Antenatal care

Presented by: L: EmanAbu-

Alfawaris
Antenatal Assessment
 Introduction
Every year there are an estimated 200 million
pregnancies in the world. Each of these
pregnancies is at risk for an adverse outcome for
the woman and her infant. While risk can not be
totally eliminated, they can be reduced through
effective, affordable, and acceptable maternity
care. To be most effective, health care should
begin early in pregnancy and continue at regular
intervals.
 Definitions
• It is a planed examination and observation
for the woman from conception till the
birth .
Or
• Antenatal care refers to the care that is given
to an expected mother from time of
conception is confirmed until the beginning
of labor.
 Goals and Objectives of Antenatal Care
Goals:
*To reduce maternal mortality and morbidity
rates.
* To improve the physical and mental health of
women and children.
* Antenatal care aims to prevent, identify, and
recognize maternal and fetal abnormality that
can adversely affect pregnancy outcome.
 Objective:
To ensure normal pregnancy with delivery of
healthy baby from healthy mother
 Criteria of normal pregnancy
• Delivery of single baby in good condition
• At term delivery
• Fetal weight- 2.5 kg or more
• No maternal complications
Component of antenatal
assessment
 Assessment

History Examination Investigation

 Assessment:
1. The initial assessment interview can
establish the trusting relationship between
the nurse and the pregnant woman.
2. Establishing rapport
3. Getting information about the woman’s
physical and psychological health,
4. Obtaining a basis for anticipatory guidance
for pregnancy .
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
 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
 Aims of Booking Visit
oGet detailed history & assess if high risk

oEstablish correct gestational age and date pregnancy

oProvide information about what is to expected, the

danger signals etc. which she should know of

oPerform baseline investigations like

HB, blood group, Rh typing & urine
analysis
• During the firs visit, assessment and
physical examination must be completed.
Including:

 history.
 Physical examination.
 Laboratory data.
 Psychological assessment.
 Nutritional assessment.
 History

• Welcome the woman, and ensure a quite place

where she can express concerns and anxiety
without being overheard by other people.
 Preliminary information:
• Name,
• Age,
• Occupation,
• Address and phone number,
• Marital status,
• Duration of marriage,
• Religion ,
• Nationality and language,
• Gravida & Para status
 Present illness history:

Discuss about the chief complaints

as regard their onset, duration, severity,
use of medications & progress of its.
 Present Pregnancy History :
- Nausea & vomiting.
- Abdominal pain.
- Headache.
- Urinary complaints.
- Vaginal bleeding.
- Edema.
- Backache.
- Heartburn.
- Constipation.
 Menstrual history:
A compete menstrual history is important to establish the
estimated date of delivery. It includes:

- Last menstrual period (LMP).

- Age of menarche.
- Regularity and frequency of menstrual cycle.
- Contraception method.
- Any previous treatment of menstrual problems
• Expected date of delivery (EDD) is calculated as
followed:
- This is done as Naegele’s formula :
1st day of LMP +9 months +7 days,
• Obstetrical history:
This provides essential information about the previous
pregnancies that may alert the care provider to
possible problems in the present pregnancy. Which
includes:

 Gravida, para, abortion, and living children.

 Weight of infant at birth & length of gestation.
 Labor experience, type of delivery, location of birth,
and type of anesthesia.
 Maternal or infant complications.
• Medical and surgical history:
Chronic condition such as diabetes mellitus,
hypertension, and renal disease can affect
the outcome of the pregnancy and must be
investigated.

Prior operation, allergies, and medications

should be documented.
Previous operations such as cesarean section,
genital repair, and cervical cerclage.
Accidents involving injury of the bony pelvis
• Family history:
Family history provides valuable information about
the general health of the family, and it may reveal
information about patters of genetic or congenital
anomalies.
Including:
- D.M.
- Hypertension.
- Heart disease.
- Cancer.
- Anemia.
• Personal History:
Including:
- Contraceptive practices.
- Smoking
- Alcohol
- Previous history of blood transfusion
- Any drug allergy
- Immunization against tetanus
 Physical examination
Physical examination is important to:
 Detect previously undiagnosed physical
problems that may affect the
pregnancy outcome.
 To establish baseline
levels that will guide the
treatment of the expectant
mother and fetus throughout pregnancy.
 Physical examination

General Obstetric Systematic

Examination Examination Examination
 General Examination

• General appearance
• Pallor
• Eyes
• Nutrition level
• Posture and gait:
Body mechanics and changes
in posture and gait should be
addressed. Body mechanics
during pregnancy may
produce strain on the
muscles of the lower back
and legs.
 • Height & weight:

An initial weight is needed to establish a baseline for

weight gain throughout pregnancy.

Preconception:
 Wt. lower than 45kg, or Ht. under 150 cm is associated
with preterm labor, and low birth weight infant.

 Wt. higher than 90 kg is associated with increased

incidence of gestational diabetes, pregnancy induced
hypertension, cesarean birth, and postpartum infection.

Recommendation for weight gain during pregnancy are

often made based on the woman’s body mass index.
 Vital signs:
 Temperature:
normal temperature during pregnancy is 36.2C to
37.6C./ 98.6 F
Increased temperature suggests infection.

 Pulse:
The normal pulse rate = 60-90 BPM.
Tachycardia is associated with anxiety, hyperthyrodism,
or infection.
 Respiratory rate:
The normal is 16-24 BPM.
Tachypnea may indicate respiratory infection, or
cardiac disease.
 Blood pressure:
1. It is taken to ascertain normality and provide a
baseline reading for a comparison throughout the
pregnancy.
2. In late pregnancy, raised systolic pressure of 30
mm Hg or raised diastolic pressure of 15 mm Hg
above the baseline values on at least two occasions
of 6 or more hours apart indicates toxemia.
 Obstetric Examination

Abdomen Breast

Vagina
 Abdomen

 Objectives:
 Preliminaries:
 Methods:
 1-Inspection:

• Uterine contour
• Enlargement of uterus
• Skin changes
Abdomen:

 The size of the abdomen

is inspected for:

- the height of the fundus,

which determines the
period of the gestation.

- multiple pregnancy.
 The shape of the abdomen is inspected for:
 Fetal lie & position.
- the abdomen is longer if the fetal
lie is longitudinal as occurs in
99.5% of cases.
- the abdomen is lower & broad if
the lie is transverse.
 2-Palpation

• The uterus will be palpable per abdomen after the

12th week of gestation

Abdominal palpation includes

Estimation of the period of gestation. This is done by

determination of fundal height.
• Calculation of gestation using fundal
height
– McDonald’s method: Measure from symphasis
pubis to top of fundus in cm.
– Gestation is measurement + or – 2 weeks
• The uterus may be higher than expected :
1. large fetus, multiple pregnancy
2. polyhydrammnios
3. mistaken date of last menstrual period

• The uterus may be lower than expected :

1. small fetus, intrauterine growth restriction
2. oligohydramnios
3. mistaken date of last menstrual period.
 12 weeks :the uterus fills the
pelvis so that the fundus of the
uterus is palpable at the
symphysis pubis .

16 weeks, the uterus is

midway between the
symphysis pubis and the
umbilicus.

20 weeks, it reaches the

umbilicus
Methods for Determining Fetal
Presentation
Leopold's maneuvers
Fundal grip
• Fundal palpation is performed to determine
whether it contains the breech or the head.
This will help to diagnose the fetal lie and
presentation.
Lateral Grip
First pelvic grip
Second pelvic grip
 3-Auscultation

•Auscultation of fetal heart sounds not only helps in

diagnosis of a live baby but its location can resolve the
doubt about the presentation of the fetus.

•The maximum intensity of FHS

is below the umbilicus in cephalic
presentation & around the
umbilicus in breech presentation.

The normal FHS ranges

from 120-160 beats per min.
 Breast
• Assess breast size, symmetry, cutaneous
changes, condition of nipple and the
presence of colostrum.
 Vaginal Examination

•It is done in the clinic when the patient attend the

clinic for the first time before 12 weeks.

The patient must empty the bladder before

examination.

It is done:

•To diagnose the pregnancy. 

•To corroborate the size of the uterus with
the period of amenorrhoea.
•To exclude any pelvic pathology.
• Pelvic measurement:
The bony pelvis is evaluated early in the
pregnancy to determine whether the
diameters are adequate to permit vaginal
delivery.
Systemic Examination
 Cardiovascular system:

• Venous congestion:
Which can develop into
varicosities, venous congestion
most commonly noted in the
legs, vulva, and rectum.

• Edema:
Edema of the extremities or face
necessitates further assessment
for signs of pregnancy-induced
hypertension.
 Neurological system

• Deep tendon reflexes should be evaluated

because hyperreflexia is associated with
complications of pregnancy.
 Skin
• Pallor of the skin my indicate anemia.
• Jaundice may indicate hepatic disease.
• Chloasma and linea nigra related to pregnancy.
• Striae gravidarum should be noted.
• Nail beds should be pink with instant capillary
return.
 Gastrointestinal systems
• Mouth:
• The gum may be red, tender, edematous as a result
of the effects of increased estrogen. Observe the
mouth for:
• Dryness or cyanosis of the lips.
• Gingivitis of the gums.
• Septic focus or caries of the teeth

• Intestine:
Assess for the bowel sound.
Assess for constipation or diarrhea.
 Neck

• Observe for neck veins, thyroid gland or lymph glands

for any abnormalities.
• Physiological enlargement of thyroid gland occurs
during the pregnancy in 50% cases.
 Legs:
* Legs should be noted for edema.
* They should be observed for varicose veins
* The calf must be observed for reddened areas which
may be caused by phlebitis and white areas which
could be caused by deep vein thrombosis.
* Ask the woman to report tenderness during
examination.
* The legs should be observed for unequal length or
muscle wasting which may be an indication of
pelvic abnormalities.
 Reproductive System
• Vaginal discharge:
* Ask the woman about any increase or
change of vaginal discharge.
• Report to the obstetrician any mucoid loss
before the 37th week of pregnancy.

Vaginal bleeding:
* Vaginal bleeding at any time during
pregnancy should be reported to the
obstetrician to investigate its origin.
 Investigations
• Routine investigations
• Specific investigations
 Laboratory data
Test Purpose
Blood group To determine blood type.

Hemoglobin To detect anemia.

(RPR) rapid plasma reagin To screen for syphilis

Rubella To determine immunity

Urine analysis To detect infection or renal disease.

protein, glucose, and ketones
Papanicolaou (pap) test To screen for cervical cancer

Chlamydia To detect sexual transmitted disease.

Glucose To screen for gestational diabetes.

Test purpose

VDRL To screen for syphilis

Hepatitis To screen for hepatitis

HIV To screen for AIDS

 Routine Investigations
Name First done Repeated Interpretation
1. Hb, PCV Booking Once every <10 g/dL or < 11 g/dL
trimester (WHO) consider as anemia

2. Blood group & Booking --- If Rh –ve, husband’s group

Rh typing & ICT

3. HbsAg, HIV, Booking --- If +ve, refer for counselling

VDRL & PPTCT

4. Urine routine Booking Every visit Pus cells> 5, do a culture

examination Alb+ or >, consider pre-
eclampsia

5. GTT 24-48 weeks --- 130 mg/dL or more, do a

GTT
 Specific Investigations
• Serological test for Rubella & hepatitis B
• Maternal Serum Alpha feto Protein
 Ultrasound
Is performed to:
• Estimate the gestational age.
• Check amniotic fluid volume.
• Check the position of the
placenta.
• Detect the multifetal
pregnancy.
• The position of the baby.
  Services at subsequent visits:
• the nurse inquires about physical changes that are
related directly to the pregnancy, such as the
woman’s perception of fetal movement, any
exposure to contagious illness, medical treatment
and therapy prescribed for non-pregnancy
problems since the last visit,
• prescribed medications that were not prescribed as
a part of the women’s prenatal care.
Thank You…..