1. Taking history

2. Complete physical and pregnancy

examination

3. Laboratory investigation

4. Health education and follow up

 Initial ( first ) visit.

 Subsequent ( return ) visits.

 First visit (Initial visit)

 Establish a relation.

 Registration.

 Orientation.

 History taking

 Investigations.

 Health teaching
 History
 Personal history
 Menstrual history
 Obstetrical history
 Family history
 Medical and surgical history
 History of present pregnancy
 Personal History

 Name

 age

 duration of marriage

 number of marriages if present

 occupation, address and telephone number

 Menstrual history
Ask about
1- Age of Menarche

2. duration of menstrual bleeding, length of cycle ,

amount (slight, moderate or excessive),

3. the presence of pain and its relation to bleeding

4. the first day of last menstrual period (L.M.P)

 What is my due date?

 Menstrual history
 First day of last normal period (LMP)
 Pregnancy duration

 40 wks or 280 days from LMP

 +7 days+9 months.

 EDD = Estimate Due Date

LMP + 7 days + 9 months
Using Nagel’s rule:
Example:
 Obstetric History

 In each delivery we ask about:

 Duration of pregnancy (preterm, full term or post
term);
 Mode of delivery (spontaneous vaginal delivery, by
forceps, etc.);
 The newborn (male or female, alive or dead);
 Fetal or maternal complication in the puerperium;
 Time of last delivery.
In each abortion we ask about:
 Duration of pregnancy;

 Mode of termination (spontaneous or induced);

 Complication in the post abortive period;

 Time of last abortion.

 Medical and surgical history:

1-Chronic conditions : as diabetes mellitus,

hypertension, and renal disease ,cardiac disease.

2-Prior operation: as cesarean section, genital

repair, and cervical cerclag.
3-Allergies, and medications.

4-Accidents involving injury of the bony pelvis

 History of present pregnancy
The patient is also asked about other symptoms as
 headache

 visual disturbances,

 gastrointestinal symptoms as nausea, vomiting,

diarrhea or constipation,

 urinary symptoms as burning pain and frequency,

vaginal bleeding, vaginal discharge and itching as

well as the presence of edema.
 Social history

 Ask about special habits of medical importance as

smoking, alcohol and drugs.

 2-Examination

 General examination

 Abdominal examination
Assessment and physical
examination
 General Eamination
Examine from Head to Toe
 General condition (good, moderate or bad).

 Height; weight; gait.

 Vital signs.

 Eye examination: pallor; jaundice

; edema of eye lids.

 Nose: e.g. saddle nose due to syphilis.

 Cheeks: for cloasma gravidarum.

 Mouth: tongue; teeth; tonsils.

 Neck: thyroid gland; lymph glands;

 congested neck veins.

 Chest: heart; lungs; breasts.

 Lower limbs: varicose veins; bony

deformities.
 Ultrasound: Is performed to:

1. Estimate the gestational age.

2. Check amniotic fluid volume.

3. Check the position of the placenta.

4. Detect the multifetal pregnancy.

5. The position of the baby

6. Fetal weight
 Vaginal examination: PV

 It is performed during pregnancy in the following

conditions:

1. In early pregnancy, at the first visit, to confirm the

diagnosis and to exclude any pelviclesion.

2. At the 36th week to do internal pelvimetry and

cephalopelvic proportion.

3. When complication occurs as bleeding or discharge

 Investigations

1. Urine is tested for protein, ketones and sugar.

Urine culture to diagnose significant bacteriuria.

2. Complete blood count, blood group and Rh

determination. Anaemia (may be done each
trimester) ,hemoglobin will be repeated at 36
weeks of gestation and every 4 weeks if Hb is <
9 g/d
3. Screening test for syphilis.

4. Hepatitis B surface antigen is tested.

5. Screening test to diagnose gestational diabetes.Done

between 24-28 weeks.

6. Other investigations according to need as pregnancy

test
 Diagnosis:
 Gravidity.  Gravida 1
 Para x + z  Para 0 + 0
 Duration of pregnancy in  More or less 36 weeks
weeks.  Longitudinal lie
 Lie.  Cephalic presentation.
 Presentation.  Diabetes mellitus.
 Associated conditions as
diabetes mellitus.
 Local Examination
(abdominal examination
Do
Leopold’s exam
 Component of local examination:

Inspection

Palpation

Auscultation
 Inspection

1. Pregnancy marks:

• linea nigra

• Striae gravidarum.

2. Shape ( round or oval)

3. Size: Appropriate or inappropriate for GA

4. Any scars (C.S)

 Palpation

1. Fundal Grip:
 Fundal level (G.A)

 Fundal Content ( head,

breech)
2. Umblical Grip:

 Right Side

 Left Side
3. Pelvic Grip:
 1st Pelvic Grip

(Engagement or
Ballotment)

 2nd Pelvic Grip ( degree

of fetal head flexion

Auscultation
 Provide Advice on

1.Diet and weight gain

2.Medication
3.Avoid Radiation exposure
4.Self-care during pregnancy
5.Minor complaints.
6. Family planning
7. Breastfeeding
8.Birth place preparation and anticipation of
complication& Emergency situations.
At Each Visit
 At each visit
 1-Questions about fetal movement:
 Fetal kick count
The pregnant woman reports at least 10 movements in 12 hours.
Absence of fetal movements precedes intrauterine fetal death by 48 hours.

 2-Ask for danger signs during this pregnancy

 3-Ask patient if she has any other concerns

 Supplementation

 1-Folic acid 0.4 mg tab daily

 2- iron (ferrous sulphate or gluconate )300 mg/daily
 3- Ca 1200mg /daily
 4-Those with a normal balanced diet
• probably don’t need extra vitamins
 Weight Gain in Pregnancy:

 There is a slight loss of pounds during early

pregnancy if the patient experiences much nausea
and vomiting.

 Weight gain of (0,5-2 kg) by the end of the first

trimester.

 Gain of (0.5)/ per wk is expected during the

second and third trimesters.

 Monitoring of weight gain should be done in

conjunction with close monitoring of BP.
 Health education during pregnancy

1. Diet:
 Daily requirement in pregnancy about 2500 calories.
 Protein requirement is increased, starch, carbohydrates
and fats should not be
given in excess.
 Vitamin A and B are essential for growth of fetus and
formation of fetal skeleton.
 Vitamin C and K reduce the incidence of abortion and
either ante or post partum hemorrhage.
 Ca + and iron should be given.
 Sufficient fluids should be available.
 Some important points regarding the diet:
1. Don’t take excess salt.
2. Don’t drink strong coffee and tea.
3. Don’t take alcohol.
4. Take 10-12 glasses of water per day.
5. Take small quantities of food in frequent intervals.
6. Eat fiber containing food and vegetables.
7. Wash vegetables before cutting.
8. Eat fruits and vegetables without peeling the skin if
possible
 Health education during
pregnancy
2. Exercise and Relaxation:
 Exercise should be simple. Walking 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.
 She should avoid long period of standing
because it predisposes her to varicose vein.
 She should avoid setting with legs crossed
because it will impede circulation
 Contraindications for exercises during
pregnancy:
1. Vaginal bleeding.
2. Severe anaemia.
3. History of preterm labor,
4. Extreme over or under weight.
5. Hypertension, heart, lung,and thyroid diseases
3. Sleep and Rest:

 Eight hours at night and 2 hours rest in the

afternoon.
4. bowel-habit:

 Avoid constipation because it leads to straining

down, so, piles and genital prolapse may occur.
 This could be avoided by eating fresh
vegetables, milk, performing pelvic floor
exercise and taking mild laxatives
5. Hygein:
1. The bath is given by shower. Tub and sea bathing are
avoided for fear of ascending infection

2. Hot bath should be avoided because they may cause

fatigue and fainting

3. Regular washing for genital area, axilla, and breast

due to increased discharge and sweating.

6. Breast care:
1. Wear firm, supportive bra with wide straps to spread
weight across the shoulder.

2. Wash breasts with clean tap water (no soap, because that
could be drying). Daily to remove the colostrums and
reduce the risk of infection.
7. Dressing:
1. Woman should avoid wearing tight cloths such as
belt or constricting bans on the legs, because these
could impede lower extremity circulation.

2. Suggest wearing shoes with a moderate to low heel

to minimize pelvic tilt and possible backache

3. Loose, and light clothes are the most comfortable

8. Immunization:
1. The nurse instructs the woman to receive immunization
against -tetanus to prevent the risk for her and her fetus.

 Tetanus toxoid is given during pregnancy to protect the

baby against tetanus during the neonatal period. The dose

is 0.5 ml., IM given as two doses at least 4 weeks apart
9. Travel:
1. Safe during the first half of pregnancy, but it is
restricted in later months. It is not allowed

2. If there is a tendency to abortion, or preterm labor.

Air travel is better than train or car for long

distances.
10. Coitus:
 It is avoided if there is tendency to abortion or
preterm labor
11. Warning signs:
 Vaginal bleeding.
 Swelling of the face or the fingers.
 Severe persistent headache.
 Dimness or blurring of vision.
 Flashes of light or dots before the eyes.
 Abdominal pain.
 Persistent vomiting.
 Chills and fever.
 Sudden escape of fluid from the vagina.
 Common discomforts of pregnancy

 Discomforts related to the gastrointestinal system:

 1.Nausea and Vomiting (Morning Sickness):
 Occur between 4-6 weeks gestation
Causes:
 Hormonal influences: human chorionic gonadotropin

(HCG) or progesterone, and estrogen.

 Emotional factors like tension

 Management:

1. Avoid an empty stomach.

2. Eat dry crackers or toast before arising in morning.

3. Eat small, frequent meals.

4. Drink fluids between meals.

5. Avoid greasy, spicy, or gas-forming foods.

 2. Heartburn (Pyrosis):
 Heartburn is a burning sensation in the epigastric
and sternal region.
 Causes:
 Progesterone hormone relaxes the cardiac sphincter
of the stomach and allows reflex or bubbling back of
gastric contents into the esophagus.
 The pressure of the growing uterus on the stomach
from about 30-40 weeks.
 Management:

1. Sit up for 30 minutes after eating a meal.

2. Avoid gas-forming and greasy foods.

3. Avoid overeating.

4. Use low-sodium liquid antacids (liquid will coat lining

better than tablets).

3 . Constipation:
Causes:
 Intestinal motility decreased during pregnancy as a

result of progesterone.

 Iron supplementation (side effect of iron therapy is

constipation).
Management:
1. Increase fluid intake, roughage in diet, exercise.

2. Regular schedule for bowel movement.

3. DO not take mineral oil or enemas.

4. Consult health care provider before taking stool softener

4. Ptyalism (excessive salivation):
Relieve measures:
1. Perform frequent mouth care.
2. Chew gum.
3. Decrease fluid intake at night.
4. Maintain fluid intake during day.
5.Shortness of breath:
Relieve measures:
 Use extra pillows at night to keep more upright.
 Limit activity during day.
 Discomfort related to the cardiovascular system
1. Supine Hypotension (Vena Cava Syndrome):

 Causes:
Caused by pressure of the gravid uterus on the ascending
vena cava when the woman is supine which decreases the
return of the blood.
Management:
 Get up slowly.
 Use the side-lying position, preferably on the left side.
2.Varicose Veins(Varicosities):
1. Avoid lengthy standing or sitting, constrictive clothing, and bearing
down with bowel movements.

2. Rest with legs elevated.

3. Wear support stockings.

4. Exercise (to stimulate venous return).

5. Warm sits baths, local application of astringent compresses.

Dyspnea:
Management:
1. Sleep with several pillows under head.

2. Use deep chest breathing before going to sleep.

3. Use proper posture when sitting or standing

Discomfort related to the Reproductive
system

Leucorrhea:
 Leucorrhea is a white or yellowish mucous discharge from
the cervical canal or the vagina.
Causes:
 It is caused by the hormonal stimulation of the cervix,
which becomes hypertrophic and hyperactive producing an
abundant amount of mucous.
 Leucorrhea is not preventable and the patient should not
douche.
 Leucorrhea may lead to purities (severe itching), burning
on urination, foul odor from the discharge, or edema of the
vulva.

Management:
1. Reassuring the patient that this is normal.

2. Tell the patient to use perineal pads and to change them

frequently

3. Cleanse the vulva at least once a day with soap and water
and to dry thoroughly.

4. Advising the patient to maintain good hygiene.

5.
Braxton Hicks' Contractions:
 These are mild, intermittent, usually painless, uterine
contractions. These contractions are in the preparation for
the work of labor.
Management:
1. That these are normal contractions.
2. To get plenty of rest.
3. To change position as often as possible.
4. To practice breathing techniques when contractions are
bothersome
 Discomfort related to the urinary
system

 Urinary frequency and urgency:

Relieve measures:
 Void when urge is felt (prevent urinary stasis).

 Increase fluid intake during day.

 Decrease fluid in late evening to lessen nocturia.

 Limit caffeine
Backache:
Management:
1. The pregnant woman is reassured that once birth has occurred, the
ligaments will return to their pre-pregnant strength.
2. To practice good posture and good body mechanics (use the pelvic tilt
and bend at the knees).
3. Wear shoes with low heels.
4. Sit with knee slightly higher than the hips.
5. Use firmer mattress.
6. Backaches may indicate a kidney or bladder infection. The patient
must inform the physician of backache problems. Backaches should
be carefully evaluated.
 Muscle Cramps:
Causes:
1. Compression of nerves supplying the lower
extremities due to the enlarging uterus.
2. Reduced level of diffusible serum calcium or
elevation of serum phosphorus in the bloodstream.
3. Fatigue, chilling, or tense body posture.
4. Muscle cramps are not considered a serious
condition, but they may be quite painful.
 Management:
1. Avoid fatigue and cold legs.
2. Eat a diet with adequate calcium or prescribed
calcium.
3. Dorsiflex foot and straighten leg with downward
pressure on knee or stand with feet flat on floor
when cramps occur.