ANTENATAL CARE

Systematic supervision (examination & advice) of a woman during pregnancy is called

antenatal (prenatal) care. Actually prenatal care is the care in continuum that start before
pregnancy and ends at delivery and the postpartum period. Supervision should be regular and
periodic in nature frequently according the need of the individual.

Antenatal care consists of-

 Careful history taking and examination. (general & obstetrics)

 Advice given to pregnant women.

Aims of antenatal care-

 To screen ‘high risk’ cases.

 To prevent or detect and treat at the earliest stage of any complication.
 To educated the mother about the physiology of pregnancy and labour by
demonstration.
 To discuss with the couple about the place, time and mode of delivery and care of
new born.
 To motivate the couple about the need of family planning also appropriate advice to
couple seeking medical termination of pregnancy.

Objectives- To ensure a normal pregnancy with delivery of a healthy baby from healthy
mother.

Procedure at the first visit-

Historytaking-

 Name- …………
 Age- …..
 Address-……………
 Gravida- A pregnant women called gravid. Primigravida first time pregnant. Gravid
2nd means second time pregnant
 Parity- number of pregnancies that have reached viability regardless of whether the
fetus was born alive alive or still born.
 Duration of marriage-…………..
 Religion-……………………
 Occupation-…………………
 Periods of complication-…………..
 Any complication-…………………
 History of present illness-………..
 History of present pregnancy-……….
  Obstetrical history- Gravida, para, menstrual history, past surgical history, related to
pregnancy history, related to contraceptive and disease.

Examination-

General examination-

 Head to toe examination.

 Nutrition examination.
 Height and weight.
 Tongue, teeth, gum examination.
 Check vital sign.

Obstetrical examination-

 Abdominal examination- A thorough and systemic abdominal examination beyond

28 weeks of pregnancy can reasonably diagnose the lie, presentation, position, and the
attitude of the fetus.
Preliminaries- verbal consent for examination is taken. She is then made to lie in
dorsal position with the thighs slightly flexed. Abdomen is fully exposed. The
examiner stands on the right side of the patient.
Inspection-
 Whether the uterine ovoid is longitudinal or transverse or oblique.
 Undue enlargement of the uterus.
 Skin condition of abdomen for evidence of ringworm or scabies.
 Any incisional scar on the abdomen.

Palpation-

 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. Fundus
hight can be measured with a tape.
 Obstetric grips (Leopold maneuvers)-
 Fundal grip (first manoeveuvre) -the palpation is done facing the patient’s
face.
Both hands are placed on the women’s fundus and fingers are curved around
the top of fundus. Palpation is done for fetal parts. The round, hard and
movable part suggests of fetal head. Whereas broad, soft and irregular mass
suggests of breech. If nothing like this palpated, it is suggested of transverse
lie.
 Lateral or umbilical grip (second manoeuvers) – examiner continue to
facing the mother. Both hands are placed on the uterus, between the symphysis
pubis and the uterine fundus. Gently pressure is put, pushing the fetus to the
other side. With pressure on one side, the other side is palpated. A smooth,
curved and resistant feel suggests of fetal back. If there is feel of irregular
 mass, which moves when pressed, it suggest of fetal limbs. Another method to
locate the fetal back is by walking the fingertips of both hands over the
abdomen.
 Pawlik’s grip (third manoeuvers) – the examination is done facing towards
the patients face. the overstretched thumb and four fingers 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 parts is grasped distinctly (if not engaged) and
also the mobility from side to side is tested. In transverse lie, pawlik’s grip is
empty.
 Pelvic grip (forth manoeuvers) – examiner should face women’s feet and
knees of the women are bent. Hands are placed on the sides of the uterus, just
below the umbilical level and grasped snugly. Held close together, pointing
downwards & inwards.
 Auscultation – with the use ofpinard’s fetal stethoscope, examiner can hear the heart
sound of the fetus. It is placed on the mother’s abdomen, at right angles to it over the
fatal back. Ear is firm contact with the fetoscope, without touching it. The fetoscope is
moved to the point of maximum intensity of the sound and F.H.S. is heard. Generally,
it is heard below the umbilicus in cephalic presentation and around the umbilicus in
breech presentation. F.H.S. depends upon the position of the back of the fetus.

 Vaginal examination- first timebefore 12week-

 To diagnose pregnancy.
 To diagnose amenorrhea.
 To check pelvic pathology.
 USG examination.

Steps of vaginal examination-the patient must empty her bladder prior to examination and
placed in the dorsal position with the thighs flexed along with the buttocks placed on the foot-
end of the table.

 Inspection- by separating the labia- using the left two fingers (thumb and index), the
character of the vaginal discharge if any.
 Speculum examination- this should be done prior to bimanual examination
especially when the smear for exfoliative cytology or vaginal swab is to be taken. A
bivalve speculum is used. The cervix of the vagina is inspected with the help of good
light source. Vaginal swab from upper vagina, if presence of discharge.
 Bimanual- two fingers (index) of the right hand are introduced deep into the vagina
while separating the labia by left hand. The left hand is now placed suprapubically.
gentle and systematic examination are to be done to note:- cervix- consistency,
direction and pathology. Uterus- size, shape, position, and consistency, early
pregnancy is the best time to correlate accurately uterine size and duration of
gestation. Adnexae- any mass felt through the fornix. If the introitus is narrow, one
finger may be introduced for examination.
Relationship of fetus to uterus and pelvis-

 Attitude- attitude is the relationship of the fetal body part to another. Normal
intrauterine attitude is flexion, in which the fetal back is rounded, the head is forward
on the chest and arms and legs are folded in against the body. The other attitude is
extension.
 Lie- relationship of the spine of the fetus to the spine of the mother. Longitudinal or
vertical- fetal spine is parallel to the mother’s spine. Fetus is cephalic or breech
presentation.Transverse or horizontal- fetal spine is at a right angle or perpendicular
to the mother’s spine. Presenting part is shoulder.
 Presentation- portion of the fetus that enters the pelvic inlet first. Cephalic (head
first), breech (buttocks first) and shoulder presentation.

Routine investigations-

Examination of blood, urine, cervical cytology examination.

Number of visit-

Generally checkup is done at interval of 4 week up to 28 weeks. At interval of 2 weeks up to

36 weeks and weekly till the delivery.

Visit according to W.H.O. -At least 4 visits

 1st visit in 2nd trimester around 16 weeks.

 2nd visit between 24 to 28 weeks.
 3rd visit at 32 weeks.
 4th visit at 36 weeks.

Antenatal advice-

Principles-

 To improve patient health.

 To impress the patient about importance of regular checkup.
 To maintain and improve health status of women till delivery and advice related to
first diet, second drugs and third hygiene.

Diet- diet during pregnancy should be adequate to provide-

 Maintain maternal health.

 Need of growing foetus.
 Provide strength during labour.
 Successful lactation.
 The pregnancy diet should be light, nutritious, easily diagestable and rich in protein,
mineral and vitamin.

Menu-
  one litter- milk (contain 1gm calcium)
 Plenty of green vegetables and fruits.
 Sufficient amount of salt.
 Amino acid.
 Majority of fat that contain vitamin A & D.

Supplementary nutritional therapy-

 1 tablet – ferrous sulfate (fasolate) that containing 60mg of iron i.e. enough for 100
days.

Hygiene/ antenatal hygiene-

 Rest and sleep- hard work avoid. Especially in 1st trimester and last 4 weeks of
delivery.
 Sleep duration increase at least 2 hrs.
 Bowel- there is tendency of constipation during pregnancy so provide sufficient
amount of fibrous diet and two spoon of isafgul.
 Bathing- patient should take daily bath carefully against sliping.
 Clothing, shoes, wears loose garments, avoid high heel shoes.
 Care of the breast- if the nipple is cracked than treat according to physician.
 Travel- air travel is contraindicated avoid the travelling for the jerks at least 1 st& 2nd
trimester.
 Avoid smoking and alcohol.

Drug / immunization-

 Immunization in pregnancy for tetanus.

 Liver virus vaccine- rubella, measles, mumps are contraindicated. Rabies, hepatitis-A
& B give in non-pregnant stage.
 Tetanus- 16-24 weeks and 2nd is after 6 weeks.

Minor elements in pregnancy-

 Nausea and vomiting.

 Backache.
 Constipation.
 Leg cramps.
 Acidity.
 Heat burn.
 Ankle edema.
 Vaginal discharge.
 NURSING PROCESS FOR THE ANTENATAL MOTHER:-
Step 1:- Collection of the database.
Step 2:- Interpretation of database.
Step 3:- Development of a comprehensive plan of care.
 Risk factors:-
 Change in fetal movement pattern
 Weight loss or poor weight gain
 Proteinuria, glycosuria
 Hypertension
 Uterus large or small for dates
 Excess or decreased liquor
 Malpresentation
 Vaginal bleeding
 Vaginal or urinary infection
 Premature labor.
 BIBLIOGRAPHY:-

 Das S. Antenatal Care. In: Bennett RV, Linda KB(Eds). Myles Textbook, 13th edn.
Edinburgh: Churchill Livingstone;1999.
 Dutta DC. Textbook of Obstetrics, 5th edn. Calcatta: New Central Book
Company;2001.