ANTENATAL CARE,MINOR DISORDERS IN PREGNANCY & ITS MANAGMENT

2.  ANTENATAL CARE/ADVICE/MINOR DISORDERS OF
PREGNANCY
 ANTENATAL EXERCISES/PRENATAL
COUNSELLING

3.  Antenatal care is an excellent
example of preventive medicine.
 practice of antenatal care is almost
a century old; Haig Fergusson first
established an antenatal clinic in
Edinburgh in 1913 and was later
followed by Janet Campbell in
London (1926).
 The prenatal period is a preparatory
time for the mother to prepare
herself both physically and
psychologically.

4. Nullipara: - is one who has never
conceived or who has not carried her
pregnancy beyond 28 weeks of fetal
viability.
Primigravida: - is one who is pregnant
for the first time.
Primipara: -is one who has delivered one
viable child.

5. Mutigravida: - is a pregnant woman
who has conceived before. She may
have had a full term, preterm deliveries
or abortion.
Multipara: - is one who has two or
more children.
Grandmultipara: - is one who has
given birth to four or more children.

6. Abortion: - Termination of pregnancy
before the fetus is viable and capable
of extrauterine existence.
Conjugate: - An important diameter of
the pelvis, measured from the center of
the promontory of the sacrum to the
back of the symphysis pubis.

7. Ischial Spines: - Two relatively
sharp, bony projections protruding
into the pelvic outlet from the Ischial
bone that form the lower lateral
border of the pelvis. They are used
when determining the progress of the
fetus down the birth canal.

8. Ischial Tuberosities: - A
major bony, sitting support;
important in measuring a
transverse diameter of the
pelvis.
Miscarriage: - Spontaneous
abortion; lay term usually
referring specifically to the
loss of the fetus between the
fourth month and viability.

9. Placenta Abruptio: -
Premature separation
of a normally,
implanted placenta.
 Placenta Previa: - A
placenta that is
implanted in the lower
uterine segment so
that it adjoins or
covers the internal os
of the cervix.

10. Term Pregnancy: - A
gestation of 38 to 42
weeks.
Toxoplasmosis: - A
congenital disease
characterized by lesions
of the central nervous
system which may lead to
blindness, brain defects.

11.  “Antenatal or prenatal
care refers to the
medical and nursing
supervision and care
given to the pregnant
patient during the
period between
conception and the
onset of labor.”

12. During the initial visit,
the objectives are
directed toward
confirming a diagnosis
of pregnancy and
beginning the process
of data collection to act
as a basis for ongoing
prenatal care. These
objectives include:

13. To prevent pregnancy complication.
To maintain the health of the pregnant
woman throughout pregnancy.
To diagnose and treat maternal and
obstetric complications.
To refer complicated and high risk
pregnancies to the referral centre or
the tertiary centre as the need may
be.

14. To screen a pregnant woman for
anemia, sexually transmitted disease
(STD), systemic disease and cervical
cancer.
To screen the fetus for fetal
anomalies and terminate the
pregnancy if the fetus is grossly
abnormal. To monitor the fetus
growth and its wellbeing and to
maintain fetal health.

15. To decide the time, mode, and place
of delivery.
To provide guidance in contraception,
spacing of births and post-coital
contraception. To guide the parents in
infant and child care with regard to
nutrition, immunization and breast
feedings.

16. Modification of those complications
that may develop.
Support of the patient's goal to carry
the infant to term and deliver a
healthy baby.
Education of the mother-to-be and
her family for the parenting role.
Inclusion of the family as a whole in
the concept of "family-centered
maternity care."

17. Careful history taking.
General examination
Midwife examination
Obstetric examination
Advice to the pregnant
woman.

18.  IDENTIFYING INFORMATION OF CLIENT
 PAST INFORMATION
 PERSONAL INFORMATION
 FAMILY INFORMATION
 HEALTH INFORMATION
 MENSTRUAL INFORMATION
 OBSTETRIC INFORMATION

19.  Temperature
 Pulse
 Respiration
 Blood pressure
 Height
 Weight
 Urinanlysis
 Blood tests
 ABO Blood groups & Rhesus factor
 Hemoglobin
 Venereal Disease research Laboratory test.
 Human Immunodeficiency Virus
 Rubella Immune status
 Other blood disorders.

20.  General appearance
 Breast evaluation
 Elimination
 Vaginal discharge
 Vaginal bleeding
 Oedema
 Varicosities

21. ABDOMINAL INSPECTION.
Shape of the uterus
Fetal movement
Contour of the abdominal wall
Skin changes

22. ABDOMINAL PALPATION
Estimating the period of
gestation
Fundal palpation
Lateral palpation
Pelvic palpation
Pawlik’s palpation

23.  Vaginal examination
 Routine Investigations
 Special investigations
Serological tests
Maternal serum alpha feto
protein
Ultra sound examination

24.  FINDINGS OF FIRST STAGE OF LABOUR
 Gestational age
 Lie
 Attitude
 Presentation
 Denominator
 Position
 Engagement
 Presenting part

25.  PRINCIPLES :-
 To impress the patient about the importance of
regular check-up
 To maintain improve health status to the
optimum till delivery.
 To improve and tone up the psychology and to
remove the fear
 ADVICE FOR DIET
 ADVICE FOR ANTENATAL HYGIENE
 IMMUNIZATION
 GENERAL ADVICE

26.  Identification of high risk factors
 Base level health status
 Rubella and hepatitis immunization
 Folic acid supplementation
 Maternal health is optimised preconceptionally.
 Fear of the incoming pregnancy
 Patient with medical complications
 Drugs used before pregnancy
 Inheritable genetic diseases
 Importance of prenatal diagnosis
 Inheritable genetic diseases
 Couples with history of recurrent fetal loss

27. The diet during pregnancy should
be adequate to provide:
The maintenance of maternal
health,
The needs of the growing fetus,
Successful lactation during
pregnancy there is increased
calories requirement due to
increased growth of the maternal
tissues, fetus, placenta and
increased BMR,

28. She should eat adequate so as to
gain the optimum weight(11 kg).
1litre of milk (1 litre of milk
contains about 1gm calcium),
plenty of green vegetables and
fruits. The amount of salt should
be of sufficient amount to make
the food tasty. Protein should be
first class containing all the amino
acids and majority of the fat
should be animal type which
contains vitamins.

29. Hard and strenuous work
should be avoided specially
in the first trimester and last
4 weeks.
Patient should be in bed for
about 10 hours (8 hours at
night and 2 hours at noon)
especially in the last 6
weeks.
In late pregnancy lateral
posture is more comfortable.

30. There is of constipation
during pregnancy which may
be related with backache and
abdominal discomfort.
Regular bowel movement may
be facilitate regulation of diet
taking plenty of fluids,
vegetable and milk laxative at
bed time or Isafgul 2 tea
spoons at bed time to be taken
with warm milk.

31. The patient should take
bath daily but be careful
against slipping in the
bathroom due to imbalance.

32.  The patient should wear loose but
comfortable garments.
 As woman’s tummy gets bigger
often don't just need more width to
go around it. Its need length to
cover it up.
 Also neck and arms are not
necessarily going to grow in
proportion to match

33. High heel shoes should
better be avoided in
advanced pregnancy
when the centre of
balance may be alters.

34. The dentist should be
consulted at the earliest, if
necessary.
This will facilitate
extraction or filling of the
caries tooth, if required,
comfortably, in the2nd
trimester, the best time for
such procedure.

35. If the nipples are
anatomically normal,
nothing is to be done
beyond ordinary
cleanliness. If the
nipples are retracted,
correction is to be
done in later months
by manipulation.

36. Coitus should be avoided
during the first trimester
preferably during the 12
weeks of missed periods
and also during the last 6
weeks.
Coitus is avoided if there is
risk of abortion or preterm
labour. Otherwise it is not
harmful.

37. Travel by vehicles having jerks is
better to be avoided specially in first
trimester and the last weeks.
The long journey is preferably being
limited to the second trimester.
Rail route is preferably to bus route.
Travel in pressurized aircraft offers
less risk. Air travel is contraindicated
in cases with placenta Previa, pre-
eclampsia, severe anemia and sickle
cell disease.

38. Heavy smokers have smaller
babies and there is also
more chances of abortion.
Similarly alcohol
consumption is to be
drastically curtailed or
avoided, so as to prevent
fetal maldevelopment or
growth restriction.

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

40. Immunization against tetanus not
only protects the mothers but
also the neonate in unprotected
women, 0.5 ml tetanus toxoids is
given intramuscularly at 6 weeks,
intervals for 2 such, the first one
to be given between 16-24
weeks.
Women who are immunized in
the past, a booster dose of 0.5
ml I.M. is given in the last

41. All most all the drugs
given to the mother will
cross the placenta to
reach the fetus.
Possibility of pregnancy
should be kept in mind
while prescribing drugs
to any women or
reproductive age.

42. Minor disorder is define
as the discomforts which
associated with
pregnancy e.g. nausea
vomiting heart burning etc

43.  Nausea and vomiting
 Backache
 Constipation
 Leg cramps
 Acidity and heartburn
 Varicose vein
 Ankle edema
 Hemorrhoids:
 Breast tenderness
 Urinary frequencies
 Dyspnea
 Broad& round ligament pain
 Vaginal discharge

44. They usually appear following
the first or second missed
period as the result of
hormonal changes and
slowing of peristalsis due to
increase in chorionic gonado –
trophin and subside by the end
of first trimester.
 But some women experience
these symptoms throughout
the pregnancy

45. Advice to move the limbs for
few minutes before getting out
of bed or taking a dry toast or
biscuit before rising from the
bed and avoidance of fatty
foods and liquid in empty
stomach are usually enough to
relieve the symptoms.
plenty of glucose drink usually
cure the condition.

46. Peppermint, tea soothing &
comforting to the gastro intestinal
tract, may give some relief.
Morning sickness should not be
confused with severe nausea &
vomiting (hyper emesis
gravidum), which can causes
severe dehydration, putting the
woman & fetus at risk and
requiring hospitalization

47. The enlarging uterus causes
the woman to change her
posture to maintain her
balance.
Advice woman to wear low
heel shoes,because joints of
pelvis relax during pregnancy
as a result of hormonal
changes, causing lumbosacral
lordosis; changes in posture
also occur as a result of shift in
woman‘s centre of gravity due
to enlarging uterus.

48. Improvement of posture, well
fitted pelvic girdle belt which
corrects the lumbar lordosis
during walking, and rest in firmer
mattress may help by increasing
support to the lower back.
A hard board under the mattress
also can achieve the necessary
firmness.

49. Although backache is a
common discomfort during
pregnancy it needs to be
carefully assed because it
also could signal urinary tract
infection or pre mature labour.
Massaging the back muscles,
analgesics and rest relieve the
pain due to muscle spasm.

50. Atonicity of the gut due to
the effect of progesterone,
relax the bowel, it
diminished physical activity
and pressure of the gravid
uterus on the pelvic colon is
the possible explanations.
Iron supplements also can
contribute to constipation.

51. Increasing intake of fresh
fruits & vegetable, whole
grain cereals, and fluids,
especially water may offer
relief. Exercise especially
walking may be beneficial.
If constipation continues,
the physician may
prescribe a stool softener.

52. Mineral oil interferes with
the absorption of vitamins
A, D, E, K (the fat soluble
vitamins) which could
cause deficiencies in the
woman & fetus.
Enemas are
contraindicated because
they can cause premature
labour.

53. Many women suffer from
painful leg cramps,
especially during the night,
interfering with their rest.
It may be due to deficiency
of serum calcium or
elevation of serum
phosphorus level in the
blood, tension and the
normal stretching of the
muscles & tendons.

54. Simple bed rest or
elevation of the feet can
offer some relief.
Cramping can be
immediately relieved by
straightening the extremity
& bending the foot toward
the knee (dorsiflexion).

55. Massaging the ‘muscle
knot’ may help however, if
there are any signs of
thrombophlebitis (red,
swallow, tender, or warm
he areas) the leg should
be massaged, if this
continues to be a problem
the physician may order
medication specific to the
problem.

56. Supplementary calcium
therapy in tablet or syrup
after the principal meals
may be effective.
Massaging the leg,
application of local heat
and vitamin B1 [30 mg]
daily may be effective.

57. It is s not a “burning or pain
in the heart” but primarily
as the result of the growing
uterus pressing on the
stomach, rising
progesterone levels, and
decreased gastric motility.

58. Teach woman to eat small Meals at more
frequent intervals throughout day because
Cardiac sphincter of stomach relaxes,
causing gastric contents to enter
esophagus; small meals prevent further
pressure.
Instruct woman to sit up for 30 min
following meals because sitting up may
prevent reflux.
Antacid preparations either chewable
tablets or gels after meals can be
prescribed .

59. The legs may ache and feel
‘heavy’ or ‘tired’ .Varicose veins in
the legs and vulva [varicosities] or
rectum [hemorrhoids] may appear
for the first time or aggravate
during pregnancy usually in the
later months.
It is due to obstruction in the
venous return by the pregnant
uterus.

60. For leg varicosities, elastic
crepe bandage during
movements and elevation of
the limbs during rest can give
symptomatic relief.
For maximum benefit, the
stockings should be put on
before getting out of bed in
the morning before the veins
become distended.

61. The nurse cautions the
woman to avoid crossing
her legs because this can
increase pressure on the
lower extremities veins.
Prolonged standing or
sitting also should be
avoided because this
interferes with circulation.
Specific therapy is better
to be avoided.

62. Varicosities usually disappear
following delivery. Instruct the
woman to report any signs of
thrombophlebitis, legs that
are red, tender, swollen or
warm to touch.

63. Varicose veins
occurring in the
rectum are called
hemorrhoids.
It may result from
the increasing
weight of the
uterus pressing
on the rectal
vessels.

64. This causes them to enlarge or
bulge produce pain, itching &
generalized rectal discomfort.
Constipation also can
contribute to the formulating of
the hemorrhoids by making it
necessary to strain during
defecation. May cause bleeding
or may get prolapsed.

65. Increasing use of fluids & fiber in
the diet to prevent constipation
offers some relief. Alternative
use of ice packs & sitz baths
also may bring temporary relief.
 If the hemorrhoids feel hard or
causes rectal bleeding, the
woman needs to notify the
physicians.

66. He/ she order topical ointments
or local anesthetics to relieve the
pain.
Regular use of laxative to keep
the bowel soft, local application
of hydrocortisone ointment and
replacement of the piles if
prolapsed, are essential.
Surgical treatment is better to be
withheld as the condition sharply
improves following delivery.

67. Ankle edema is during
pregnancy and results from
normal sodium & water
retention.
 As the enlarged uterus
pressing on the large veins
in the pelvic region, it
causes decreased venous
return from the lower
extremities contributing to
ankle edema.

68. Excessive fluid retention as evidenced by
market gain in weight or evidences of
pre-eclampsia has to be excluded.
No treatment is required for physiological
edema or orthostatic edema.

69. Edema subsides on rest
with slight elevation of the
limbs, lying on the side
also is helpful.
Caution the woman to
avoid knee high stocking
and panty girdles which
constrict circulation.
Diuretics should not be
prescribed.

70. It is a normal for the pregnant
woman to have increased
vaginal discharge (leucorrhea)
resulting from increased
estrogen levels.
 Normally it is white or
yellowing, any itching, burning
or odor indicates infections.
Irritation can be relieved by
wearing loose cotton or cotton
lined underwear.


71. Instruct the woman to
keep the perineal area
clean and dry.
Instruct the woman to
avoid use of feminine
hygiene deodorant
sprays, tampons. (Even
though she may have
vaginal discharge) and
vaginal douching unless
ordered by the
physicians.

72. Odor indicates
Assurance to the patient
and advice Presence of
any infection
[trichomona, Candida,
bacterial vaginosis]
should be treated with
vaginal application of
metronidazole or
miconazole.

73. Breast, including the
nipples, may become very
tender.
The woman may report
fullness, tingling and
soreness, caused larged
by increased levels of
progesterone and
estrogen.

74. •Instruct the mother to
wear a well-fitted
supportive bra with
wide straps offers some
relief.

75. This condition occurs during the first &
third trimesters because the enlarging
uterus is pressing on the bladder.
During the 2nd trimester the uterus
moves up into the abdominal cavity and
provides temporary relief.
If the woman coughs or sneeze during
the 3rd trimester. However, she may
dribble small amount of urine.

76. perineal pads may be used to
keep undergarments dry if
dribbling becomes a problem.
Instruct the woman to report any
blood in the urine or burning
with urination because urination
infections can develop frequent
during pregnancy.
Encourage adequate fluids
intake 8-10 glasses per day to
prevent dehydration.

77. At the uterus enlarges it
presses up against the
diaphragm, causing
shortness of breath.
This problem occurs
especially during the 3rd
trimester.

78. Maintaining good erect
posture when sitting or
standing helps relieve
dyspnea by increasing
oxygen intake.
Pillows to elevate the
upper torso may help
when sleeping or resting
in a reclining position.

79. As the uterus increases in size
and weight, it stretches and
pulls on the broad and round
ligaments that support it.
Getting up from a sitting or
jerking may causes a sharp pain
in the lower outer aspect of the
abdomen.

80. Resting on the left side with
the knees drawn up close to
the abdomen can offer some
relief.
Sudden position changes
position changes, twisting and
jerking movements should be
avoided.
Localized heat may give
temporary relief.

81. Introduction:
As modern medicine
advances, more and more
information becomes
available regarding how
diseases are inherited, and
parents are given different
choices to make about the
health of their child even
before he/she is born.

82. In some cases, a
prenatal diagnosis
can be made by
testing fetal cells,
amniotic fluid, or
amniotic membranes
to detect fetal
abnormalities in the
womb.

83. “Genetics is the study of the
patterns of inheritance - how traits
and characteristics are passed
from parents to their children.”
Genes are formed from segments
of DNA (deoxyribonucleic acid), the
molecule that encodes genetic
information in the cells.
 DNA controls the structure,
function, and behavior of cells and
can create exact copies of it.

84. The baby's gender is
determined by one of the
chromosome pairs: females
have two X chromosomes and
males have one X and one Y
chromosome
Just as traits such as blue eyes
and curly hair are passed from
genetic information of the
parents to a baby, inherited
diseases and abnormalities are
also passed on.

85. When a gene is abnormal, or
when entire chromosomes are
left off or duplicated, defects in
the structure or function of the
body's organs or systems can
occur.
These mutations or abnormalities
can result in disorders such as
cystic fibrosis, a recessive
genetic disease, or Down
syndrome, an abnormality that
occurs when a baby receives
three #21 chromosomes.

86. Definition:
A "birth defect" is a
health problem or
physical change,
which is present in a
baby at the time
he/she is born.

87. Inheritance:
Inheritance is a word used
to describe a trait given to
baby or "passed on" to baby
from one’s parents.
Examples of inherited traits
would be parent’s eye color
or blood type.

88.  Single gene defects:
 Single gene disorders are genetic
conditions caused by the alteration or
mutation
of one specific gene in the affected p
erson’s DNA.
 Examples of single gene disorders
are cystic fibrosis, sickle cell anemia,
, myotonic dystrophy, and muscular
dystrophy

89. Multifactorial inheritance
means that "many
factors" (Multifactorial)
are involved in causing a
birth defect.
The factors are usually
both genetic and
environmental.

90. Teratogens are an agent,
which can cause a birth defect.
It could be a prescribed
medication, a street drug,
alcohol use, or a disease that
the mother has, which could
increase the chance for the
baby to be born with a birth
defect.

91. Many birth defects can be diagnosed
before birth with special tests (prenatal
diagnosis).
Fetal ultrasound during pregnancy can
also give information about the possibility
of certain birth defects, but ultrasound is
not 100 percent accurate.
A chromosome analysis, whether
performed on a blood sample or cells from
the amniotic fluid or placenta, is over 99.9
percent accurate.

92. Alpha-fetoprotein:-
This blood test measures the
levels of alpha-fetoprotein (AFP),
a protein released by the fetal liver
and found in the mother's blood.
A baby with an open spinal
defect often leaks larger
quantities of AFP into the
amniotic fluid, and in turn, into
the mothers bloodstream)

93. Human chorionic
gonadotropin (HCG) is a
hormone secreted by the
early placental cells.
 High HCG levels may
indicate a fetus with Down
syndrome (a chromosomal
abnormality that includes
mental retardation and
distinct physical features).

94. A hormone produced by the
placenta and by the fetal liver and
adrenal glands. Low levels may
indicate a fetus with Down
syndrome.
Nuchal translucency screening
- an ultrasound test usually
performed in the late first
trimester. Thickening of the area
at the back of the fetal neck may
indicate an increased risk for
Down syndrome or other
chromosomal problems.

95.  A prenatal test that involves
taking a sample of some of the
placental tissue.
 This tissue contains the same
genetic material as the fetus and
can be tested for chromosomal
abnormalities and some other
genetic problems.
 In comparison to amniocentesis,
CVS does not provide
information on neural tube
defects such as spina bifida.

96. A procedure used to obtain
a small sample of the
amniotic fluid that surrounds
the fetus to diagnose
chromosomal disorders and
open neural tube defects
(ONTDs) such as spina
bifida.
Amniocentesis performed
around 15 weeks to 20
weeks of pregnancy.

97. women who are over age 35
years of age at delivery, or
those who have had an
abnormal maternal serum
screening test, indicating an
increased risk for a
chromosomal abnormality or
neural tube defect.

98. A diagnostic technique
that uses high-frequency
sound waves to create an
image of the internal
organs. Many birth
defects can be detected
with ultrasound.

99. Sometimes, birth defects
are not diagnosed until
physical examination of the
baby after birth.
To confirm the physical
findings, a small blood
sample can be taken and
the chromosomes can be
analyzed.

100. However, an older
mother may be at
increased risk for
miscarriage, birth
defects, and pregnancy
complications such as
twins, high blood
pressure, gestational
diabetes, and difficult
labors.

101. Risks for having a baby with a birth
defect from a genetic abnormality
may be increased when:
The parents have another child with
a genetic disorder.
There is a family history of a genetic
disorder.
One parent has a chromosomal
abnormality.
The fetus has abnormalities seen on
ultrasound.

102. Chromosomal
abnormalities
Single gene defects
Multifactorial problems
Teratogenic problems

103. Aneuploidy - more or
fewer chromosomes
than the normal number,
including:
Down syndrome
(trisomy 21) - cells
contain three #21
chromosomes.

104. Turner syndrome - one of
the two sex chromosomes is
not transferred, leaving a
single X chromosome, or 45
totals.
Deletion - part of a
chromosome is missing, or
part of the DNA code is
missing.

105. - when a chromosome
breaks and the piece of
the chromosome turns
upside down and
reattaches itself.
Inversions may or may
not cause birth defects
depending upon their
exact structure.

106. A rearrangement of a
chromosome segment
from one location to
another, either within
the same
chromosome or to
another.

107. Dominant - an abnormality
occurs when only one of the
genes from one parent is
abnormal.
Achondroplasia - imperfect
bone development causing
dwarfism.
Marfan syndrome - a
connective tissue disorder
causing long limbs and heart
defects.

108. An abnormality only
occurs when both
parents have abnormal
genes.
If both parents are
carriers, a baby has a
25 percent chance of
having the disorder.

109.  A disorder of the
glands causing
excess mucus in
the lungs and
problems with
pancreas function
and food
absorption.

110. Sickle cell disease - a
condition causing abnormal red
blood cells.
Tay Sachs disease - an
inherited autosomal recessive
condition that causes a
progressive degeneration of
the central nervous system
which is fatal (usually by age
5).

111. A bleeding disorder
caused by low
levels, or absence
of, a blood protein
that is essential for
clotting.

112. Certain medications (always
consult your physician
before taking any
medications during
pregnancy)
Alcohol
High level radiation
exposure
Lead
Certain infections (such as
rubella)

116.  Annicimma Jacob “A comprehensive
textbook of midwifery”,2nd edition,
published by jaypee brothers, New
delhi,page no:98-102,615-619.
 BT Basvanthappa “A Textbook of Midwifery
& Reproductive Health Nursing”, 1st
edition: 2006, published by Jaypee
Brothers, New Delhi, page no: 209-223.
 Christine neff,Martha Spray, “Introduction
to maternal &child Health
Nursing”, published by lippincot;reprint
1996,Page no: 104-117

117.  D.C.Dutta, “Text Book of Obstetricts”,published by
New Central Book Agency (p) LTD;6th
Edition,2004,Page no: 95-104
 Lowdermilk,Pery, “Maternity woman’s care”,
published by Mosby;8th Edition, page no:349-368
 Neelam Kumari,Shivani Sharma,Dr. Priti Gupta
“Midwifery & Gynecological Nursing”,2010 Edition;
S.Vikas & company (medical Publishers)India.
Page no:145-155
 V.Padubidri, Ela Anand “Textbook of obstretrics”,1st
Published, 2006;BI Publications Pvt.Ltd. Page
no:53-60

118. http://living.oneindia.in/pregnancy-
parenting/prenatal
http://www.pregnancyandchildcare.in
http://www.lauriechamberlin.com
http://en.wikipedia.org/w/index