1. What is it? The care of the pregnant woman with the aim of achieving a healthy pregnancy and delivery of a normal baby Good antenatal care helps a woman to face labour in good health and in optimum condition

2. Why Promote, protect & maintain the health of mother Detect high-risk cases Proactive approach to complications Remove the anxiety and dread associated with pregnancy Reduce maternal and infant mortality and morbidity rate Teach mother the elements of child care, nutrition, personal hygiene & environmental sanitation To attend to the under-fives

3. Schedule For Antenatal Visits in India Monthly up to 28 weeks Two weekly between 28 and 36 weeks Weekly 36 weeks onwards. ( This equals about 15 visits )  High-risk cases more frequent visits

4. Booking Visit ?? First visit that the woman makes to the health care facility. Should be as early possible and preferably in the first trimester :  To detect high-risk cases  To offer MTP if required

5. Aims of Booking Visit o Get detailed history & assess if high risk o Establish correct gestational age and date pregnancy o Provide information about what is to expected, the danger signals etc. which she should know of o Perform baseline investigations like HB, blood group, Rh typing & urine analysis

6. Routine Investigations NameFirst doneRepeatedInterpretation 1. Hb, PCVBookingOnce every trimester <10 g/dL or < 11 g/dL (WHO) consider as anemia 2. Blood group & Rh typing Booking---If Rh –ve, husband’s group & ICT 3. Hb s Ag, HIV, VDRL Booking---If +ve, refer for counselling & PPTCT 4. Urine routine examination BookingEvery visitPus cells> 5, do a culture Alb+ or >, consider pre- eclampsia 5. GCT24-48 weeks---130 mg/dL or more, do a GTT

7. History & Examinatioin History taking Systemic & obstetric examination Palpation: symphyseofundal height on every visit Pelvic examination in 1 st trimester

8. Continued.. Sometimes other tests in individual cases like: Testing for hemoglobinopathies Glycosylated Hb Maternal serum for screening Down’s syndrome

9. Immunizations in Pregnancy Tetanus toxoid – safe& mandatory 1 st dose- at booking visit & then 6 weeks later If already takes within last 3 years, booster at 36 weeks Usually others not given SafeOnly in epidemics C.I TetanusTyphoidRubella HepatitsCholeraMMR RabiesVaricella BCG Yellow fever

10. Medications 1. Folic acid – 5mg during 1 st trimester ( if not begun preconceptionally ) 2. Fe & Ca started at 13 wks continued for 3 months after pregnancy Fe- 100mg Ca- 1mg/day

11. Health Education for the Pregnant woman Diet  need extra 300kcal/day from 2nd trimester onwards  Protein  Salt  Iron  Calcium : 1.5 g daily  Vit. C, folic acid, Vit. B12  + tablets

12. Continued.. Weight gain: total of 11 kg. 500 g/wk during 2 nd trimester Rest: Activity & Exercise: Clothes : Coitus Smoking & alcohol : abortion, growth restriction, fetal alcohol syndrome restricted Drugs : Care of breasts: Travel :

13. Warning signals !!! Bleeding p/v at any time in pregnancy Head ache, blurring vision, epigastric pain & oliguria Pedal oedema, severe, not subsiding with rest, or on face & hands Decrease/ loss of fetal movements Abdominal pain Urinary infection with vulvovaginitis Clear fluid p/v PROM

14. Common Symptomatology in pregnancy Nausea & vomiting Backache Varicose veins Hemorrhoids Vaginal discharge Acidity & heart burn Constipation

15. Antenatal care up to 28 weeks Woman should seek care every month Weight, bp & urine checked at each visit Quickening, anemia, oedema (!!) Symphyseofundal height Others: Targeted ultrasound scan for anomalies (18-20 wks)…….

16. Antenatal care after 28 weeks Crucial period: pre-eclampsia, GDM, growth disorders bp, weight, urine routine, Hb Symphyseofundal height: detect IUGR & macrosomia She should be made aware….. Vaginal examination

17. Ultrasound in Pregnancy.. If only single scan, ideally in 2 nd trimester to look for anomalies & dating. Booking scan : 10-14 wks confirm gestational age assess nuchal translucency 1 st trimester scan : 3 rd trimester scan:

18. Preconceptional / Prepregnancy Councelling 1. General advice for all women: Preconceptional folate Rubella & Hep B vaccine Weight reduction in obesity Cessation of smoking / alcohol Advice regarding drug intake Rule out STDs, & HIV counseling Avoid teratogens

19. Continued.. 2. Medical disorders Preconceptional glycemic control in diabetes Remission in chronic diseases like SLE & chronic renal disease Cardiac surgery prior to pregnancy Avoiding pregnancy in certain cardiac diseases Changing teratogenic drugs as in epilepsy

20. Continued.. 3. Recurrent pregnancy loss Checking for antiphospholipid antibody syndrome Correction of uterine septum by hysteroscopic septal resection 4. Genetic problems Parental karyotyping Carrier screening based on ethnicity or family history Dietary advice in PKU