Dr. Fouzia Shaikh Associate professor LUMHS Antenatal Care Dr. Fouzia Shaikh Associate professor LUMHS

Definition of Antenatal care comprehensive health supervision of a pregnant woman before delivery Or it is planned examination, observation and guidance given to the pregnant woman from conception till the time of labor.

Goals To reduce maternal and perinatal mortality and morbidity rates To improve the physical and mental health of women and children

Importance of Antenatal Care To ensure that the pregnant woman and her fetus are in the best possible health. To detect early and treat properly complications Offering education for parenthood To prepare the woman for labor, lactation and care of her infant

Schedule for Antenatal Visits: The first visit or initial visit should be made as early is pregnancy as possible. Return Visits: Once every month till 7th month. Once every 2 weeks till the 9th month Once every week during the 9th month, till labor.

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

Physical Examinations Height of over 150 cm indication of an average- sized pelvis The approximate weight gain during pregnancy is 12 kg.; 2kg in the first 20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term).

Obesity (more than 20 kg above the weight- height formula) leads to an increased risk of gestational diabetes, pregnancy-induced hypertension and thrombo-embolic disorders

Local Examination The uterus may be higher than expected due to large fetus, multiple pregnancy, polyhydrammnios or mistaken date of last menstrual period. The uterus may be lower than expected due to small fetus, intrauterine growth retardation, oligohydramnios or mistaken date of last menstrual period.

Fetal heart sound is heard by sonicaid as early as 10thweek of pregnancy. Fetal heart sound is heard by Pinard' s fetal stethoscope after the 20thweek of pregnancy. The normal fetal heart rate is 120-160 beats/min

Investigations: Urine should be tested for sugar, ketones and protein. Hemoglobin will be repeated: At 36 weeks of gestation. Every 4 weeks if Hb is < 9 g/dl.

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.

Health Teaching during the First Trimester Physiological changes during pregnancy Weight gain Fresh air and sunshine Rest and sleep Diet Daily activities Exercises and relaxation Hygiene Teeth Bladder and bowel Sexual counseling Smoking : Medications Infection Irradiation Occupational and environmental hazards Travel Follow up Minor discomforts Signs of Potential Complications

Exercise should be simple, mild exercise avoid lifting heavy weights A tooth can be extracted during pregnancy, but local analgesia is recommended Catheter and enema should be avoided. Smoking may lead to ptyalism, nervousness and hyper emesis and make pregnant woman at increased risk of chest infections and thrombo-embolic disorders

Pregnant woman should avoid contact with infectious diseases especially rubella or (German measles) because it has deleterious effects on the fetus Pregnant woman should avoid exposure to x-ray or irradiation because of possible teratogenic effects on the fetus such as birth defects or childhood leukemia

FOCUSED ANTENATAL CARE The high risk approach intended to classify pregnant women as “low risk” or “high risk” based on predetermined criteria and involved many ANC visits. This approach was hard to implement effectively since many women had at least one risk factor, Focused or goal oriented ANC services provide specific evidence-based interventions for all women, carried out at certain critical times in the pregnancy.

The essential elements of a focused approach to antenatal care • Identification and surveillance of the pregnant woman and her expected child • Recognition and management of pregnancy-related complications, particularly pre-eclampsia • Recognition and treatment of underlying or concurrent illness • Screening for conditions and diseases such as anaemia, STIs (particularly syphilis), HIV infection, mental health problems, and/or symptoms of stress or domestic violence

Preventive measures, including tetanus toxoid immunisation, de-worming, iron and folic acid, Intermittent preventive treatment of malaria • Advice and support to the woman and her family for developing healthy home behaviours and a birth and emergency preparedness plan to: o Increase awareness of maternal and newborn health needs and self care during pregnancy and the postnatal period, including the need for social support during and after pregnancy

recognition of danger signs for the woman and the newborn as well as transport and funding plans in case of emergencies o Help the pregnant woman and her partner prepare emotionally and physically for birth and care of their baby, particularly preparing for early and exclusive breastfeeding and essential newborn care Promote postnatal family planning/birth spacing

How many visits A recent multi-country randomized control trial led by the WHO17 and a systematic review showed that essential interventions can be provided over four visits at specified intervals, at least for healthy women with no underlying medical problems. • First visit: On confirmation of pregnancy • Second visit: 20-28 weeks • Third visit: 34-36 weeks • Fourth visit: before expected date of delivery or when the pregnant woman feels she needs to consult health workerLeading causes of maternal mortal

Common Discomforts of Pregnancy, Etiology, and Relief Measures : Urinary frequency RELIEF MEASURES: Decrease fluid intake at night. Maintain fluid intake during day. Void when feel the urge.

Fatigue RELIEF MEASURES: Rest frequency. Go to bed earlier.

Sleep difficulties Rest frequency RELIEF MEASURES: Decrease fluid intake at night

Breast enlargement and sensitivity RELIEF MEASURES: Wear a good supporting bra. Assess for other conditions.

Nasal stuffiness and epistaxis ETIOLGY: Elevated estrogen levels RELIEF MEASURES : Avoid decongestants. Use humidifiers, and normal saline drops.

Ptyalism (excessive salivation) ETIOLGY: Unknown RELIEF MEASURES: Perform frequent mouth care. Chew gum. Decrease fluid intake at night. Maintain fluid intake during day.

Nausea and vomiting RELIEF MEASURES: Avoid food or smells that exacerbate condition. Eat dry crackers or toast before rising in morning. Eat small, frequent meals. Avoid sudden movements. Get out of bed slowly Breath fresh air to help relieve nausea.

Shortness of breath RELIEF MEASURES: Use extra pillows at night to keep more upright. Limit activity during day

Heartburn RELIEF MEASURES: Eat small, more frequent meals. Use antacids. Avoid overeating and spicy foods.

Dependent edema Avoid standing for long periods. Elevate legs when laying or sitting. Avoid tight stockings.

Varicosities Rest in sims' position. Elevate legs regularly. Avoid crossing legs. Avoid tight stockings. Avoid long periods of standing

Hemorrhoids RELIEF MEASURES: Maintain regular bowel habits. Use prescribed stool softeners. Apply topical or anesthetic ointments to area.

Constipation RELIEF MEASURES: Maintain regular bowel habits. Increase fiber in diet. Increase fluids. Find iron preparation that is least constipating

Leucorrhea RELIEF MEASURES: Take a daily bath or shower. Wear cotton underwear.

Backache RELIEF MEASURES: Wear shoes with low heels. Walk with pelvis tilted forward. Use firmer mattress. Perform pelvic rocking or tilting

Leg cramps RELIEF MEASURES: Extend affected leg and dorsiflex the foot. Elevate lower legs frequently. Apply heat to muscles. Evaluate diet.

Faintness RELIEF MEASURES: Rise slowly from sitting to standing. Evaluate hemoglobin and hematocrit. Avoid hot environments