ANTENATAL CARE & MANAGEMENT

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, and acceptable
maternity care.

To be most effective, health care should begin early in pregnancy and continue at regular intervals.

MEANING-
Systematic supervision (examination&advice) of a woman during pregnancy is called antenatal
(Prenatal) care. The supervision should be regular and periodic in nature according to the need of
the individual.

Antenatal care comprises of:

 Careful history taking and examination(general and obstetrical)

 The advicewas given to the pregnant woman

DEFINITION-
1. Antenatal care refers to the care that is given to an expected mother from time
of conception is confirmed until the beginning of labor.
2. Planned examination and observation for the woman from conception until
the beginning of labor.

AIMS AND OBJECTIVE –

The aims are-
1. To screen the ‘high risk’ cases.
2. To prevent or to detect and treat at the earliest any complications.
3. To ensure continued risk assessment and to provide ongoing primary preventive health
care.
4. To educate the mother about the physiology of pregnancy and labor by demonstration,
charts,and diagrams, so the fear is removed, and psychology is improved.
5. To discuss with the couple about the place, time and mode of delivery, provisionally and
care of the newborn.
6. To motivate the couple about the need for family planning and appropriate advice to a
couple seeking medical termination of pregnancy.
 OBJECTIVE –

1. To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
2. Prevention, early detection,and treatment of pregnancy-related complications as Pre-
eclampsia, eclampsia,andhemorrhage.
3. Prevention, early detection and treatment of medical disorders as anemia and diabetes.
4. Detection of early malpresentation, malposition’s,and disproportion that may influence the
decision of labor.
5. Instruct the pregnant woman about hygiene, diet and warning symptoms.
6. Laboratory studies of parameters may affect the fetus as blood group, Rh typing,
toxoplasmosis,and syphilis.

CRITERIA OF A NORMAL PREGNANCY –

Delivery of a single baby in good condition at term ( 38 – 42 weeks), with a fetus weight of
2.5 kg or more and with no maternal complication.

FREQUENCY OF ANTENATAL VISIT S –

 Generally,a check-up isdone at an interval of 4 weeks upto 28 weeks, at an interval of 2

weeks upto 36 weeks and thereafter till delivery.
 WHO recommends the visit may be curtailed to atleast 4 visits,
1st visit – around 16 weeks
2nd visit – Between 24 -28 weeks
3rd visit – around 32 weeks
4th visit – around 36 weeks

PROCEDURE AT THE FIRST VISIT -

The first visit should not be referred beyond the second missed period.

OBJECTIVES –
1. To assess the health status of the mother and fetus.
2. To assess the fetal gestational age and to obtain baseline investigation.
3. To screen out the “at risk” pregnancy and to formulate the plan of subsequent
management.

HISTORY TAKING –

1. Vital statistics
a) General Examination of the Mother name, age, gravida, parity, expected date of
delivery.
b) Period of gestation
  Gravida denotes a pregnant state both present and past irrespective of the

 period of gestation.
 Parity denotes the state of previous pregnancy beyond the period of
viability.
c) Duration of marriage- This is relevant to note the fertility or fecundity. A
pregnancy long after marriage without taking any method of contraception is
called low fecundity and soon after marriage is called high fecundity. A woman
with low fecundity is unlikely to conceive frequently.
d) Religion
e) Occupation – It is helpful to interpret symptoms of fatigue due to excess
physical workor stress occupation hazard. Such women should be informed to
reduce such activities.
f) Occupation of husband-
 To access the socioeconomic condition of the patient,
 To anticipate the complications likely to be associated with low social
status such as anaemia, pre-eclampsia, prematurity etc.
 To give reasonable and realistic antenatal advice during family planning
guidance.
g) Period of gestation- The duration of pregnancy is to be expressed in terms of
completed weeks, a fraction a week of more than 3 days is to be considered as
completed week. In the early pregnancy it is calculated from the first day of last
normal menstrual period(LNMP) and in later month of pregnancy it is
calculated from the expected date of delivery.
2. Complaints

Categorically, the genesis of complaints is to be noted, even if there is no complaint,

inquiry is to be made about the sleep appetite, bowel habit and urination.

3. History of present illness

Elaboration of the chief complaints as regard their onset, duration, severity, use of
medications and progress.

4. History of Present pregnancy

 Last menstrual dates – Calculate expected date of delivery
 Cycle regularity
 History of recent oral contraceptive pill use
  Early ultrasound assessment of gestational age.
 Important complications in different trimesters
of the present pregnancy are to be noted
carefully these are hyperemesis and
threatened abortion in first trimester,
features of pyelitic, in second trimester
and anaemia, pre-eclampsia and
antepartum hemorrhage, in the last
trimester number of previous antenatal
visits immunization status must be noted
any medication or radiation exposure
rarely pregnancy or medical surgical events
during pregnancy must be noted.

Calculation of EDD

5. Past Obstetrical History

Ask for details, Date of pregnancy, Outcome, Gestation, Weight and sex of the baby,
wellbeing now, Problems in labor or pregnancy, delivery mode.

6. Menstrual History
Age at menarche, frequency, duration and amount of flow, premenstrual symptoms,
dysfunctional uterine bleeding.
Calculation of the expected date of delivery(EDD)- This is done according to Naegele’s
formula by adding 9 calendar month and seven days to the first day of the last menstrual
period. Alternatively, one can count back 3 calendar months from the first day of last
period and then add 7 days to get the expected date of delivery.

7. Past medical History

Relevant history of past medical illness that is urinary tract infection tuberculosis is to be
inquired.

8. Past surgical History

Any previous pregnancy e.g. General or gynecological, if any, is to be inquired.

9. Family History
Family History of diabetes, hypertension, tuberculosis, multiple pregnancy, non-hereditary
disease if any or twinning, congenital anomaly of fetus is to be inquired.
 10. Personal History
 About the nutrition, morning sickness, weight gain.
 Rest and sleep 8 hours during night and 2 hours during day time.
 Activity and exercise.
 Habits such as alcoholism, smoking, tobacco chewing.
 Marital, any consanguineous marriage and duration of marriage.
 Contraception such as pills or intra uterine devices.
 Drugs during pregnancy
 Sexual history- any intercourse during pregnancy.
 Elimination- Frequency of micturition, Constipation.

11. Previous Gynecological Problems

STI’s endometriosis, infertility, surgery, polycystic ovarian diseases.

PHYSICAL EXAMINATION-

1. General Physical Examination:

 Build-obese/average/thin
 Nutrition- Good/Average/Poor
 Height- Short Stature is likely to be associated with a small pelvis.
 Weight- Weight should n=be taken in all cases in an accurate weighing
machine. Repeated weight checking in subsequent visit should be done in the
same weighing machine.
 Pallor- The sites to be noted as lower Palpebral conjunctiva, dorsum of the
tongue and nailbeds.
 Jaundice- The sites to be noted as vulbarconjunctiva, under surface of the
tongue, hardpalape skin.
 Tongue, teeth’s, gums and tonsils- Evidence of malnutrition are evident from
glossitis and stomatitis. Any infection in mouth is to be eradicated, any source
of infection is to be eradicated.
 Neck- Neck veins, thyroid gland, lymph glands are looked for any abnormality.
 Odema of the legs- Both the legs are to be examine the sites are over the medial
malleolus and interrail surface of the lower 1/3 RD of the Tibiya.
2. Vital Signs:
Assess the pulse, BP, respiration and temperature.
3. Systemic Examination:
Heart, lungs, Liver and spleen- are to be check for any abnormality.
 Breast- needs to be checked for nipples (Cracked or depressed and skin condition
areola).
4. Obstetrical Examination
 Eyes: Pallor, Jaundice
 Breast: Nipple cracked/ depressed, symmetry, Secondary areolar , montuberg
tubercle
 Abdominal Examination
 Vaginal Examination
5. Routine Investigation
 Examination of the blood
 Urine is examined routinely for protein, Sugar and pus cells.
6. Special Investigation
 Serological tests for rubella and hepatitis B virus
 Ultrasonography examination
 Maternal serum alpha Feto protein
7. Booking should be done.

Procedure at the subsequent Visits

Generally check up is done at interval of 4 weeks up to 28 weeks ; at interval of 2 weeks up to

36 weeks and there after weekly till-the expected date of delivery. In the developing countries,
as per WHO recommendation, the visit may be curtailed to at least 4 ; first in second trimester
around 16 weeks, second between 24-28 weeks, the third visit at 32 weeks and fourth visit at 36
weeks.

Objectives-

To assess-
 Fetal well being.
 Lie , presentation, position and number of fetuses.
 Anaemia, pre-eclampsia, amniotic fluid volume and fetal growth.
 To organize specialist antenatal clinics for patients with problems like cardiac disease
and diabetes.
 To select, time for ultrasonography amniocentesis or chorionic villous biopsy when
indicated.
 History Collection
Appearance of any new complaints, quickening, lightening, examination.
Weight, pallor, oedema of legs, BP monitoring Abdominal examination.
1st trimester: Height of the fundus
2nd trimester: External ballotment, fetal movements, palpation of the fetal parts, fundal height
3rd trimester: Identify lie, presentation, position, growth pattern, engagement, girth of the
abdomen, fundal height.

Uncover the patient’s abdomen from the xiphisternum to the public hairline, ensuring
adequate exposure while allowing for patient modesty. Abdominal wall relaxation is maximized
by the patient resting her arms alongside her abdomen, rather than behind her head. The
patient’s legs may also be slightly flexed at the hips to aid relaxation.

Inspection: The presence of an abdominal mass arising from the pelvis consistent with
pregnancy, scars, pigmentation or other skin lesions are noted. Fetal movements may be observed.

Fundal Palpation  Fundal palpation can be done  Round, hard, readily,

(First Maneuver) using the finger tips or palmar
surface of the fingers.
 First nurse should face
towards the women head.
 Whole fundal area is
palpated by both hands laid
flat on it to find which pole of
fetus is lying in the fundus.
 Palpate for size, size, shape,
consistency and mobility of
the fetal part in the fundus.
movable part, ballotable
between the fingers of both
hands is indicative of head.
 Irregular, bulkier, less firm
and not well defined or
movable part is indicative of
breech.
 Neither of the above is
indicative transverse lie.
Lateral Palpation  Continue to face the woman  A smooth, curved, hard
(Second Maneuver) or head side resistant surface indicate
Umbilical grip  Place the hands on both back.
side of the uterus about  Small, knob irregular parts
midway between the or modules indicate limb.
symphysis pubis and the
fundus.
 Apply pressure with one
hand against the side of the
uterus pushing the fetus to
the other side and
stabilizing it there.
 Palpate the other side
abdomen with the
examining finger from the
midline to the lateral side
and from the fundus using
the smooth pressure and
rotator movements.
 Repeat the procedure for the
opposite.
Pawlicks grip  Continue to face the woman  If the fetal head is above
(Third Maneuver) head side. brim, it will be readily
 Woman should be placed as movable and ballotable.
knee bent.  If it is not ballotable, it
 Grasp the portion of the indicates head is engaged.
lower abdomen
immediately above the
symphysis pubis between
the thumb and middle
finger of one of the hand.
Pelvic Palpation  Nurse should face towards  This maneuver determines
(Fourth Maneuver) the woman feet side, woman the engagement of the
should be placed as knee bent. head.
 Place the hands on the sides  If the head is presenting,
of the uterus, with the palm of the fingers of one hand
the hands just below the level will feel the occiput and
of the umbilicus and fingers those of the other hand
directed towards the the cephalic prominence.
symphysis pubis.
 Press deeply with fingertips
into the lower abdomen and
move them towards the pelvic
 inlet.
 The hand coverage around
the presenting part when the
head is not engaged.

FHR monitoring: A Normal fetal heart rate is 110-160 beats per minute. The fetal heart is best
heard over the fetal back, particularly when listening with a pinard stethoscope.

Vaginal Examination:
Vaginal examination in the early weeks of pregnancy helps
 To establish the diagnosis of pregnancy
 To decide whether the pregnancy is uterine or extra uterine.
 To ascertain whether there there are any tumors or abnormalities in the genital tract
complicating pregnancy.

In the later weeks and particularly near team, it helps in the diagnosis of the presentation and
position of the fetus and in assessing the pelvis. The risk of infection by a careless vaginal
examination is always present: hence the examination should be with all antiseptic solution.
The fetus – in - Utero
1. Lie: The lie refers to the relation of the long axis of the fetus to the long axis of the uterus
or maternal spine. The lie may be longitudinal(99%), it may be transverse or oblique.
2. Presentation: The part of the fetus which occupies the lower pole of the uterus. The
presentation may be cephalic(96%), podalic(3%), shoulder and other (0.5%).
3. Presenting Part: The part of the presentation which overlies the external os. Thus in
cephalic presentation the presenting part is vertex(commonest), brow or face, depending
upon the degree of flexion of the head.
4. Attitude: The relation of the different part of the fetus to one another. The common
attitude is flexion.
5. Denominator: It is an arbitrary bony fixed point which comes in relation with the various
quadrants of the maternal pelvis. The following are the denominator of the different
presentation occiput in the vertex, mentum in the face, frontal eminence in brow, sacrum
in breech and acromian in shoulder.
6. Position: It is the relation of the denominator to the different quadrants of the pelvis. The
pelvis is divided into equal segments of 45 degree to place the denominator in each
segment. Thus there are 8 positions with each presenting part. The situation of the fetus in
the pelvis, determined and described by the relation of the given arbitrary point in the
coronal plane of the maternal pelvis(Maternal Index).
Cephalic Presentation
Vertex presentation (Point of direction: Lambdoid, occipital, posterior, smaller or
triangular fontanelle; commonly occiput)(95%).
 Left occipitoanterior (LOA)(Left ileo-pectineal eminence)(60%).
 Left occipitoposterior(LOP)(Left sacroiliac symphisis)(3%).
 Left Occipitotransverse(LOT)
Right Occipitoanterior (ROA) (Right ileo-pectinal eminence)(6%).
 Right occipitoposterior(ROP)(Right sacroiliac symphisis)(30%).
 Right occipitotransverse(ROT)
 Bregma presentation (Point of direction : bregmatic, frontal or larger fontanelle)
 Face presentation (Point of direction : chin) (0.5%)
 Left mentoanterior (LMA)
 Left mentoposterior (LMP)
 Left mentotransverse (LMT)
 Right mentoanterior (RMA)
 Right mentoposterior (RMP)
 Right mentotransverse (RMT)
 Brow presentation (point of direction : nose root)
 Left frontoanterior (LFA)
 Left frontoposterior (LFP)
  Left frontotraverse (LFT)
 Right frontoanterior (RFA)
 Right frontoposterior (RFP)
 Right frontotransverse (RFT)
 Pelvic presentation (breech) (4%)
Complete breech presentation (25-30-%, especially in multiparae): feet crossed and
thighs flexed on abdomen; buttocks and feet against the outlet (point of direction:
sacrum)
 Left sacroanterior (LSA)
 Left sacroposterior (LSP)
 Left sacrotransverse (LST)
 Right sacroanterior (RSA)
 Right sacroposterior (RSP)
 Right sacrotransverse (RST)
 Incomplete breech presentation(30-35%): same designations as above
 Buttocks variety(70%)
 Incomplete variety with procidentia: one or more little parts(footling, knees)
precede the buttocks
 Shoulder presentation(point of direction: acromion)(<0.5%)
 Left sacpulanterior (LScA)
 Left scapuloposterior (LScP)
 Right scapuloanterior (RScA)
 Right scapuloposterior (RScP)
ANTENATAL ADVICE:
Principles:

1) To counsel the women about the importance of regular checkup.

2) To maintain or improve, the health status of the woman to the optimum till delivery by
judicious advice regarding diet, drugs and hygiene.
3) To improve the psychology and to remove the fear of the unknown by counselling the
women.

Diet: The diet during pregnancy should be adequate to provide-

a) Good maternal health

b) Optimum fetal growth
c) The strength and vitality required during labor and
d) Successful lactation. During pregnancy, there is increased calorie requirement due to
increased growth of the maternal tissues, fetus, placenta and increased basal metabolic rate.
The increased calorie requirement is to the extent of 300 over the non- pregnancy state
during second half of pregnancy. Generally the diet in pregnancy should be with woman’s
choice as regard the quantity and the type. Woman with normal BMI should eat
adequately so as to gain the optimum weight (11 kg). Overweight women with BMI
between (26-29) should limit weight gain to 7 kg and obese women (BMI>29) should gain
less weight. Excessive weight gain increases antepartum and intrapartum complications
including fetal macrosomia.

Antenatal Hygiene: In otherwise uncomplicated cases, the following advises are to be given.
Rest and Sleep: The patient may continue her usual activities throughout pregnancy.
However, excessive and strenous work should be avoided specially in the first trimester and
the last 4 weeks. Recreational exercise are permitted as long as she feels comfortable.
Bowel: Constipation is common. It may cause backache and abdominal discomfort.
Regular bowel movement may be facilitated by regulation of diet taking plenty of fluids,
vegetables and milk or prescribing stool softners at bed time. There may be rectal bleeding,
painful fissures or haemorrhoids due to hard stool.
Bathing: The patient should take daily bath but be careful against slipping in the bathroom
due to imbalance.
Clothing, shoes and belt: The patient should wear loose but comfortable garments. High
heel shoes should better be avoided in advanced pregnancy when the centre of balance
alters. Constricting belt should be avoided.
Dental care: Good dental and oral hygiene should be maintained. The dentist should be
consulted, if necessary. This will facilitate extraction or filling of the caries tooth, if
required, comfortably in the 2nd trimester.
Care of the breasts: Breast engorgement may cause discomfort during late pregnancy. A
well fitting brassiere can give relief.
Coitus: Generally coitus is not restricted during pregnancy. Release of prostaglandins and
oxytocin with coitus may cause uterine contractions. Women with increased risk of
miscarriage or preterm labor should avoid coitus if they feel such increased uterine activity.
Travel: Travel by vehicles having jerks are better to be avoided specially in first trimester
and the last 6 weeks. The long journey is preferably be limited to the second trimester. Rail
route is preferable to bus route. Travel in pressurized aircraft is safe upto 36 weeks. Air
travel is contraindicated in case with placenta praevia, pre-eclampsia, severe anaemia and
sickle cell disease. Prolonged sitting in a car or aeroplane should be avoided due to the risk
of venous stasis and thromboembolism. Seat belt should be under the abdomen.
Smoking and alcohol: In view of the fact that smoking is injurious to health, it is better to
stop smoking not only during pregnancy but even thereafter. Heavy smokers have smaller
babies and there is also more chance of abortion. Similarly alcohol consumption is to be
drastically curtailed or avoided, so as to prevent fetal maldevelopment or growth restriction.

IMMUNISATION:
Fortunately most of the life threatening epidemics are rare. In the developing countries
immunization in pregnancy is a routine for tetanus; others are given when epidemic occurs
or travelling to an endemic zone or for travelling overseas.

Live virus vaccines (rubella, measles, mumps, yellow fever) are contraindicated. Rabies,
Hepatitis A and B vaccines, toxoids can be given as in nonpregnant state.

Tetanus: Immunization against tetanus not only protects the mother but also the neonates.

Drugs: Almost all the drugs given to mother will cross the placenta to reach the fetus.
Possibility of pregnancy should be kept in mind while prescribing drugs to any woman of
reproductive age.

GENERAL ADVICE:

The patient should be persuaded to attend for antenatal check up positively on the
schedule date of visit. She is instructed to report the physician even at an early date if some
untoward symptoms arise such as intense headache, disturbed sleep with restlessness,
urinary troubles, epigastric pain, vomiting and scanty urination.

She is advised to come to hospital for consideration of admission in the following

circumstances:
  Painful uterine contractions at interval of about 10 minutes or earlier and continued
for at least an hour- suggestive of onset of labor.
 Sudden gush of watery fluid per vaginam- suggestive of premature rupture of the
membrane.
 Active vaginal bleeding, however slight it may be.

RISK APPROACH OF OBSTETRICAL NURSING CARE AND SCREENING OF HIGH

RISK PREGNANCY:

High risk pregnancy is one in which mother, fetus and new born is or will be at increased risk for
modality and morbidities due to problems and complication during pregnancy.

The risk approach strategy is expected to have far-reaching effects on the whole organization of
MCH/FP services and lead to improvements in both the coverage and quality of health care, at all
levels, particularly at primary health care level. Inherent in this approach maximum utilization of
all resources including some human resources that are not conventionally involved in such care
like traditional birth attendants, community health workers, women’s group.

Risk Approach of Obstetrical Nursing Care

The risk approach is a managerial tool for improved MCH care.

Purpose

To provide better services for all, but with special attention to those who need the most.

A high-risk pregnancy is one in which some condition puts the mother, the developing fetus or
both at higher-than-normal risk for complications during or after the pregnancy and birth.

High Risk Mothers

The high risk mothers are :-

1. Women below 18 years of age over 35 years in primigravida.

2. Women who have had four or more pregnancies and deliveries.
3. Elderly grandmultiparas.
4. Women who had a history of previous CS, instrumental delivery.
5. Short statured primi(140 cm and below)
6. Malpresentation like breech, transverse lie, shoulder presentation etc.
7. Antepartum haemorrhage
8. Preeclampsia and eclampsia
9. Anaemia
10. Twins, hydraminos
11. Manual removal of placenta
12. Previous stillbirth, intrauterine death and Abortion.
13. Prolonged pregnancy(14 days – after expected date of delivery)
14. Pregnancy associated with medical disease like cardiac disease, epilepsy, psychiatric illness,
thyroid disorder, spinal injury, kidney disease, hypertension, diabetes, tuberculosis, liver
disease etc.
15. Unmarried mother of low economic status.
16. Those who have practiced less than 2 years or more than 10 years or more than 10 years of
birth spacing.
17. Obstructed labor
18. Congenital abnormalities of fetal.
19. Those with cephalon pelvic disproportion(CPD).
20. The mother with blood -Rh negative.
21. Those with obesity or malnutrition.

Maternal Risk Factors

Maternal risk is defined as the probability of dying or experiencing serious injury as a result of
pregnancy or child birth. The risk of developing problem and complications varies. Some are
at risk than other depend upon various risk factors. These are discussed as under:-

a) Young Primi i.e. below 19 years

There is a grave risk to both mother and the child because the teenage mother :-
 Is Still growing and is not adequately equipped to cope with pregnancy and labor.
There is increasing chance of abortion, poor uterine function during labor premature
labor, low birth weight baby, poor breast feeding due to incomplete development of
breasts.
 Is not psychologically prepared for the responsibilities of marriage, pregnancy and
rearing children. This created tensions and discord in the family.
 Has increasing nutritional requirements by virtue of her own growth and the
growing foetus thus has greater risk of anaemia, malnutrition and low birth weight
baby.
b) Elderly Primi i.e. 30 years and over
 Having babies too late in life, leads to increased risk of complications in pregnancy
and labor which include:-
 Heavy bleeding before and after child birth.
 Malpresentation resulting in difficult labor.
 Include/Aggravated blood pressure
 Forceps delivery or by caesarean operation
 Delay in expulsion of placenta.
 Low birth weight babies.
c) Having too many babies
 When the mother bears more than three babies, she is at high risk of developing
problems due to repeated pregnancies and labor. This is due to weakening of tissues,
depletion of nutrients and overall poor physical health of the mother which happens
because of repeated pregnancies. Some of the complications due to multiparity
includes:-
 Malnutrition leading to anaemia.
 Antepartum and postpartum haemorrhage
 Difficult and obstructed labor resulting in perineal tear, uterine rupture
involving immediate surgical intervention.
 Prolapse of uterus
 Still birth
 Neonatal death
 Premature delivery
 Low birth weight baby
d) Having too close pregnancies
When the interval between the two pregnancies is less than three years, it can create
problems during the pregnancy. It is because mother did not get enough time to
recover completely and fully from the stress and strain of the previous pregnancy.
Repeated pregnancies at short interval can cause nutrional deficiency, anaemia, low
birth weight baby and all the rest of the problems mentioned earlier when also the
number of the children being born, increases.
Pregnancy at short intervals not only affects the health of the mother and child being
born but also the health of other children in the family because they get neglected as
mother cannot give her attention to them.
e) Associated medical conditions
This includes:
 Heart disease
 High blood pressure
 Kidney disease
 Tuberculosis
 Diabetes
 Repeated attacks of malaria
 Hepatic disorder
f) Other conditions in mothers
These includes:
 Mothers with short height i.e. less than 145 cms having a small and inadequate
pelvis. Such mothers usually have difficult labor and require caesarean delivery to
avoid complications.
  Mothers having less than 40 kg of weight: usually underweight mothers are
malnourished and anaemic and have high risk of developing complications in
pregnancy.
 Mothers having more than 70 kg of weight have difficulty during childbirth. They
may also develop respiratory distress and problem while in anaesthesia.
Sometimes it may be fatal to mother.
 Mothers having malnutrition and anaemia. These mothers are weak and find it
difficult to tolerate the stress and strain of pregnancy and child birth.
g) Previous abnormal obstetrical history
These includes history of:-
 Antepartum haemorrhage, threatened abortion.
 Preeclampsia and eclampsia
 Malpresentations, twins, hydramnios.
 Intrauterine death, stillbirth, manual removal of placenta.
 Instrumental or caesarean delivery.
These conditions can pose serious problem to the life of both mother and
baby. These can be reduced considerably with adequate proper care and timely
medical attention.

Prevention of High Incidence of High Risk Pregnancies

 By improving pre pregnancy health of women.

 Providing quality antenatal care.
 Screening all pregnancies for high risk.
 Provide appropriate clinical and technological care by specialist on time.
 Health education on MCH-FP care.

Screening of High Risk Pregnancy

A) Biophysical Assessment
1. Ultrasonography
2. Radiology in Obstetrics
3. Magnetic Resonance Imaging
B) Biochemical Assessment
1. Amniocentesis
2. Alpha-fetoprotien (AFP)
3. Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis
4. Chrionic Villus Sampling
5. Maternal Blood Assessments
6. Placental Biopsy
7.
 C) Electronic Monitoring
1. Nonstress test
2. Contraction Stress Tests/ Oxytocin Challenge test
3. Daily Fetal Movement Count (DFMC) or Kick Counts.

ABSTRACTS-

1. A questionnaire study of mothers' views of the antenatal care provided in Belfast showed
general satisfaction. Retrospective examination of their charts, however, showed in some cases
that insufficient attention was paid to the medical and obstetric history in the selection of the
type of care made by the women and their doctors. Some women with high-risk factors were
booked for shared care and some patients at low risk were booked for total hospital care. The
reasons for this are unclear. The mothers felt that continuity of care and communication at
the health center were better than at the hospital. Analysis of the number of hospital
attendances showed that shared care patients appeared to be making an excessive number of
visits to the hospital. Many total hospital care patients also admitted that they were attending
their general practitioners. There appeared to be marked duplication of effort as a result of
poor communication between patient, general practitioner and hospital. Alternative ideas for
care are suggested a more integrated system for sharing antenatal care, and the development
of general practitioner units within the specialist obstetric hospital. (McKenzie-Mcharg, 2014)

2. Both the under 18 conception and birth rates are falling. However, despite this, the United
Kingdom has a high rate of teenage pregnancy compared to similar countries in Western
Europe. Young mothers and their babies have poorer access to maternity care and experience
worse obstetric outcomes than older mothers. It is likely that the risks associated with teenage
pregnancy reflect a significant interplay between the socio-demographic status of many of
these teenagers, their nutritional status and their uptake of antenatal care. This review looks at
the complications associated with teenage pregnancy and how the implementation of
specialized antenatal care aims to improve outcomes. (Whitworth, 2017)

3. Within the continuum of reproductive health care, antenatal care (ANC) provides a platform
for important healthcare functions, including health promotion, screening and diagnosis, and
disease prevention. It has been established that, by implementing timely and appropriate
evidence-based practices, ANC can save lives. Endorsed, by the UN Secretary-General, this is
a comprehensive WHO guideline on routine ANC for pregnant women and adolescent girls.
It aims to complement existing WHO guidelines on the management of specific pregnancy-
related complications. The guidance aims to capture the complex nature of the issues
surrounding ANC health care practices and delivery and to prioritize person-centered health
and well-being, not only the prevention of death and morbidity, in accordance with a human
rights-based approach. "To achieve the Every Woman Every Child vision and the Global
Strategy for Women's Children's and Adolescents' Health, we need innovative, evidence-
based approaches to antenatal care. I welcome these guidelines, which aim to put women at
the center of care, enhancing their experience of pregnancy and ensuring that babies have the
best possible start in life." Ban Ki-moon, UN Secretary-General (WHO, 2013)
 4. Early and frequent antenatal care attendance during pregnancy is important to identify and
mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at
childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care
attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit
from its preventive and curative services. This study assesses the timing of adult and
adolescent pregnant women's first antenatal care visit and identifies factors influencing early
and late attendance. The study was conducted in the Ulanga and Kilombero rural
Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory
studies informed the design of a structured questionnaire. A total of 440 women who
attended antenatal care participated in exit interviews. Socio-demographic, social, perception-
and service-related factors were analyzed for associations with the timing of antenatal care
initiation using regression analysis. The majority of pregnant women initiated antenatal care
attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group
compared to other ethnic groups such as the Pogoro, Mhehe, Mindoand others, perceived
the poor quality of care, late recognition of pregnancy and not being supported by the
husband or partner were identified as factors associated with a later antenatal care enrolment
(p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated
with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started
antenatal care no later than adult pregnant women despite being more likely to be single.
Factors including poor quality of care, lack of awareness about the health benefit of antenatal
care, late recognition of pregnancy, and social and economic factors may influence the timing
of antenatal care. Community-based interventions are needed that involve men and need to
be combined with interventions that target improving the quality, content,and outreach of
antenatal care services to enhance early antenatal care enrolment among pregnant women.
(Gross, 2012)

BIBLIOGRAPHY-

1. Bhaskar Nima. Midwifery & Obstetrical Nursing: Administration of Midwife and Obstetrical
Nursing. 2nd ed. Bangalore: EMMESS Medical Publishers, 2015.P- 130 – 40

2. Dutta DC. Text Book of Obstetrics including Perinatology and Contraception: Antenatal care,
Pre-Conceptional Counselling,and Care.In:Konar Hiralal editor.7th ed.London.New Central
Book Agency (P ) Ltd:2011.P.106-18

3. Jacob Annamma. A Comprehensive Text Book of Midwifery & Gynecological Nursing :

Antenatal Care in Maternity Nursing, 3rd ed.Karnataka : JAYPEE Brothers Medical Publishers
(P) Ltd,2012.P.461-68
 CONTENT
ON
“ANTENATAL CARE
AND MANAGEMENT”

SUBMITTED TO- SUBMITTED BY-

Mrs. Debjani Nayak Itismita Biswal
Assistant Professor M.Sc.Nursing 1st yr Student
Obstetrics & Gynaecological Nursing Obstetrics & Gynaecological Nursing