1. ANTENATAL CARE
DR. MADHAVI KARKI

2. ANC
Care of the woman during pregnancy to achieve healthy mother and healthy baby at the end of pregnancy.

3. IMPORTANCE OF ANC:-
1.Promote, protect & maintain health during pregnancy.
2.Detect high risk cases during ANC examination and take proper action during delivery.
3.Many maternal diseases diagnosed and treated, which prevent transmission to infant. e.g. syphilis, hepatitis.
4.Tetanus immunization to mother can prevent tetanus neonatorum in infant.

4. ANC VISIT Standard:- Total 14 visits Intermediate:- Total 5 visits
Every 4 week up to 32 weeks.
Every 2 week from weeks.
Every week from 36 weeks till delivery.
Intermediate:- Total 5 visits
1st: before 12 week
2nd: 20-22week
3rd: week
4th: 34-36week
5th: 38- till delivery
Minimum:- Total 3 visits
1st visit: 4-12 weeks
2nd visit: weeks
3rd visit: weeks

5. ACTIVITIES DURING ANTENATAL VISIT
Advice
Essential investigation
Antenatal examination
History taking
Registration of the pregnant women.

6. HISTORY 1 General information 2 Chief complaint
Name, age , gravidity, parity, LMP, EDD
2 Chief complaint
3 History of present illness
4 History of current pregnancy
Details of the 1st ,2nd & 3rd trimester
Lab tests & USG

7. 5 Menstrual & gynecological history
Contd...
5 Menstrual & gynecological history
LMP
Menstrual cycles, flow, dysmenorrhoea, menorrhagia
OCP
Surgical procedures
History of infertility
Sexually transmitted diseases
Uterine anomalies

8. 6 Past obstetric history
Contd...
6 Past obstetric history
Outcome of previous pregnancies in details including the abortions
Any significant antenatal, intrapartum or postpartum events
Previous maternal complications
Mode of delivery
Birth Weight
Life & health of the baby

9. 7 Past medical/ surgical History
Contd...
7 Past medical/ surgical History
Some medical conditions may have impact on the course of the pregnancy or the pregnancy may have an impact on the medical condition examples:
Heart disease
Kidney disease
UTI
Autoimmune disease
Psychiatric disorders
Hepatitis
Venereal diseases
Blood transfusion
Hypertension DM
Epilepsy
Thyroid disease
Bronchial asthma
Any previous surgery.

10. 8. Drug History 9. Family History 10. Social History
Contd...
8. Drug History
9. Family History
Hereditary illness → DM., HTN, thalassemias, sickle cell disease, hemophilia
Congenital defects e.g.. neural tube defects, Down syndrome
Twins
10. Social History
Cigarette smoking, illegal drug use, domestic violence

11. ANTENATAL EXAMINATION
GENERAL EXAMINATION:-
Height
Weight BP
Pulse
Head, eyes, ears, nose & throat  no changes
Thyroid to rule out thyroid disease.

12. SKIN - pigmentation of the face (chloasma), abdomen (linea nigra) and vulva
Stretch marks on the abdomen, thighs & breasts
BREAST -  nodularity
CVS - HR 
Soft systolic murmur
S2 - loud
LUNGS - Elevation of the diaphragm -  total lung capacity
OPHTHALMOSCOPY - hypertensive /diabetic women

13. ABDOMINAL EXAMINATION
1 Inspection
Shape & size
Asymmetry
Fetal movement
Surgical scars
Cutaneous signs of pregnancy
Linea nigra, striae gravidarum, striae albicans, umbilicus flat or everted, superficial veins

14. 2 PALPATION 3 AUSCULTATION 4 PERCUSSION
Fundal height
Obstetrical Grips:-
Fundal grip
Two Lateral grip
Pelvic grip-1st and 2nd
3 AUSCULTATION
Fetal heart at wks 4
PERCUSSION
No importance

15. OBSTETRICAL GRIPS :

16. VULVAL &VAGINAL EXAM not routinely performed until some complaints.
done only in 1st visit and during labour.
Hyper pigmentation
Look for abnormalities - Varicose veins/ hemorrhoids,
Warts or herpes
 vaginal secretions
Cx - Softer, pigmented with thick , yellowish mucous
Uterus enlarged

17. PRENATAL LABORATORY TESTING
8.Hepatitis B
7.VDRL for both partners
6.HIV test.
5.Stool R/E-to rule out parasitic infestation
4.Urine R/E-to see pus, glucose, protein, albumin
3.Blood glucose Random
2.Blood grouping and RH typing
1.Hb
FIRST TRIMESTER LABORATORY TESTS
Repeat of the investigations -Hb is repeated at 28th and 36th week

18. SECOND TRIMESTER LABORATORY TESTS
1.MATERNAL SERUM ALPHA FETO PROTEIN (MSAFP):-
AFP is protein produced by yolk sac and fetal liver and is present in the mothers blood.
When MSAFP is elevated, one must suspect of:-
a. open neural tube defects
b. multiple pregnancy
c. anterior abdominal wall defects
d. renal anomalies.
Low levels are found in Downs syndrome.
Test is done between weeks.

19. 3. ACETYL CHOLINESTERASE
It is a combined biochemical test which includes maternal serum alpha fetoprotein, hCG and UE (unconjugated oestradiol). It is done for detection of Downs syndrome. In the affected pregnancy level of MSAFP and UE tend to be low whereas hCG tends to be high. It is also performed at 15-18weeks. Confirmation to be done by amniocentesis.
2.TRIPLE TEST
Amniotic fluid Acetyl cholinesterase is elevated in open neural tube defects.
3. ACETYL CHOLINESTERASE

20. ANTENATAL ADVICE
1. The mother should have nutritious diet rich in protein, vitamins and minerals. The diet should contain milk, egg, plenty of green vegetables and fruits and majority of animal fat containing vitamin A and D.
2.The women is advised not to have strenuous work in the first trimester and last 6 weeks.
3. The patient is advised to have sleep for 10 hrs i.e. 8 hrs at night and 2 hrs at noon.

21. Contd...
4.Coitus should be avoided during first trimester and also during last 6 weeks for fear of premature labour and introduction of infection.
5. Smoking and alcohol should be stopped because this may induce abortion or congenital anomalies of fetus.
6.Travel by jerky vehicles is avoided during 1st trimester and last 6 weeks .The long journey is limited during the second trimester.

22. Contd... 7. Advice for regular ANC check-up.
8. She is advised to come to hospital, when there is intense headache, disturb sleep with restlessness ,urinary troubles, epigastric pain, vomiting and scanty urination.
9. She is advised to come to the hospital for admission-
Painful uterine contraction lasting for more than 10 min or earlier and continued for at least 1 hr suggestive of labour.
Sudden gush of watery per vagina.
Vaginal bleeding