Shahida Abbasi

Nursing Instructor
PGCN
October, 2020
 Objectives

At the completion of this unit learners will be able to:

1. Discuss the objectives of MCH Services
2. Explain pre- conception factors contribute to
healthy/unhealthy pregnancy
3. Discuss the objectives of antenatal care
– History taking
– Physical examination
– Investigations
– Follow up
4. Describe the guidelines for antenatal assessment, care
and teaching.
 MCH Services

Maternal and Child Health Services (MCH) refers to

promoting, preventing, therapeutic or rehabilitation
facility or care for fetus, mother and child.
Objectives of MCH are:
• Reduce maternal, perinatal, infant and childhood
mortality and morbidity.
• Promotion of Reproductive Health/safe motherhood.
 Conti…

• Ensure birth of healthy child

• Prevent malnutrition and its related problems
• Early diagnosis and treatment
• Promote health of mother, infant and family
 Preconception Assessment /Counseling

Age
Nutrition status (anemia)
Immunization status (TT)
Medication (Folic acid)
Medical problems (HTN, DM…)
Genetics screening (thalassemia)
Habits (tobacco and alcohol…) need to stop
Hazards at work/home (prick injury, radiation…)
Psychological/emotional status (stress and coping)
 Antenatal Care

Antenatal Care (ANC): It is the preventive branch

of obstetric and consist of systemic supervision of
women during pregnancy.

Care of the mother and baby during pregnancy from

conception until the beginning of labour.

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 Aim and Objectives
The aim of ANC is to:
• Discuss with the couple about the place, time and
mode of the delivery.
• Advice the mother about breast-feeding, post- natal
care and immunization.
• Educate the couple about family planning.
Objectives
To ensure a normal pregnancy and delivery of a healthy
baby from a healthy mother.
 Importance of Antenatal Care

• Support and encourage psychological adjustment to

pregnancy, childbirth, breastfeeding and parenthood
• Monitor pregnancy progress to ensure the health and
wellbeing of mother and foetus.
• Monitor all women for signs of obstetric difficulties;
early identification of problem and management
• Recognize deviations from the normal, and treat or
refer as required.
• build a trusting relationship between the woman and
her care givers.
 Conti…

• Provide the woman with information with which she

can make informed decisions.
• Actively involve woman’s family or friends.
• To prevent maternal and neonatal mortality, injury,
& ill health

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 Trimesters of Pregnancy

First trimester
1st week till13th week

Second trimester
14th week till 26th week

Third trimester
27th week till 38/40 weeks
 Schedule of Antenatal Visits

Prenatal visits
• Every 4 weeks until 28 week (7 visits)
• q 2 weeks until 36 week (4 visits)
• q week until delivery
• At least 4 visits are required
• First trimester 1 visit
• 2nd trimester 1 visit
• 3rd trimester 2 visits

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 The First ANC Visit

Objectives
• To assess the health status of the mother and foetus to
screen out the risk pregnancy.
• To obtain baseline information.
a. History taking
b. Physical Examination
c. Investigation
 History Taking
Personal profile
i. Name
ii. Age
iii. Gravida and parity
iv. Address
v. Date of first Examination
Chief complaints with duration
i. Period of amenorrhea
ii. Nausea & vomiting, vertigo
iii. Increased frequency of micturition
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 Conti…

iv. Constipation
v. Rise of temperature
vi. Edema
vii. Pain in the abdomen
viii. Backache
ix. Vaginal bleeding
 Conti…

Past History
i. HTN
ii. DM
iii. Renal Disease
iv. Psychiatric illness
v. IHD
vi. Any previous operation
Menstrual history
i. Menstrual cycle
ii. LMP
iii. EDD calculation by naegele’s formula
 Expected Date of Delivery

• The duration of pregnancy is usually taken to be 40

weeks, with normal labour occurring between 38 and
42 completed weeks of gestation.
• (Nägele’s Rule - 1st day of LMP; subtract 3 months;
add 7 days = Expected date of birth (EDB, EDD)
• Nine months, and seven days are added to the first
date of the last menstrual period.
 Expected Date of Delivery

Expected Date of Delivery (EDD)

• A women comes to an antenatal clinic. Her history
reveals that she is fourth time pregnant her all
babies are alive. Her LMP is 6-10-20.
• What will be her EDD/EDB
• Gravida =
• Para =
 History Conti…

Obstetric history
i. Gravida
ii. Para
iii. No. of living children
• Previous pregnancies (length & problems), labor
(place, type & postnatal , birth weight &
complications)
• Health status of the babies (term, preterm, abortions ,
still born)
 Gravida and Para

Gravida: # of pregnancies (+ present pregnancy)

Para: # of deliveries (born alive + still born)
 Conti…

Medical and surgical history

(complicating pregnancy/ recent abdominal
surgery/blood transfusion in past)
 Family history; inherited diseases/ twins
 Partner history, smoking, blood type if mother
negative
 Pregnancy history ---any concern in this pregnancy
 Medications /allergies

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 Physical Examination

General examination
• Appearance
• Vital signs
• Height of patient
• Weight of patient
• Anemia
• Jaundice
• Edema
 Conti…

BP: each visit to identify signs of hypertension.

a rise in the diastolic reading to above 90 mmHg or
of more than 10 mmHg from the baseline reading
taken before the twentieth week of pregnancy may
require evaluation
• Weight : 1st 20 weeks weight gain—2kg
remaining 20 weeks wt gain—9kg
• Height < than 5 feet concern
• Examine legs for varicose Vein

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 Conti…

Per Vaginal (P/V) examination

Before 16 weeks
• At first visit to confirm pregnancy, cervical
cytology
Last trimester
• Labor progress
Note ask women to void before vaginal
examination

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 Abdominal Examination

Height of fundus (compare with LMP, fetal growth)

Two methods
• McDonald’s Rule - between 16 and 36 weeks,
height of fundus in cm = weeks gestation
• Manual method
• Lie (longitudinal , transverse, oblique)
• presentation (breech , shoulder, cephalic)
• Fetal heart sound
• Fetal movement
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 Investigation

i. CBC
ii. Blood grouping & Rh typing
iii. Urine R/E
iv. RBS in case of family history of diabetes
v. VDRL
vi. HBS Ag, HIV
vii. Maternal serum alpha protein
viii.Serological for rubella and hepatitis
ix. Ultrasound
 Investigations Conti…

Pregnancy test After fertilization hCG released in blood

& some passed in urine. In first few weeks of
pregnancy, the amount of hCG in the urine rises
rapidly, doubling every 2 to 3 days.
• Blood test Hb hematocrits
If anaemia present one tablet of 60 mg elemental iron
with folic acid 0.5 mg twice a day for at least 90
consecutive days.

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 Conti…

Ultrasound can be done as early as 6 weeks

• normally done at 16 weeks to detect any
abnormities and after 32 weeks to see the CPD
• Alpha fetoprotein ( 16 -18 weeks)
• Fetal proteins detected in mothers’ blood they
detect some congenital or genetic disorders
• Amniocentesis ( 11 -18 weeks) amniotic fluid test
(insertion of needle in Abdominal wall to detect
chromosomal abnormalities
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 Urinalysis

• To check for the presence of bacteria to screen for

asymptotic bacteriuria.
• If a high level of bacteria is found (greater than 100
000 colonies per ml), a suitable antibiotic is required.
• Urine test for Albumin and sugar
 Rhesus
• Rhesus factor and antibodies should be checked and
preparations made to provide anti-D for Rh negative
to non-sensitized women following any
procedure/event that could result in fetomaternal
transfusion, also on 28th week of gestation and after
delivery.
 Records

• All findings should be recorded on the

antenatal records.
• The records should be accurate and contain the
signature of the person making the record.
 Health Education

• Better self care improves maternal and neonatal

outcome
• Teach expected changes
• Reassurance of normal discomforts
• Warning signs of complications
• Avoidance of teratogens (warfarin, Isotretinoin)
• Others (x-rays, Radiation, chemotherapy)

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 Nutritional Requirements
Calories Increase of 250 kcal per day.
• Additional requirement is less important in the first &
most important in last trimester.
Calcium - 1200 mg/day. ↓intake of calcium ↑risk of
pre- eclampsia. up to 2,000 mg of calcium
supplement / day in pregnancy.
Protein - 60 grams/day essential for fetal & placental
growth.
Carbohydrates – 100 grams/day (fibers)
Fat - 20-30% of caloric intake
Iron - 30-60 mg supplement/day
Folic acid - 0.8-1 mg/day. Deficiency linked to LBW &
neural tube defects.
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 Teratogens
• Any substance that alters cell differenciation or
growth of fetus
Alcohol: first ten weeks cause malformations
Drugs: Cocaine and heroine cause blood vessels to
constrict----, IUGR higher risks of miscarriage,
premature labor, abruptio placentae (the partial
separation of the placenta from the uterus wall, causing
bleeding) respiratory difficulties and intracranial
hemorrhage

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 Medication
• Anticonvulsants
• Anti-migraine
• Anticoagulant
• Non-steroidal anti-inflammatory drugs (NSAIDs)
(Aspirin, ibuprofen)
– interfere with blood clotting
– hinder production of the hormones that stimulate
labor,
– facial malformations and mental retardation

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 Risks Factors

Smoking
Risk of miscarriage or premature labor, IUGR
Nicotine depresses the appetite and reduces the ability
of the lungs to absorb oxygen. The fetus, deprived of
sufficient nourishment and oxygen, may not grow as
required
Other Risks are:
• Chemicals (household, work)
• Radiation exposures
• Infectious diseases
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Travel
• Avoid long traveling
• Avoid travel during last month of gestation
• Avoid travel to the area where medical care is not
available
• Use seat belts during travelling
Work
• Avoid excess lifting (>60 lbs)
• Avoid fatigue, don’t work > 8 hour days
• Avoid exposures, x-rays, or toxins
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Personal Hygiene
• May need to bathe more frequently
• Safety precautions when bathing
• Tub baths contraindicated in ROM
Dental Care
• Continue regular dental exams & cleanings
• Local anesthetics without added epinephrine is
recommended

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Exercise
• May continue with accustomed exercise but do not
initiate overly vigorous program
• Avoid excessive fatigue; keep pulse 120 bpm
• Wear supportive shoes and appropriate clothing
• Discontinue if short of breath
• If vaginal bleeding or abdominal pain, see doctor
immediately

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Immunizations
• Live virus vaccines contraindicated (measles, mums,
rubella)
• Inactivated bacterial vaccines, immune globulins and
DNA-based vaccines safe when indicated
(e.g., Hepatitis B vaccine, TT)
Childbirth Preparation
• Studies show women have easier, faster labors if attend
childbirth classes
• Teach danger signs, medications, stages of labor,
breathing & relaxation methods, newborn care & breast
feeding.

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 Danger Signs
Ensure that woman and family know danger
signs, which indicate need to consult doctor
 Vaginal bleeding
 Breathing difficulty
 Fever
 Severe abdominal pain
 Severe headache /blurred vision
 Convulsions / loss of consciousness
 Foul smelling greenish /brownish vaginal discharge
 Decreased / absent fetal movements
 Prepare for home delivery

• Clean and loose cotton clothes for mother

• Clean, soft and loose cotton clothes for baby
• Clean, soft cotton sheets to wrap baby
• Cotton wool or clean old clothes
• Buy disposable birth kit.
• Take bath after delivery

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 High-risk Pregnancy

• Advanced maternal age Pregnancy risks are higher for

mothers age below 18 and over 35.
• Medical history.
• A prior C-section, low birth weight/preterm birth
• Death of a baby shortly after birth.
• Underlying conditions.
• such as diabetes, high blood pressure, epilepsy, anemia,
infection.
 Conti…

Multiple pregnancy Placenta praevia

twins or higher order
multiples.
Pregnancy complications.
Cervix or placenta
Polyhydramnios (increase
amniotic fluid )
Oligohydramnios (low
amniotic fluid)
Primary Health care level
• Register, note name of referee, if high risk put red
mark,
• TT vaccine
• Iron, folic acid / iodine supplements/ calcium
• Identification of high risk
• Identification of STI
• Strategies to address malaria, HIV where prevalent
• Follow up
• Referral level Management of complication

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 Normal weight gain in pregnancy
• Fetus 3.2 Kg
• Placenta 0.5 Kg
• Amniotic fluid 0.9 Kg
• Uterus 0.9 Kg
• Breasts 0.4 Kg
• Blood volume 1.3 Kg
• ECF 1.1 Kg
• Fats 2.7 Kg

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 References
Bennett, R & Brown K (2009) Myles' Textbook for Midwives
(15th ed.) Churchill Livingstone: London