ANTENATAL CARE

This is a supervision or care given to the pregnant women during pregnancy to ensure that a healthy
live baby is delivered.
Aims
1) To encourage and support the family to achieve a healthy psychological adjustment to
childbearing
2) To monitor the progress of pregnancy in order to promote well-being of mothers and babies.
3) To help support the mother to her choice of infant
4) To help offer advice on the advantages of planned parenthood
5) To advice and prepare mother physically and emotionally for breast feeding
6) To build up a trusty relationship between the patients and health worker so as to enhance
acceptance of health care
7) To recognized deviation from normal and provide management P.R.N
8) To promote an awareness of the sociological aspect of child bearing and the influences that
may have on the family
Booking: is an initial assessment during the first visit to the antenatal clinic by the pregnant women –
this should be encouraged as early as possible when pregnancy is confirmed.
Objectives of booking
1) To assess the level of health by taking a detailed history or appropriate test
2) To ascertain baseline recording of weight, height, blood pressure level in order to assess
normality for subsequent comparison (in later stage of pregnancy).
3) To identify risk factors by taken accurate detailed of past and present obstetric and medical
history
4) To provide an opportunity for the women and family to express any doubt concerning the
pregnancy or precious obstetric experiences
5) The give advice on general health matters and pertaining to pregnancy, to maintain the mother
and festal health
6) To start building a trusting relationship in realizing plans of care are discuss
The process of booking involves
Taking history
Personal data – name, age, address, etc.
Social history: seek information like is she married or not? It also explore history concerning her
habit, smoking, alcohol, colanut, and so on.
Obstetric history obtain previous obstetric history i.e. previous pregnancy. If a primi or elderly
primigravidae, she need closer observation and should be delivered in hospital. Adequacy of the

1
pelvic can be estimated if a normal size baby can be delivered without difficulty. If she has five or
more delivery, she is at risk so she should be referred to the hospital due to risk of malpresentation.
To give a summary of a woman child birth bearing history, the descriptive term gravida and para
should be used.
Gravida: pregnant woman; subsequent number indicates the number of times she has been pregnant
regardless of the outcomes.
Para: having giving birth, a woman parity refers to the number of times that she has given birth to a
child live or stillbirth excluding abortions.
Grand multigravida: a woman who have been pregnant five time or more tells nothing of the
outcome.
Grand multipara: a women who have giving birth five times or more. For completeness of the history,
reference to old case note should be made to know whether she is at risk.
Present obstetric history: Here we ask when last she saw her menses (LMP) to help calculate her
expected date of delivery (EDD), which is calculated by obtaining LMP date + 9 month + 7 days.
Obtain history for regularity of menstrual period, when it started, palpate to aid in calculation of EDD.
Medical history: to rule out condition such as diabetes mellitus (may result in faetal macrosomia),
hypertension, tuberculosis, kidney problems, ulcer, hepatitis, mental illness etc.
Surgical history: previous C/S due to cephalo-pelvic disproportion, find out the cause for C/S and
indicate on card with red biro.
Family history: to rule out condition that run in family like mental ill health, sickle cell, twin
pregnancy.

PHYSICAL EXAMINATION
This entailed observing the woman from head to toe. The height is taken and recorded. A height of
160cm and above is suggestive of normal pelvic. Anything less than that is suggested of a
concentrated pelvic. Small shoe size is also suggested of contracted pelvis. Take the weight and
record for excessive obesity or pre-eclampsia or for weight lower than normal in abnormal foetel
growth.
Abdominal Examination
Observation: Inspect the abdomen for its shape and size, distribution of strie gravidarum and linea
migra. Observe if pendulum in shape or broad. If the hair distribution is up to abdomen, it can be
suggestive of contracted pelvis; scar tissue indicated C/S. it is advisable for patient to empty bladder
before observation or palpation.
Palpation: Before palpating, make sure the hands are warm to avoid inducing contraction. Instruct the
woman to lie on her back with arms relaxed on the couch. The midwife should use the pad of her hand
and not the fingertip to palpate in order not to stimulate contraction. The hands should be moved
smoothly over the abdomen.

2
Types of palpation
Fundal palpation: assess whether the content within the fundus is head or the breach. This helps in
determine the lie and/or presentation of the foetus. The midwife put both hands on the site of the
fundus with fingers held loosely covering round the upper boarder of the uterus. Gentle and deliberate
pressure is applied to determine the consistently of what is contain in the fundus. If a soft mass is felt,
it is a buttock or breach but a hard round movable part is felt it indicates a head in the pelvis.
Lateral palpation: often use to locate the foetal back to determine position. The hands are placed on
either side of the uterus about the level of the umbilicus. Gentle pressure is applied with alternative
hand to determine which side of the uterus offers greater resistant. The midwife work one hand down
the one side of uterus while the other hand stabilizes. The same movement is applied on the other side
while the other hand stabilizes. Take note whether it feels smooth (the back) or irregular surface
which suggests the foetal limb. Fetal heart beat can be listen where the back is palpated.
Pelvic palpation: palpation of the lower pole of the uterus just above the symphysis pubis also help in
determination of presentation. The patient lie on dorsal position with the knees flexed. You grasp the
site of the uterus just above the symphysis pubis with the palm of the hand and fingers held closely
together pointing inward and downward. If the head is presenting a hard round mass is palpated.
While if it is buttock a soft mass will be palpated. If the head is palpated effort should be made to find
out if the head is completely flexed, deflexed (erect) or extended. Try to find out if the head has pass
through the pelvic brim (i.e. engagement of the faetal head).
Pawlik’s maneuver: is a term use to judge the size, flexion, and mobility of the head but care must be
taken to avoid undue pressure. Engagement take earlier in primi due to the strength of the abdominal
muscle.

Auscultation: this usually follows abdominal examination to assess faetal well-being. A pinnal
faetoscope is used to listen to the faetal heart sound. It is placed on the mother’s abdomen and at right
angles. The ear must be in close firm on the fetoscope but the hand should not touch it while listening
to avoid extraneous sound. The foetoscope is moved about until the point of maximum intensity is
located where the faetal heart is heard more clearly. Also ultrasound can be used for the purpose. It is
usually a double sound but more rapid than the adult heart sound the normal is 120-160.

FINDING FROM ABD EXAM

The health personnel in making diagnosis should assesses all the information gathered from
inspection, palpation and auscultation before making conclusion. The following are the finding:
1. Gestational age: the uterus is expected to grow at a predicted rate and in early pregnancy, the
uterine size usually equate with the gestational age estimated by date. Multiple pregnancy
increase the overall uterine size and should be diagnosis by about 24weeks of gestation. In a
singleton pregnancy, the fundus reaches symphysis pubis at 12 weeks, half way between

3
 symphysis pubis and umblicus at 18 weeks, umbilicus at 22-24weeks, and the xiphoid
sternum at 36weeks (half way between umbilicus and xiphoid sternum at 30-34). In the last
month of pregnancy, lightening occur and faetus sink down into the lower pole of the uterus.
2. Lie: This is the relationship between the long axis of the foetus and long axis of the uterus. In
about 99.5% of cases, the lie is longitudinal, then oblique line when the fetus lie diagonally
across the long axis of the uterus. Next lie is transverse i.e. faetus lie in right angle across the
long axis of the uterus.
3. Attitude: the relationship of the faetal head and limbs to the trunk should be that of flexion.
The faetus curled with chin on chest and arm, legs flexed.
4. Presentation: refers to the part of the faetus which lies at the pelvic brim or in the lower pole
of the uterus. There are five presentation:
Vertex – 96.8%
Breach – 2.5%
Shoulder – 0.4%
Face – 0.2% extension
Brow – 0.1% erect
Vertex, face, and brow are cephalic presentation
Denominator: is the name of the part of the presentation which is used when referring to faetal
position in vertex presentation we have occiput while in breach it is the sacrum.
In shoulder – acromion process
In brow no denomination
Position: the relationship between the denominator of the presentation and six point on the pelvis
brim i.e anterior, lateral and posterior. Anterior position are more favourable.

Engagement: this is said to have occurred when the widest presenting transverse diameter have pass
through the pelvic brim. In head presentation, it is the bipariental diameter. In breach is bitrochanteric
diameter. Engagement is important sign that the maternal pelvis is likely to be adequate for the faetal
size and vaginal delivery expected. In primigravida women, the head engages between 36-38 weeks
while in multiparous women this may not occur until the onset of labour.

Indication of faetal well-being

1. Increasing maternal weight is associated with an increase in uterine size compatible with the
gestational age of the faetus.
2. Faetal movement: follows a regular pattern throughout pregnancy.
3. Faetal heart rate: which should be between 120 to160 during auscultation.

Factors that requires additional antenatal advice

4
Findings from initial assessment:
Grand multi party
Vaginal bleeding at any time during pregnancy
Unknown or uncertain date of delivery
Past obstetric history:
Stillbirth or neonatal death
Baby small or large for gestation
Congenital abnormality
Rhesus isoimmunization
Pregnancy induce intension
Two or more termination of pregnancy
Two or more spontaneous abortion
Previous preterm labour
Cervical cerclage in past/present habitual abortion
Previous C/S, antepartum haemorrhage, postpartum haemorrhage, precipitated labour.
Maternal health
- Previous history of deep venous thrornbosis or pulmonary embolism
- Chronic illness, hypertension
- History of infertility
- Uterine abnormality including fibroid
- Family history of diabetes
Examination at the initial assessment
- Blood Pressure 140/90 and Above
- Maternal weight (gain) over 85kg or <45
- Maternal height <5 feet
- Cardiac murmur detected
- Other pelvic mass detected
- Rhesus negative
- Blood disorders

SIGNS AND DIAGNOSIS OF PREGNANCY

Most often when a healthy married woman missed her period, pregnancy is suspected and most
(98%) of the cases are positive. However, some conditions could imitate pregnancy given an
inaccurate result. For descriptive purpose, the signs and diagnoses of pregnancy are group into 3:
1. Possible or presumptive signs
2. Probable signs
3. Positive signs

5
Possible or presumptive sign
1. Amenorrhoea (4weeks and above): is seization of menstruation and a significant sign of
pregnancy. Sometimes very light bleeding may be experience during implantation and could
be mistaken for menses. So there is a need to inquire for regularity from the woman. It is
important to note that environmental changes, emotional stress, serious illness, and
discontinuation of contraceptives could cause amenorrhoea. It is therefore advisable for the
woman to watch for other sign of pregnancy, such as breast changed, morning sickness etc.
2. Brest changes (3-4weeks): prickling and tingling sensation, vein enforcement, and colour
changes of the breast often occur during pregnancy. However woman on contraceptive pills
can experience the same changes thus further pregnancy test is necessary for confirmation.
3. Morning sickness (nausea and vomiting): this occur in about 50% of pregnant woman during
the 4th and 14th weeks of pregnancy. Other condition such as ovarian cyst, gastro enteritis can
also cause nausea and therefore different diagnosis is necessary to confirm pregnancy.
4. Bladder irritability: this usually occur 6-12weeks of pregnancy and characterized by
frequency of micturition that pain. That is as a result of the pregnant uterus pressing on the
bladder. It should be note that urinary tract infection (such as cystitis) also cause increase
frequency accompanied by pain and burning sensation.
5. Skin changes: this include linea migra, darkening of the areola of the breast, and chloasma.
This are useful signs but also disputable because they can be observe with women on pills
6. Quickening: this is movement of the faetus in the uterus recognized or felt by the mother at
about 16-20weeks of pregnancy. This movement can be felt in non-pregnant women which is
related to peristaltic movement of the intestine.
Probable signs
These are usually detected by the midwife or obstetrician to further confirm pregnancy:
1. Hegar’s sign (marked at 6-12weks): softening of the isthmus that is usually detected when
two fingers are inserted into the anterior fornix of the vagina and the other placed
abdominally. If the fingers of either hands meet or are felt, it indicate pregnancy. This is
seldom employed or rarely used due to the risk of miscarriage.
2. Jacquemier sign (6-12weeks): is the bluish colouration of the vagina membrane due to
increased blood supply. Should be noted that this can also occur in retrovated uterus and
pelvic cellulitis they should be differentiated.
3. Osiander’s sign (from 8 weeks): refers to increase pulsation of the lateral vaginal fornice due
to increase vasculation. This can be found in some pathological condition like tumour.
4. Uterine soufle: is a soft blowing sound which can be heard from the uterus at about the
16weks onward and correspond to the mother pulse. This is as a result of in blood flow
through the uterus. This can also be experience when uterine fibroid and present.

6
5. Uterine growth or enlargement: pregnancy, the uterus usually enlarges steading from about
the 8weeks on ward. A times condition like tumours full bladder ascites can make the uterus
to enlarge.
6. Braxton hick’s contraction: this is painless uterine contraction often felt on abdominal
palpation from the 16weeks of gestation upward can also be found in uterine tomours.
Pregnancy can further be confirmed with the aid of ultrasound.
7. Internal ballottement of the uterus: this can be detected from 16-28weeks of pregnancy. Two
fingers are inserted into the vagina and the uterus given a sharp tap at the cervix this causes
the fetus to float upward in the amniotic fluid the impact of the floating is felt by the hand that
is place abdominally.
8. Presence of human chorionic gonadotrophin (HCG) this is usually present in the blood of 4-
12weeks and in urine 6-12weeks. A times in choriocarcinomas, hydatidiform mole HCG can
be found
Positive Sign
1. Visualization of the faetus by a ultra sound at 6weeks + b x-ray 16weeks onward
2. Fetal heart sound in the use of
a. Ultrasound 6weeks +
b. Fetal stethoscope 20weeks
3. Fetal movement
a. Palpable 22 weeks +
b. Visible at late pregnancy
4. Fetal parts palpated 24 weeks +
The signs have no alternative diagnosis