Preventive and Social Medicine

Seminar
on
“Antenatal Care”
Guided by:- Submitted by:- Ritika Jain
Dr. Neera marathe Rupali Sehgal
Dr. Alka modi Rounak Bhandari
• CM10.2
Enumerate and describe the methods of screening high risk groups
and common health problems
PSM IN OBSTETRICS and Paediatrics
• Mother and children constitute large group (70%)
• Women of Child bearing age and children <15 yrs 57.5%
• Major consumers of health care services
• Vulnerable group
• Mother and child one unit
• Preventable conditions
• Social factors affective health
 Definition
• Care provided by skilled health care professionals to pregnant women
and pregnant adolescent girls in order to ensure the best health
conditions for both mother and baby during pregnancy.

• Ideally this care should begin soon after conception and continue
throughout pregnancy.
• Advanced approach: Care should begin right from the childhood
 Objectives of ANC
1. To promote, protect and maintain the health of the mother during
pregnancy.
2. To detect high risk cases.
3. To foresee complications and prevent them.
4. To remove anxiety.
5. To reduce maternal mortality and infant mortality and morbidity.
6. To teach the mother elements of child care, nutrition, personal hygiene
and environmental sanitation.
7. To sensitize the mother to the need for family planning, including advice
to cases seeking MTP.
8. To attend to the under fives accompanying the mother.
 Antenatal Visits
• According to WHO guidelines,
• the mother should ideally visit antenatal clinic:
• once a month during first 7 months
• twice during 8th month
• once a week thereafter
• A minimum of 4 visits
▪︎ 1st visit: within 12 weeks (as soon as pregnancy is suspected)
▪︎ 2nd visit: between 14 and 26 weeks
▪︎ 3rd visit: between 28 and 34 weeks
▪︎ 4th visit: between 36 weeks and term.
Early detection of pregnancy
• Early planning and adequate care
• Calculation of EDD
• Detection of complication and high risk pregnancy
• Safe abortion
Essential components of Antenatal checkup
• HISTORY TYAKING
• PHYSICAL EXAMINATION
• ABDOMINAL PALPATION and AUSCULTATION
• LAB INVESTIGATIONS
 Antenatal Checkup for Mothers
The first visit should include:
1. History Taking: ︎Confirmation of pregnancy
︎Calculation of expected date of delivery (9 month+ 7 days to 1st
day of LMP)
︎Identification of any medical, surgical or obstetric condition
that can complicate pregnancy
︎History of any current systemic illnesses like hypertension,
diabetes, HIV, jaundice, asthma, epilepsy, etc.
︎Recording of symptoms indicating complications like fever,
abnormal vaginal discharge or bleeding, palpitations,
breathlessness at rest,etc.
• Family history of twins , HTN, DM, TB, Thalessemia
• History of allergy
• Substance abuse
2. Physical examination:

▪︎Pallor:
▪︎Pulse: Normal pulse rate is 60 to 90 beats per minute.
▪︎Respiratory Rate: Normal: 18 to 20 breaths per minute.
▪︎Oedema: Any swelling which appears in the evening and disappears in
the morning is physiological. Any swelling of face, hands, abdominal
wall and vulva is abnormal.
▪︎Breast examination: The size and shape of nipples are assessed to rule
out inverted or flat nipples.
▪︎Blood Pressure: Hypertension is diagnosed when two consecutive readings
taken four hours or more apart show the systolic BP >140mm Hg and/or the
diastolic BP > 90mm Hg.

Pre-eclampsia: High BP + presence of albumin (+2) in urine.

If diastolic BP is above 110 mmHg, it is a danger sign that points towards
imminent eclampsia. A woman with PIH/ pre-eclampsia or imminent
eclampsia requires hospitalization and treatment at a 24 hr PHC/FRU.

︎Weight: Normally, a woman should gain about 9-11 kg during her pregnancy.
Low weight gain less than 2kg/monthlead to IUGR and low birth babies.
Excessive weight gain (>3kg/month) indicates pre eclampsia, twins or
diabetes.
3. Abdominal Examination:

It is done to monitor the progress of the pregnancy and foetal growth.

1. Measurement of fundal height:

a) 12 weeks: uterune fundus just palpable per abdomen
b) 20 weeks: Fundus flat at the lower border of unbilicus
c) 36 weeks: Fundus felt at the level of xiphisternum
2. Foetal heart sounds can be heard after 6th month. Normal rate: 120-140
per minute.
3. Foetal movements can be felt by exmainer after 18-22nd week.
4. Foetal parts: Felt about 22nd week. After 28th week, it is possible to
distinguish the head, back and limbs.
5 Multiple pregnancy
4. Laboratory Investigations:

A) At the subcentre:
- Pregnancy detection test
- Hemoglobin examination
- Urine test for presence of albumin and sugar
- Rapid malaria test

B) At the PHC/CHC/FRU:
- Blood group Rh factor - Rapid malaria test - VDRL/RPR
- HIV testing - Blood sugar test - HBsAg for Hepatitis B infection
 “High-risk” cases
1. Elderly primi (30 years and over)
2. Short statured peimi (140cm and below)
3. Malpresentations, viz breech, transverse lie, etc
4. Antepartum hemorrhage, threatened abortion
5. Pre-eclampsia and eclampsia
6. Anemia
7. Twins, hydramnios
8. Previous still birth, intrauterine death, manual removal of placenta
9. Elderly grand multiparas
10. Prolonged pregnancy (14days after EDD)
11. History of previous caesarean delivery.
12. Pregnancy associated with general diseases, viz. TB, kidney disease, liver disease, malaria, asthma, RTI, STI, etc.
13. Treatment for infertility.
14. Three or more spontaneous consecutive abortions.
 Prenatal advice
• A major component of ANC is prenatal care,as mother is more
receptive to advice during this time.
• The advices should be regarding specific problems of pregnancy
and child birth along with child health care.
DIET
:
• A pregnancy in total consumes about 60,000kcal,over and above
normal metabolic requirements.
• Lactation demands about 550kcal a day.
• If maternal iron stores are insufficient then the baby might present with
normal haemoglobin at birth but will lack stores of iron necessary for
rapid growth
• Calcium
PERSONAL HYGIENE
1. Personal cleanliness- the need to bathe daily and wear clean clothes.
2. Rest and sleep-8hrs. Sleep and at least 2 hrs reat after mid day meal.
3. Bowels-constipation should be avoided and purgatives should not be used to
relieve constipation .
4. Exercise- light household work can be done .manual pysical work avoided.
5. Smoking-nicotine has vasoconstrictor influence and affects placental
circulation .The adverse effect will be low birth baby and increased risk
of perinatal death upto 10-40%.
6. Alcohol-associated with heavy risk of pregnancy loss.FAS includes IUGR
and developmental delay with spontaneous abortion.
7. Dental care-should maintain good oral hygiene.
8. Sexual intercourse-should be restricted during last trimester.
DRUGS:
• Certain drugs taken by mother during pregnancy may affect the foetus
adversely and cause foetal malformations.
• Classical example THALIDOMIDE, causes deformed hands and feet of the
babies born.
• Other examples LSD, Streptomycin, corticosteroids,tetracyclines,etc.
• Anaesthetic agents PETHIDINE may cause depressant effect on baby and delay
the onset of effective respiration.

RADIATION:

The most common source of radiation is abdominal X-ray during pregnancy this
leads to congenital malformations such as microcephaly.
WARNING SIGNS:
Mother should report following warning signals immediately:
• Swelling of feet.
• Fits.
• Headache
• Blurring of vision
• Bleeding or discharge per vagina
• Any other unusual symptoms.

CHILD CARE:
Special classes are held for mothers attending antenatal clinics.
Mother craft education consists of nutrients education child rearing etc.
 SPECIFIC HEALTH PROTECTION:
1.Anaemia- Surveys of India shows 50-60% of women belonging to low socio-economic
groups are anaemic in the last trimester of pregnancy.
Prophylactic dose : 100mg of elemental Iron and 500mcg of folic acid are being distributed
daily for 100 days to pregnant women. If women have anaemia dose is BD
2.OTHER NUTRITIONAL DEFICIENCY- Mother should be protected from other
nutritional deficiencies .
The Fresh milk is supplied to all expectant mothers.capsules of vitamins Aand D are also
suppilied free of cost. Calcium tablets.
3. ASYMPTOMATIC BACTERIURIA(ASB)- UTI is of high risk to both mother and
foetus.
because Of physiological changes Mother is more prone to such infections.The patient
should be appropriately treated for ASB.
4.GESTATIONAL DIABETES-
•It is high blood sugar that develops during pregnancy and usually
disappears after giving birth.
•Mostly occur in second half of pregnancy.
•If untreated poses the risk of high blood pressure, preclampsia,
miscarriage or still birth, birth defects and big baby (weigh more than
4.5 kgs).
•Symptoms of DM
• Mother is more prone for type 2 DM
5. TOXEMIA OF PREGNANCY- the presence of Albuminuria and high blood pressure
indicates toxemia of pregnancy.early detection and management is indicated.
6.TETANUS- If mother was not immunised earlier, 2 doses of absorbed tetanus toxoid should
be given –the first dose at 16-20 wks and second dose at 20-24 wks of pregnancy.
If immunised earlier, then a booster dose will be sufficient and will give immunity for next
5years.
7. SYPHILIS- It causes neurological damage with mental retardation. When mother is suffering
from syphilis foetus is not infected till 4 th month and get infect around 6 th month . Congenital
syphilis is easily preventable .Ten daily injections of procaine penicillin (6lakh units) are
almost always adequate.Test should be done early and late in pregnancy
8.GERMAN MEASLES- When rubella is contracted in 16 wks of pregnancy
foetal death occurred in about 17% of population and major defect in about
15% minor defects in 16%.It can be prevented by vaccinating 8 wks before
pregnancy plans. Vaccination done in schools. MR campains

9.Rh STATUS- The foetal RBC enter maternal circulation a number of

times .The intrusion of these cells.if mother is Rh negative and child is Rh
positive,provokes an immune response In her so that she forms antibodies to
Rh which can cross placenta and produce foetal haemolysis.
• The blood should be examined at visits and if found such then Rh antiD
immunoglobulin should be given at 28wks. It should be given within 72 hrs
of delivery also and after abortion as well.
10. HIV INFECTION- HIV can pass through Placenta ,during delivery and breast feeding.the
risk of transmission is higher if mother is newly infected or if she has already developed AIDS.
Universal confidential voluntray screening of pregnant women in high prevalence areas prevent such
complications.and choose for therapeutic abortions.

11.HEPATITIS B INFECTION- most of the infection appear to occur at birth.Vertical

transmission can be blocked by immediate post delivery administration of B immunoglobulin
and hepatitis B Vaccine.

12.PRENATAL GENETIC SCREENING- screening for chromosomal abnormalities

associated with serious birth defects such as DOWN’S Syndrome and neural tube defects.
MENTAL PREPARATIONS:
• Mental preparation is as important as physical or material preparation.
• Sufficient time and opportunity should be given to expectant mother
to clear her queries about all aspects of pregnancy and delivery.
• This removes her fears about confinement.
• The mothercraft classess helps them a lot.
FAMILY PLANNING:
• It is related to every phase of maternity cycle.
• The mother is psychological more receptive to information at
this time.
• If mother has 2or more children she should be motivated for
puerperal sterilization.
• All India Postpartum Services are available to all expectant mothers in
India.
PAEDIATRIC COMPONENT:
• Mother should be given advice for her child care and health.
• A paediatrician should be there in all antenatal clinics to pay
attention to the under-fives accompanying the mothers.
INTRANATAL CARE
It is defined as:
Management and delivery of care to women in labour.
• 5 CLEANS
Clean hands & Finger nails
Clean surface
Clean blade
Clean cord tie
Clean umbilical stump
THE AIMS OF GOOD INTRANATAL CARE
-Thorough asepsis

-Delivery with minimum injury to infant &mother

-Readiness to deal with complications-

Prolonged labour
APH
Convulsions
Malpresentations
Prolapse of cord
INSTITUTIONAL CARE

About 1% deliveries tend to be abnormal and 4%

difficult,requiring the service of doctor

It is recommended for all high risk cases

HIGH RISK CASES:

Anaemia, Heart diseases, Ecclampsia,Short stature,

Diabetes, Jaundice, T.B, Oligohydraminos,
Malpresentations, etc.
POSTNATAL CARE
• Care of mother and newborn after delivery is known as postnatal or postpartum
care.
• Broadly this care falls into 2 categories :-

1. Care of mother
• Primary responsibility of Obstetrician.

2. Care of Newborn
• Combined responsiblity of Obstetrician and pediatrician and this is known as
Perinatology.
CARE OF MOTHER

• Objectives:-
1. Provide care for Rapid Restoration of mother to Optimum Health.

2. Check adequacy of breast feeding.

3. Provide family Planning services.

4. Provide Basic Health education to mother and to her family.

5. Prevent Complications of Postpartum period.

• Complications:-
1. Pueperal Sepsis :-
• Infection Of genital tract within 3weeks after Delivery accompanied by increase temperature,
pulse ,foul smelling lochia, pain and tenderness in lower abdomen.
• Prevented by attention to sepsis before and after delivery.

2. Thrombophlebitis:-
• Infection of veins of legs frequently associated with varicose veins and legs become tender ,pale
and swollen.

3. Secondary heamorrhage:-
• Bleeding from vagina anytime from six hours after delivery to end of puerperium(6weeks) which is
due to retained placenta or membranes.

4. Others- Urinary Tract Infection

Mastitis
RESTORATION OF MOTHER TO OPTIMUM HEALTH

1. PHYSICAL
2. PYSCHOLOGICAL
3. SOCIAL
• PHYSICAL :-
1. Postnatal examinations
• Twice per day for first three days
• Once per day till umblical cord drops off.
• Each examination FHW checks temperature, pulse ,respiration,examination of
breast, normal involution of uterus,checks urine and bowels.
• Next examinations at end of 6 weeks for completion of involution of uterus.
• Then 1 visit/month for next 6 months.
• Later to it 1 visit/2-3months till end of one year.
• Minimum no. Of visits of FHW is 3-6 postnatal visits.
2. Anaemia:- routine hb examination during PN visits.
3. Nutrition:- Nutritional need of mother should be met.
4.Postnatal exercise:- to bring stressed abdominal and pelvic muscles
back to normal.
• Psychological:-
1. Fear born of ignorance
2. Timidity
3. Insecurity regarding baby.
*Eliminated by proper prenatal instruction*
• Social:- Proper Family atmosphere.
• Breastfeeding:-
1. Exclusive for first six months of birth.
2. No other supplementation.
3. At age of 6 month, breast milk is supplemented by additional foods such as
animal milk, soft cooked meshed vegetables.
• Family Planning:- Related to every phase of maternity cycle.
1. On second day after delivery- postpartum sterlisation is recommended.
2. Lactation:- Cannot be depended upon for protection against conception.
3. Choice for first 6 months:- IUDS and conventional (non-hormonal) contraceptives.
4. Contraindications:- Combined OCPs and sequential OCPs as they prevent
lactation.
CARE OF NEWBORN

• Immediate Care:-
1. Clearing airway(most important after birth)
2. APGAR score
3. Care of cord
4. Care of eyes
5. Care of skin
6. Maintenance of body temperature
7. Breast feeding
1. Clearing airway:- Primary and everything else is secondary.
• Airway is cleared of mucous and other secretion by positioning baby with head low to
help in drainage of secretion assisted by suction.
2. APGAR score:- Taken at one minute and again at 5 minute after birth.
• Requires:- HR,RR,Muscle tone,pallor,reflex response where each sign given score from 0,1
and 2.
• It is consider negligence to omit APGAR score of newborn especially LBW.
• It provides estimate of physical condition of baby.
• Perfect score:- 9 or 10
• Severely depressed- 0 to 3
• Moderately depressed- 4 to 6
• If score <5 , needs prompt action.
3. Care of cord:-
• Umblical cord is cut and tied when it is stop pulsating because baby derives 10ml extra blood.
4. Care of Eyes:-
• Lid margin of new born cleared with wet swab.
• To prevent gonococcal infection, 1% AgNO3 solution or tetracycline 1% ointment is used.
• Ophthalmia neonatorum:- variety of organism associated with this condition. Ex-
N.Gonorrhoea, C.trachomatis, Staphylococcus, Streptococcus, Candida species.
Treatment:- Topical Neomycin
5. Care Of Skin :-
• Newborn is wet from amniotic fluid and can become cold therfore vornix, meconium and
blood clots are removed.
• First bath:- after one week.
6. Maintain Body temperature via skin to skin contact and
breastfeeding.
7. Breastfeeding:- within one hour of birth to establish feeding and
mother child relation known as Bonding.
Colostrum:- rich in protein and anti-infective factors against
respiratory infections and diarrhoea.
Neonatal examination
• First examination:- soon after birth.
1. To confirm baby is not suffered from any birth injuries
2. To detect malformation
3. To assess maturity
• Abnormalities to be immediate attended:-
1. Cyanosis of lips and skin.
2. Difficulty in breathing.
3. Imperforated anus
4. Persistent vomiting
5. Signs of cerebral thickening:-
• Twitching
• Convulsions
• Neck rigidity
• Second examination:- within 24hour of birth by pediatrician
1. Body sign:- Body weight, head to heel high, head and thoracic perimeter.
2. Skin :- cyanosis of lips , skin,jaundice,pallor,generalised erythema.
3. Cardiac murmur, absence of femoral pulse, central cyanosis ,RR>60/min
4. Neurobehavioural activity:-
• Posture:- neck retraction,frog like posture,hyperextension of limbs.
• Muscle tone:- tendon reflexes,movements
5. Head and face:- Hydrocephalus, large fontanelles,
• Eyes:- Cataract, coloboma, conjunctivitis
• Ear:- dysmorphism, accessory auricles
• Mouth and lips:- cleft palate, lips
6. Abdomen:- signs of distention,abnormal masses,imperforate anus.
7. Limbs and joints:- deformities of joints,congenital dislocation of hips, extra digits.
8. Spine:- neuraltube defects.
9. External genitalia:-
• Male:- hyposporadius, undesecended testis.
• Female:- fused labia, enlarged clitoris.
• Measuring Newborn:-
1. Body weight:- within 1hr birth

2. Length:- within first 3 days by infantometer.

3. Head circumference:- maximum circumference of head in

occipitofrontal diameter.
• Identification of “AT RISK” Infants:-
(purpose:- to decrease perinatal,neonatal and infant mortality.)
1. Birth weight <2.5kg
2. Twins
3. Birth order 5/>
4. Artificial feeding
5. Weight <70% of expected 3rd day weight.
6. Failure to gain weight during successive 3 months.
7. Children with PEM, diameter
8. Working mother/single parent.
• Kangaroo Mother Care :-
• For LBW babies introduce in colombia in 1979.
• It has 4 components:-
1 skin to skin postioning of baby on mothers chest
2 Adequate nutrition through breast feeding
3 Ambulatory care as a result of early dicharge from hospital.
4 Support for mother and her family in caring the mother.
• Rooming In :-
• Keeping babies crib by the side of mothers bed is knoown as rooming in.
• Advantages:-
1. Give opportunity for mother to know her baby.
2. Removes fear of mother that her baby is not misplaced in central nursery.
3. Builds up her self-confidence.
THANK YOU