1. ANTENATAL CARE
Lt Col A S Kushwaha

2. INDIA
Health of Women
• Falling low sex ratio of 933 female per thousand male.
• Early marriage in women and universality of marriage are important
social issues.
• The median age at first marriage among women is 17.2 years.
• Among young women age 15-19, 16 percent have already begun
childbearing.
• Less than half of women received antenatal care during the first
trimester of pregnancy, as is recommended..
• Three out of every five births in India take place at home;. Postnatal
care is most common following births in a medical facility.
• Every seven minutes an Indian woman dies from complications related
to pregnancy and childbirth.
09/05/2012 Lt Col A S Kushwaha

3. Problems in MCH
• Varies from developing to developed countries
• Triad of malnutrition, infection & Unregulated
fertility
• Lack of health infrastructure
• Gender based discrimination
• Poor socio-economic conditions
09/05/2012 Lt Col A S Kushwaha

4. ANTENATAL CARE
Why ?
Three types of health problems exist in pregnancy.
1. The complications of pregnancy itself,
2. Second, diseases that happen to affect a pregnant
woman and which may or may not be aggravated
by pregnancy, and
3. Third, the negative effects of unhealthy lifestyles

5. Definitions
• Antenatal care
• Preconception care
• Prenatal care

6. Antenatal care
ANC includes
• visit to antenatal clinic,
• examination,
• investigations,
• immunization,
• supplements (Iron, Folic acid, Calcium, Nutritional)
• and interventions as required.

7. Preconception care
• Refers to physical and mental preparation of
both parents for pregnancy and childbearing
in order to improve the pregnancy outcome.

8. Objectives of ANC
Goal - Healthy mother and a healthy baby
Objectives-???

9. Objectives of Antenatal Care
1. To promote , protect and maintain health of the mother
2. To detect ‘ at risk’ cases and provide necessary care
3. To provide advise on self care during pregnancy
4. To educate women on warning signals, child care, family planning
5. To prepare the woman for labour and lactation
6. To allay anxiety associated with pregnancy and childbirth
7. To provide early diagnosis and treatment of any medical
8. condition/ complication of pregnancy
9. To plan for “ Birth” and emergencies / complications
( where, how, by whom, transport, blood )
10. To provide care to any child accompanying the mother

10. Visits
• Regular
• Ideally - once a month during first seven months,
- twice a month for 8th month
- and every week thereafter till delivery
• Minimum -4
• Besides 1st visit, visits at 20, 32 and 36 weeks are
recommended.
• Essential Antenatal Care

11. Preconception Care
Indications for Preconception Care
• Advanced maternal (>35 years) or paternal (>55 years) age
• history of neural tube defects in family or previous pregnancy
• Congenital heart disease, hemophilia, thalassemia, sickle cell
disease, Tay-sach’s disease, cystic fibrosis, Huntington
chorea, muscular dystrophy, Down’s syndrome.
• maternal metabolic disorders
• recurrent pregnancy loss (>3)
• Use of alcohol, recreational drugs or medications
• Environmental or occupational exposures

12. ANC – First Visit
The functions of this visit are-
1. Confirmation of pregnancy
2. Screening for high risk pregnancy
3. Baseline investigations
4. Initiation of Iron and Folic Acid supplementation
5. Immunization with Tetanus toxoid
6. Education of the mother on pregnancy and
childbirth

13. Identify “High Risk” pregnancies
• Maternal factors --???
• BOH ??
• Medical conditions ??

14. Maternal factors -
• Age- <18 years or > 35 years (especially in primigravida)
• Multiparity (>4)
• Short stature ( < 140 cms )
• Weight < 40 Kg / weight gain < 5 Kg
• Rh negative
BOH- Recurrent abortions ( 2 x1st trimester or 1 mid-trimester)
• Intrauterine death or intrapartum death/ stillbirth
• Prolonged Labour, birth asphyxia , early neonatal death
• Previous caesarean section / scar dehiscence
• Postpartum hemorrhage , manual removal of placenta
• Baby which is LBW, SFD or large for date, congenitally malformed
• Malpresentation, instrumental delivery, ectopic pregnancy
• Twins, hydramnios, pre-eclampsia
Medical Disorders-
• Cardiac ( RHD, CHD, Valve defects), renal or endocrine (Thyroid)
• Infections- TB, Leprosy, etc
• Hypertension, diabetes, IHD, seizures
• Malaria, acute febrile, gastrointestinal disease
• Anemia

15. pregnancy at any stage can be classified as
high risk if -
• Bleeding PV at any point ( Antepartum hemorrhage)
• Excessive vomiting ( Hyperemesis gravidarum)
• Hypertension, proteinuria
• Severe anemia
• Abnormal weight gain
• Multiple pregnancy, hydramnios, oligohydramnios
• Abnormal presentation in 9th month
• Preterm Labour, PROM
• Pre-eclampsia, eclampsia

16. Supplements
• Iron & Folic Acid
• Tetanus Toxoid Immunization

17. Rh Iso-immunisation
• Abortion
• LSCS
• Labour
• Monitor antibody titer at 28 and 36 wks
• Anti-D Ig- given at 28 wks/ within 72 hrs

18. Health Education
• Diet & Rest
• Personal Hygiene and Habits-.
• Sexual intercourse-
• Drugs
• Exercise
• Travel-
• Care of Breasts
• Warning signs

19. Warning Signs
• Swelling of feet
• Convulsions/ unconsciousness
• Severe headache
• Blurring of vision
• Bleeding or discharge per vaginum
• Severe abdominal pain
• any other unusual symptom

20. Subsequent Visits
• Monitor –
Progress of pregnancy
Foetal wellbeing
• Identify and manage any condition

21. 1st Trimester
• Confirmation of pregnancy
• define maternal risk status,
• counsel on early pregnancy discomforts
• Offer early prenatal screening tests ( chorionic villous
sampling, amniocentesis, USG) to those with genetic risk
factors.

22. 2nd Trimester
• confirmation of EDD,
• certain screening tests like maternal serum
alpha fetoprotein ( 16-18 weeks) for Neural tube defects ( 4 per
10,000 live births).
• Rule out gestational diabetes.
• Rh negative women are given anti-D
immunoglobulin at 28 weeks

23. 3rd Trimester
• watch for complications.
• Counsel the lady on warning signs, labour and
delivery
• Work out birth plan.
• Assess adequacy of pelvis

24. Symptoms & their Mgt
• Nausea & Vomiting
• Headache
• GI symptoms
• Urinary symptoms
• Vaginal discharge
• Vaginal bleeding
• Backache
• Swelling of feet & ankles
• Varicose veins

25. Pre-eclampsia
• Hypertensive disorders of pregnancy are the
cause of 12% of maternal deaths.
• If the diastolic BP is >or =90 mm Hg , ask for
symptoms like severe headache, blurred
vision, epigastric pain and check for proteins
in urine.
• Pre-eclampsia is diagnosed if diastolic BP is
90-110 mm Hg and proteinuria (++) is
detected.

26. Pregnancy & HIV
• Provide key information on HIV
• HIV testing and Counselling
• Care & Counselling
• Provide support
• Give ART
• Counsel on infant feeding

27. Pregnancy & HIV
`where HIV prevalence amongst antenatal cases is high.
• special handling.
• PMTCT
• Mothers2Mothers (m2m)
• ART-
-AZT 300 mg every 12 hours is given from 36 weeks of
pregnancy till onset of labour and thereafter 300mg every 3
hours.
- Alternatively, Nevirapine 200 mg single dose as early as
possible in labour and 50 mg in oral solution form to the
newborn within 72 hours
• Replacement feeding using principles of AFASS (acceptable,
feasible, affordable, safe and sustainable)

28. Intranatal Care

29. Child birth – a miracle of life should not
become a nightmare of death

30. Some facts
• 85 % women will deliver normally
• 10-15 % women will develop complications
• 3-5 % women will need surgical
interventions (blood/Cesarean etc.)
More chances of women having a normal delivery
However delivery complications can occur suddenly, without any warning
signals
30

31. Some facts
• 20-25% deaths occur during pregnancy.
• 40-50% deaths occur during labour and delivery
• 25-40% deaths occur after childbirth
(More during the first seven days)
It is important to focus attention during pregnancy and also after
childbirth
31

32. Scenario in India
 Every seven minutes an Indian woman
dies from complications related to
pregnancy and childbirth.
 The maternal mortality ratio in India
stands at 300 per 100,000 live births.
 It has some high performing states like Kerala with MMR of
110 and poorly doing states like Uttar Pradesh with MMR of
517.

33. Birth Plan
• Where is the birth going to take place?
• Who will conduct the delivery?
• Are adequate arrangements available in case of an
emergency?
• What is the arrangement for transportation?
• If required, what is the arrangement for blood?
• What is the arrangement for any neonatal
resuscitation?
• Who is going to be the attendant with the mother
and child?
• Is financial support available?

34. Objectives of Intra-natal Care
• Intranatal care (AMC-N)
• Thorough Asepsis (“The Five Cleans” - clean hands, surface,
blade, cord, tie)
• Minimum injury to mother and child
• To deal with any Complications
• Care of the Newborn

35. Institutional delivery
Institutional delivery is a must if there is-
1. Mild pre-eclampsia
2. PPH in the previous pregnancy
3. More than 5 previous births or a primi
4. Previous assisted delivery
5. Maternal age less than 16 years
6. H/o third-degree tear in the previous pregnancy
7. Severe anaemia
8. Severe pre-eclampsia/eclampsia
9. APH
10.Transverse fetal lie or any other Malpresentation
11.Caesarean section in the previous pregnancy
12.Multiple pregnancies
13.Premature or pre-labour rupture of membranes (PROM)
14.Medical illnesses such as diabetes mellitus, heart disease, asthma, etc.
15.Pregnancy in women who are HIV positive

36. • DELIVERY AT REFERRAL CENTRE
1. Prior delivery by caesarean.
2. Age less than 14 years.
3. Transverse lie or other obvious malpresentation within one month
of expected delivery.
4. Obvious multiple pregnancy.
5. Tubal ligation or IUD desired immediately after delivery.
6. Documented third degree tear.
7. History of or current vaginal bleeding or other complication during this
pregnancy.
DELIVERY AT PHC IF------
■ First birth.
■ Last baby born dead or died in first day.
■ Age less than 16 years.
■ More than six previous births.
■ Prior delivery with heavy bleeding.
■ Prior delivery with convulsions.
■ Prior delivery by forceps or vacuum.
■ HIV-positive woman.
AS PREFERRED BY WOMAN if ---
■ None of the above.

37. Role of Birth Attendant/ Midwife
• Explain all the procedures
• Praise the woman, encourage her and reassure her that things
are going well.
• Encourage the woman to bathe or wash herself and her
genitals at the onset of labour.
• Always wash your hands with soap and water before
examining the woman
• Ensure cleanliness of the birthing area.
• Enema should be given only when needed.
• Encourage the woman to empty her bladder frequently.
• Non-pharmacological methods of relieving pain during labour

38. PARTOGRAPH
visual graphic account of the salient features of labour.
RECORD OF-
Contractions, their intensity, frequency and duration are recorded.
Cervical dilatation and effacement are recorded.
FHS, amniotic fluid, vitals of the mother, fluid balance, drugs administered
etc.
Readily available tool for decision making.
Advantages:
1. reduced prolonged labours and instrumental deliveries;
2. higher APGAR scores and
3. lower perinatal mortality.
WHO modified Partograph- No latent phase

40. Domiciliary Care
• Pre-requisites for a safe home delivery-
• If the woman has chosen to deliver at home,
all family members must be explained that
safe and clean delivery with the skilled birth
attendant is ensured.
• A disposable delivery kit must be provided
and instructions on its usage are given

41. Home delivery with a skilled attendant
Advise how to prepare
Review the following with her:
■ Who will be the companion during labour and delivery?
■ Who will be close by for at least 24 hours after delivery?
■ Who will help to care for her home and other children?
■ Advise to call the skilled attendant at the first signs of labour.
■ Advise to have her home-based maternal record ready.
■ Advise to ask for help from the community, if needed I2 .
Explain supplies needed for home delivery
■ Warm spot for the birth with a clean surface or a clean cloth.
■ Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for
cleaning the baby’s eyes, for the birth attendant to wash and dry her hands, for
use as sanitary pads.
■ Blankets.
■ Buckets of clean water and some way to heat this water.
■ Soap.
■ Bowls: 2 for washing and 1 for the placenta.
■ Plastic for wrapping the placenta.

42. Home Delivery without Skilled Birth Attendant
1. To ensure that the attendant should wash her hands with clean water and
soap before/after touching mother/baby. She should also keep her nails
clean.
2. To, after delivery, place the baby on the mother’s chest with skin-to-skin
contact and wipe the baby’s eyes using a clean cloth for each eye.
3. To cover the mother and the baby.
4. To use the ties and razor blade from the disposable delivery kit to tie and cut
the cord. The cord is cut when it stops pulsating.
5. To dry the baby after cutting the cord. To wipe clean but not bathe the baby
until after 6 hours.
6. To ensure a clean delivery surface for the birth

43. 7. To wait for the placenta to deliver on its own.
8. To start breastfeeding when the baby shows signs of
readiness, within the first hour after birth.
9. To NOT leave the mother alone for the first 24 hours.
10. To keep the mother and baby warm. To dress or wrap the
baby, including the baby’s head.
11. To dispose of the placenta in a correct, safe and culturally
appropriate manner (burn or burry).

44. Advise to avoid harmful practices
For example:
1. Not to use local medications to hasten labour.
2. Not to wait for waters to stop before going to health facility.
3. NOT to insert any substances into the vagina during labour or
after delivery.
4. NOT to push on the abdomen during labour or delivery.
5. NOT to pull on the cord to deliver the placenta.
6. NOT to put ashes, cow dung or other substance on umbilical
cord/stump.
7. Encourage helpful traditional practices: