Antenatal care is the care of the woman during pregnancy.

The primary aim of antenatal care

is to achieve at the end of a pregnancy a healthy mother and a healthy baby. Ideally this care
should begin soon after conception and continue throughout pregnancy. In some countries,
notification of pregnancy is required to bring the mother in the prevention care cycle as early
as possible.
DEFINITION:-
Periodic and regular supervision including examination and advice of a woman during
pregnancy is called Antenatal care. The supervision should be of a regular and periodic
nature in accordance with the need of the individual.
AIMS:-
• To screen the high risk cases.
• To prevent or detect or treat at the earliest any complication.
• To ensure continued medical surveillance and prophylaxis.
• To educate the mother about the physiology of pregnancy and labor by demonstrations,
charts and diagrams so that fear is removed and psychology is improved.
• To discuss with the couple about the place, time and mode of the delivery, provisionally and
care of the newborn.
• To motivate the couple about the need of family planning.
• To advice the mother about breast-feeding, post-natal care and immunization.
CRITERIA OF A NORMAL PREGNANCY:-
Delivery of a single baby in good condition at term (between 38 and 42), with fetal weight of
2.5 kg or more and with no maternal complication.
COMPONENTS OF ANTENATAL CARE:-
Identification of pregnant women’s & importance of early registration.
Diagnosis of pregnancy.
Clinical assessment.
Advice during antenatal visit.
Nutrition.
Management of minor ailments.
Risk assessment & appropriate management.
Management of medical disorders during pregnancy.
Screening for congenital malformations during pregnancy.
Management of Anaemia during pregnancy.
ANTENATAL VISITS:-
 Ideally 13 visits
 7 in first 7 months
 2 in 8th month
 4 in 9th month
 Minimum 4 visits
 I: As soon as the pregnancy is suspected (For registration & first check-up)
 II: 26 weeks
 III: 32 weeks
 IV: 36 weeks
OBJECTIVES AT THE FIRST VISIT:-
(1) To assess the health status of the mother and fetus.
(2) To assess the fetal gestational age and to obtain baseline investigations.
(3) To organize continued obstetric care and risk assessment.
(4) Identification / registration
OBJECTIVES AT THE SECOND VISIT:-
Screen & treat anemia.
Initiate prophylaxis against anemia.
Screen risk factors & medical conditions.
Develop individualized birth plan.
Immunize with tetanus toxoid.
Investigate – Hb, blood group, urine examination, VDRL, Blood grouping.
OBJECTIVES AT THE THIRD VISIT:-
Aimed at the following. Detect:
PIH.
Multiple gestation.
Anemia.
Develop individualized birth plan.
Give TT.
Assess IUGR.
Repeat HB estimation.
OBJECTIVES AT THE FOURTH VISIT:-
Identify foetal & presentation.
Rule out cephalopelvic disproportion in primi gravida.
The above objectives are achieved by the following programme of health care services :
(1) Antenatal visits
Ideally the mother should attend the antenatal clinic once a month during the first 7 months;
twice a month, during the next month; and thereafter, once a week, if everything is normal. A
high proportion of mothers in India are from lower socio-economic group, and many of them
are working women. Attendance at the antenatal clinic may mean loss of daily wages.
Consequently, it is difficult for them to attend the antenatal clinic so often. In these cases, a
minimum of 4 visits covering the entire period of pregnancy should be the target, as shown
below :
The suggested schedule is as follow:
 1st visit - within 12 weeks, preferably as soon as the pregnancy is suspected, for
registration of pregnancy and first antenatal check-up.
 2nd visit between 14 and 26 weeks
 3rd visit - between 28 and 34 weeks.
 4th visit - between 36 weeks and term.
It is advisable for the woman to visit medical officer at the PHC for an antenatal check-up
during the period of 28-34 weeks (3rd visit). Besides this, she may be advised to avail
investigation facilities at the nearest PHC/CHC/FRU. Registration of pregnancy within 12
weeks is the primary responsibility of the ANM. Opportunities such as Village Health
Nutrition Day should be availed to ensure early registration of pregnancy and antenatal
check-up.
Early pregnancy detection is important for the following Reasons:
1. It facilitates proper planning and allows for adequate care to be provided during pregnancy
for both the mother and the foetus.
2. Record the date of last menstrual period and calculate the expected date of delivery.
3. The health status of the mother can be assessed and any medical illness that she might be
suffering from can be detected. Also to obtain and record the baseline information on blood
pressure, weight, haemoglobin etc.
4. It helps in timely detection of complications at an early stage and helps to manage them
appropriately by referral as and where required.
5. It also helps to confirm if the pregnancy is wanted and if not, then refer the women at the
earliest to a 24 hours PHC or FRU that provides safe abortion services. The health personnel
should be alert to the possibility of sex selective abortion as such abortions are illegal.
6. Early detection of pregnancy and provision of care from the initial stage facilitates a good
interpersonal relationship between the care giver and the pregnant woman.
Estimation of number of pregnancies in a specified area and pregnancy tracking
To ensure complete registration, it is essential that the ANM should know the estimated
number of pregnancies to be registered annually in her area. Calculating the expected number
of annual pregnancies in the area will help her judge how good her pregnancy registration is.
In case the number of pregnancies registered is less than that of the estimated pregnancies,
she needs to track down the pregnancies she has missed, with the help of ASHAs and
AWWs. Estimating the number of pregnancies will also help her judge whether she has an
adequate stock of the supplies required to provide routine ANC (such as TT injections, IFA
tablets and ANC record forms} and tackle any complications that arise during this period.
If the number of women registered is less than expected, the ANM should approach
community leaders and key people to ensure that the pregnant women are registered and
come for ANC. ASHA and link worker should visit every house in the. area and ensure that
all pregnant women are registered. Some women may be receiving ANC from the private
sector. Ensure that their names together with the names of the facilities where they are
registered are mentioned in the antenatal register.
The ANM must keep track of all pregnant women in herarea. In case a registered women
does not turn-up for her ANC check-up, ANM must follow her and counsel her for the
regular ANC check-up. An antenatal check-up after a missed appointment should include all
the components of the missed visit(s) as well as those that correspond to the present visit. For
example, the woman should be given her TT injection and supply of IFA tablets, her weight
and blood pressure should be checked besides being screened for complications.
A policy decision has been taken for a name-based tracking system whereby pregnant women
and children can be tracked for their ANCs and immunization along with a feedback system
for the ANM, ASHA etc. This has been done to ensure that all pregnant women receive their
ANCs and PNCs, and children receive full immunization. This will also help in tracking and
ensuring ANC/PNC for missed/left out cases.
PREVENTIVE SERVICES FOR MOTHERS (ANTENATAL CHECK-UP):-
A. The first visit, irrespective of when it occurs, should include the following components :

I. History-taking
During the first visit, a detailed history of the woman needs to be taken to :
(1) Confirm the pregnancy (first visit only);
(2) Identify whether there were complications during any previous pregnancy/confinement
that may have a bearing on the present one;
(3) Identify any current medical surgical or obstetric condition(s) that may complicate the
present pregnancy;
(4) Record the date of 1st day of last menstrual period and calculate the expected date of
delivery by addding 9 months and 7 days to the 1st day of last menstrual period.
(5) Record symptoms indicating complications, e.g. fever, persisting vomiting, abnormal
vaginal discharge or bleeding, palpitation, easy fatigability, breathlessness at rest or on mild
exertion, generalized swelling in the body, severe headache and blurring of vision, burning in
passing urine, decreased or absent foetal movements etc;
(6) History of any current systemic illness, e.g., hypertension, diabetes, heart disease,
tuberculosis, renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract infection,·
STD, HIV/AIDS etc. Record family history of hypertension, diabetes, tuberculosis, and
thalassaemia. Family history of twins or congenital malformation; and
(7) History of drug allergies and habit forming drugs.
II. Physical examination
1. Pallor:
Presence of pallor indicates anaemia. The woman should be examined for pallor at each visit.
Examine woman's conjunctiva, nails, tongue, oral mucosa and palms. Pallor should be co-
related with haemoglobin estimation.
2. Pulse:
The normal pulse rate is 60 to 90 beats per minute. If the pulse rate is persistently low or
high, with or without other symptoms, the woman needs medical attention.
3. Respiratory rate:
It is important to check the respiratory rate, especially if the woman complaints of
breathlessness. Normal respiratory rate is 18-20 breaths per minute.
4. Oedema:
Oedema (swelling), which appears in the evening and disappears in the morning after a full
night's sleep, could be a normal manifestation of pregnancy. Any oedema of the face, hands,
abdominal wall and vulva is abnormal. Oedema can be suspected if a woman complains of
abnormal tightening of any rings on her fingers. She must be referred immediately for further
investigations. If there is oedema in association with high blood pressure, heart disease,
anaemia or proteinuria, the woman should be referred to the medical officer. .

5. Blood pressure:
Measure the woman's blood pressure at every visit. This is important to rule out hypertensive
disorders of pregnancy. Hypertension is diagnosed when two consecutive readings taken four
hours or more apart show the systolic blood pressure to be 140 mmHg or more and/or the
diastolic blood pressure to be 90 mmHg or more. High blood pressure during pregnancy may
signify Pregnancy-Induced Hypertension (PIH) and/or chronic hypertension. If the woman
has high blood pressure, check her urine for the presence of albumin. The presence of
albumin ( + 2) together with high blood pressure is sufficient to categorize her as having pre-
eclampsia. Refer her to the MO immediately. If the diastolic blood pressure of the woman is
above 110 mmHg, it is a danger sign that points towards imminent eclampsia. The urine
albumin should be estimated at the earliest. If it is strongly positive, the woman should be
referred to the FRU IMMEDIATELY. If the woman has high blood pressure but no urine
albumin, she should be referred to the MO at 24x7 PHC. A woman with PIH, pre-eclampsia
or imminent eclampsia requires hospitalization and supervised treatment at a 24-hour
PHC/FRU.
6. Weight:
A pregnant woman's weight should be taken at each visit. The ·weight taken during the first
visit/ registration should be treated as the baseline weight. Normally, a woman should gain 9-
11 kg during her pregnancy. Ideally after the first trimester, a pregnant woman gains around 2
kg every month. If the diet is not adequate, i.e. if the woman is taking less than the required
amount of calories, she might gain only 5-6 kg during her pregnancy. An inadequate dietary
intake can be suspected if the woman gains less than 2 kg per month. She needs to be put on
food supplementation. The help of the AWW should be taken in this matter, especially for
those categories of women who need it the most. Low weight gain usually leads to
Intrauterine Growth Retardation and results in the birth of a baby with a low birth weight.
Excessive weight gain (more than 3 kg in a month) should raise suspicion of preeclampsia,
twins (multiple pregnancy) or diabetes. Take the woman's blood pressure and test her urine
for proteinuria and sugar. If the blood pressure is high and the urine is positive for protein or
sugar, refer her to medical officer.
7. Breast examination:
Observe the size and shape of the nipples for the presence of inverted or flat nipples.
III. Abdonimal examination
Examine the abdomen to monitor the progress of the pregnancy and foetal growth. The
abdominal examination includes the following:
1. Measurement of fundal height:
a. 12 weeks - Uterine fundus just palpable per abdomen.
b. 20 weeks - Fundus flat at the lower border of umbilicus.
c. 36 weeks- Fundus felt at the level of xiphisternum.
The duration of pregnancy should always be expressed in terms of completed weeks. In the
first half of pregnancy the size of the uterus is of the greatest value in confirming the
calculated duration of pregnancy.
2. Foetal heart sounds :
The foetal heart sounds can be heard after 6th month. The rate varies between 120 to 140 per
minute. They are usually best heard in the midline; after the 28th week, their location may
change because of the position and lie of the foetus.
3. Foetal movements :
 Foetal movements can be felt by the examiner after 18-22nd week by gently palpating the
abdomen.
4. Foetal parts :
These can be felt about the 22nd week. After the 28th week, it is possible to distinguish the
head, back and limbs.
5. Multiple pregnancy :
This must be suspected if the uterus is larger than the estimated gestational age or palpation
of multiple foetal parts.
6. Foetal lie and presentation :
Relevant only after 32 weeks of pregnancy.
7. Inspection of abdominal scar or any other relevant abdominal findings.
IV. Assessment of gestation age
Measurement of gestational age has changed over the time. As the dominant effect of
gestational age on survival and long-term impairment has become apparent over the last 30
years, perinatal epidemiology has shifted from measuring birth weight alone to focusing on
gestational age. The most accurate "gold standard" for assessment is routine early ultrasound
assessment together with foetal measurements ideally in the first trimester. Gestational age
assessment based on the date of last menstrual period (LMP) was previously the most
widespread method used and remains the only available method in many settings. Many
countries now use "best obstetric estimate", combining ultrasound and LMP as an approach
to estimate gestational age. It can have a large impact on the number of preterm births
reported.
Any method using ultrasound requires skilled technicians, equipment and for maximum
accuracy, first trimester antenatal clinic attendance. These are not common in low income
settings, where majority of preterm births occur. Alternative approaches to LMP in these
settings include fundal height, clinical assessment of the newborn after birth or birth weight
as a surrogate.
V. Laboratory investigations
The following laboratory investigations are carried out at the facilities indicated below :
a. At the sub-centre :
Pregnancy detection test
- Haemoglobin examination
- Urine test for presence of albumin and sugar
- Rapid malaria test.
b. At the PHC/CHC/FRU:
- Blood group, including Rh factor
- VDRL/RPR
- HIV testing
- Rapid malaria test (if unavailable at SC)
- Blood sugar testing
- HBsAg for hepatitis B infection.
Essential components of every antenatal check-up :
1. Take the patient's history.
2. Conduct a physical examination-measure the weight, blood pressure and respiratory rate
and check for pallor and oedema.
3. Conduct abdominal palpation for foetal growth, foetal lie and auscultation of foetal heart
sound according to the stage of pregnancy.
4. Carry out laboratory investigations, such as haemoglobin estimation and urine tests for
sugar and proteins.
Interventions and counselling·
1. Iron and folic acid supplementation and medication as needed
2. Immunization against tetanus
3. Group or individual instruction on nutrition, family planning, self care, delivery and
parenthood
4. Home visiting by a female health worker/trained dai
5. Referral services, where necessary.
6. Inform the woman about Janani Suraksha Yojana and other incentives offered by the
government.
RISK APPROACH
The central purpose of antenatal care is to identify "high risk" cases (as early as possible)
from a large group of antenatal mothers and arrange for them skilled care, while continuing to
provide appropriate care for all mothers.
These cases comprise the following :
1. Elderly primi (30 years and over)
2. Short statured primi (140 cm and below)
3. Malpresentations, viz breech, transverse lie, etc.
4. Antepartum haemorrhage, threatened abortion
5. Pre-eclampsia and eclampsia
6. Anaemia
7. Twins, hydramnios
8. Previous still-birth, intrauterine death, manual removal of placenta
9. Elderly grand multiparas
10. Prolonged pregnancy (14 days-after expected date of delivery)
11. History of previous caesarean or instrumental delivery
12. Pregnancy associated with general diseases, viz. cardiovascular disease, kidney disease,
diabetes, tuberculosis, liver disease, malaria, convulsions, asthma, HIV, RT!, ST!, etc.
13. Treatment for infertility.
14. Three or more spontaneous consecutive abortions.
The "risk approach" is a managerial tool for improved MCH care. Its purpose is to provide
better services for all, but with special attention to those who need them most. Inherent in this
approach is maximum utilization of all resources, including some human resources that are
not conventionally involved in such care - traditional birth attendants, community health
workers, women's groups, for example. The risk strategy is expeded 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.
MAINTENANCE OF RECORDS
A Mother and Child Protection Card should be duly completed for every woman registered. It
contains a registration number, identifying data, previous health history and main health
events etc. The case record should be handed over to the woman. She should be instructed to
bring the record with her during all subsequent check-ups/visits and also to carry it along
with her at time of delivery. This card has been developed jointly by the Ministry of Health
and Family Welfare (MOHFW) and Ministry of Women and Child Development (MOWCD)
to ensure uniformity in record keeping. This will also help the service provider .to know the
details of previous ANCs/PNCs both for routine and emergency care. The information
contained in the card should also be recorded in the antenatal register as per the Health
Management Information System (HMIS) format.

HOME VISITS
Home visiting is the backbone of all MCH services. Even if the expectant mother is attending
the antenatal clinic regularly, it is suggested that she must be paid at least one home visit by
the Health Worker Female or Public Health Nurse. More visits are required if the delivery is
planned at home. The mother is generally relaxed at home. The home visit will win her
confidence. The home visit will provide an opportunity to observe the environmental and
social conditions at home and also an opportunity to give prenatal advice.
(2) Prenatal advice
A major component of antenatal care is antenatal or prenatal advice. The mother is more
receptive to advice concerning herself and her baby at this time than at other times. The
"talking points" should cover not only the specific problems of pregnancy and child-birth but
overflow into family and child health care.
(i) DIET:
Reproduction costs energy. A pregnancy in total duration consumes about 60,000 kcal, over
and above normal metabolic requirements. Lactation demands about 550 kcal a day. Further,
child survival is correlated with birth weight. And birth weight is correlated to the weight
gain of the mother during pregnancy. On an average, a normal healthy woman gains about 9-
11 kg of weight during pregnancy. Several studies have indicated that weight gain of poor
Indian women averaged 6.5 kg during pregnancy. Thus pregnancy imposes the need for
considerable extra calorie and nutrient requirements. If maternal stores of iron are poor (as
may happen after repeated pregnancies) and if enough iron is not available to the mother
during pregnancy, it is possible that foetus may lay down insufficient iron stores. Such a baby
may show a normal haemoglobin at birth, but will lack the stores of iron necessary for rapid
growth and increase in blood volume and muscle mass in the first year of life. Stresses in the
form of malaria and other childhood infections will make the deficiency more acute, and
many infants become severely anaemic during early months of life. A balanced and adequate
diet is therefore, of utmost importance during pregnancy and lactation to meet the increased
needs of the mother, and to prevent "nutritional stress".
(ii) PERSONAL HYGIENE :
(a) Personal cleanliness:
The need to bathe every day and to wear clean clothes should be explained. The hair should
also be kept clean and tidy. (b) Rest and sleep : 8 hours sleep, and at least 2 hours rest after
mid-day meals should be advised. (c) Bowels: Constipation should be avoided by regular
intake of green leafy vegetables, fruits and extra fluids. Purgatives like castor oil should be
avoided to relieve constipation. (d) Exercise: Light household work is advised, but manual
physical labour during late pregnancy may adversely affect the foetus. (e) Smoking: Smoking
should be cut down to a minimum. Expectant mothers who smoke heavily produce babies
much smaller than the average - it is because nicotine has a vasoconstrictor influence in the
uterus and induces a degree of placental insufficiency. The adverse effects of smoking range
from low birth-weight to an increased risk of perinatal death of the infant. Women who
smoke during pregnancy give birth to babies which on an average weigh 170g less at term
than the babies of non-smokers. The perinatal mortality amongst babies whose mothers
smoked during pregnancy is between 10-40 per cent higher than in non-smokers. (f) Alcohol:
Evidence is mounting that alcohol can cause a range of fertility problems in women.
Moderate to heavy drinkers who became pregnant have greater risk of pregnancy loss, and if
they do not abort, their children may have various physical and mental problems. Heavy
drinking has been associated with a fetal syndrome (FAS) which includes intrauterine growth
retardation and developmental delay. More recently, it has been shown that the consumption
of even moderate amount of alcohol during pregnancy is associated with an increased risk of
spontaneous abortion. {g) Dental care: Advice should also be given about oral hygiene. (h)
Sexual intercourse: This should be restricted especially during the last trimester.
(iii) DRUGS :
The use of drugs that are not absolutely essential should be discouraged. Certain drugs taken
by the mother during pregnancy may affect the foetus adversely and thalidomide, a hypnotic
drug, which caused deformed hands and feet of the babies born. The drug proved most
serious when taken between 4 to 8 weeks of pregnancy. Other examples are LSD which is
known to cause chromosomal damage, streptomycin which may cause 8th nerve damage and
deafness in the foetus, iodide-containing preparations which may cause congenital goitre in
the foetus. Corticosteroids may impair foetal growth, sex hormones may produce virilism,
tetracyclines may affect the growth of bones and enamel formation of teeth. Anaesthetic
agents including pethidine administered during labour can have depressant effect on the baby
and delay the onset of effective respiration. Later still in the puerperium, if the mother is
breast-feeding, there are certain drugs which are excreted in breast milk. A great deal of
caution is required in the drug-intake by pregnant women.
(iv) RADIATION :
Exposure to radiation is a positive danger to the developing foetus. The most common source
of radiation is abdominal X-ray during pregnancy. Case cohort studies have shown that
mortality rates from leukaemia and other neoplasms were significantly greater among
children exposed to intrauterine X-ray. This is in addition to congenital malformations such
as microcephaly. The X~ray examination in pregnancy should be carried out only for definite
indications, X-ray dosage kept to minimum. Furthermore, in all women of child-bearing age
among whom there is a possibility of pregnancy, elective X-ray should be avoided in the two
weeks preceeding the menstrual period.
(v) WARNING SIGNS :
The mother should be given clear-cut instructions that she should report immediately in case
of the following warning signals : (a) swelling of the feet (b) fits (c) headache (d) blurring of
the vision (e) bleeding or discharge per vagina, and (f) any other unusual symptoms.
(vi) CHILD CARE :
The art of child care has to be learnt. Special classes are held for mothers attending antenatal
clinics. Mother-craft education consists of nutrition education, advice on hygiene and
childrearing, cooking demonstrations, family planning education, family budgeting, etc.
(3) Specific health protection

(i) ANAEMIA :
Surveys in different parts of India indicate that about 50 to 60 per cent of women belonging
to low socio-economic groups are anaemic in the last trimester of pregnancy. The major
aetiological factors being iron and folic acid deficiencies. It is well known that anaemia per se
is associated with high incidence of premature births, postpartum haemorrhage, puerperal
sepsis and thromboembolic phenomena in the mother. The Government of India has initiated
a programme in which 100 mg of elemental iron and 500 mcg of folic acid are being
distributed daily for 100 days to pregnant women through antenatal clinics, primary health
centres and their subcentres.
(ii) OTHER NUTRITIONAL DEFICIENCIES :
The mother should be protected against other nutritional deficiencies that may occur,
particularly protein, vitamin and mineral especially vit A and iodine deficiency. In some
MCH Centres fresh milk is supplied free of cost to all expectant mothers; where this is not
possible, skimmed milk should be given. Capsules of vitamin A and D are also supplied free
of cost.
{iii) TOXEMIAS OF PREGNANCY :
The presence of albumin in urine and an increase in blood pressure indicates toxaemias of
pregnancy. Their early detection and management are indicated. Efficient antenatal care
minimizes the risk of toxaemias of pregnancy.
(iv) TETANUS :
If the mother was not immunized earlier, 2 doses of adsorbed tetanus toxoid should be given
the first dose at 16-20 weeks and the second dose at 20-24 weeks of pregnancy. The
minimum interval between the 2 doses should be one month. No pregnant woman should be
denied even one dose of tetanus toxoid, if she is seen late in pregnancy. For a woman who
has been immunized earlier, one booster dose will be sufficient. When such a booster has
been given, it will provide necessary cover for subsequent pregnancies, during the next 5
years. It is advised not to inject tetanus toxoid at every successive pregnancy because of the
risk of hyper immunization and side-effects.
(v) SYPHILIS :
Syphilis is an important preventable cause of pregnancy wastage in some countries.
Pregnancies in women with primary and secondary syphilis often end in spontaneous
abortion, stillbirth, perinatal death, or the birth of a child with congenital syphilis. Syphilitic
infection in the pregnant woman is transmissible to the foetus. Neurological damage with
mental retardation is one of the most serious consequences of congenital syphilis. When the
mother is suffering from syphilis, infection of the foetus does not occur before the 4th month
of pregnancy; it is most likely to occur after the 6th month by which time the Langhan's cell
layer has completely atrophied (18). Infection of the foetus is most likely to occur when the
mother is suffering from primary or secondary stages of syphilis than late syphilis. It is
routine procedure in antenatal clinics to test blood for syphilis at the first visit. Since the
mother can subsequently get infected with syphilis, the ideal procedure would be to test blood
for syphilis both early and late in pregnancy. Congenital syphilis is easily preventable. Ten
daily injections of procaine penicillin (600,000 units) are almost always adequate.
(vi) GERMAN MEASLES : The best estimate of the total risk comes from the long-term
prospective study carried out in Great Britain. When rubella was contracted in the first 16
weeks of pregnancy, foetal death or death during the first year of life occurred in the
offspring of 17 per cent of the pregnancies. Among survivors who were followed upto age 8
years, 15 per cent had major defects, of which cataract, deafness and congenital heart
diseases were the most common. Minor defects were found in an additional 16 per cent. It
appears that the risk of all degrees of malformation may remain in the region of 20 per cent
up to the 20th week. Ideally we should prevent infection during pregnancy by preventing and
controlling the disease in the general population. In many countries, this is being attempted
by vaccination of all school-aged children with rubella vaccine. Supplementing the
community control of infection is the vaccination of all women of childbearing age who are
Sero-negative. Before vaccinating, it is advisable that pregnancy be ruled out and effective
contraception be maintained for 8 weeks after vaccination because of the possible risk to the
foetus from the virus.
(vii) Rh STATUS :
The foetal red cells may enter the maternal circulation in a number of different
circumstances, during labour, caesarean section, therapeutic abortion, external cephalic
version, and apparently spontaneously in the late pregnancy. The intrusion of these cells, if
the mother is Rh-negative and the child is Rh-positive, provokes an immune response in her
so that she forms antibodies to Rh which can cross the placenta and produce foetal
haemolysis. The same response may be produced to a greater degree by a transfusion of Rh-
positive blood. In a pregnant woman, isoimmunization mainly occurs during labour, so that
the first child although Rh-positive, is unaffected except where the mother has been already
sensitized. In the second or subsequent pregnancies, if the child is Rh-positive, the mother
will react to the smallest intrusion of foetal cells by producing antibodies to destroy foetal
blood cells causing haemolytic disease in the foetus. Clinically haemolytic disease takes the
form of hydrops foetalis, icterus gravis neonatorum (of which kernicterus is often a sequel)
and congenital haemolytic anaemia. It is a routine procedure in antenatal clinics to test blood
for Rhesus type in early pregnancy. If the woman is Rh-negative and the husband is Rh-
positive, she is kept under surveillance for determination of Rh-antibody levels during
antenatal care. The blood should be further examined at 28 weeks and 34-36 weeks of
gestation for antibodies. Rh anti-D immunoglobulin should be given at 28 weeks of gestation
so that sensitization during the first pregnancy can be prevented. If the baby is Rh-positive,
the Rh anti D immunoglobulin is given again within 72 hours of delivery. It should also be
given after abortion. Post maturity should be avoided. Whenever there is evidence of
haemolytic process in foetus-in-utero, the mother should be shifted to an equipped centre
specialized to deal with Rh problems. The incidence of haemolytic disease due to Rh factor in
India is estimated to be approximately one for every 400 to 500 live births.
(viii) HIV INFECTION·:
HIV may pass from an infected mother to her foetus, through the placenta or to her infant
during delivery or by breast-feeding. About one-third of the children of HIV-positive mothers
get infected through this route. The risk of transmission is higher if the mother is newly
infected or if she has already developed AIDS. Voluntary prenatal testing for HIV infection
should be done as early in pregnancy as possible for pregnant women who are at great risk (if
they or their partner has a number of sexual partners; has a sexually transmitted disease; uses
illicit injectable drugs etc.). Universal confidential voluntary screening of pregnant women in
high-prevalence areas may allow infected women to choose therapeutic abortion, make an
informed decision on breast-feeding, or receive appropriate care. Screening should not be
used as a substitute for primary prevention through community-wide education on safe sexual
practice, making condoms readily available and preventing parenteral transmission (20).
(ix) HEPATITIS B INFECTION :
Spread of infection from HBV carrier mothers to their babies appears to be a factor for the
high prevalence of HBV infection in some regions. The mechanism of perinatal infection is
uncertain. Most infections appear to occur at birth. Transmission of the virus to the baby after
delivery is likely if both surface antigen and e antigen are positive. Vertical transmission can
be blocked by immediate post-delivery administration of B immunoglobulin and hepatitis B
vaccine.
(x) PRENATAL GENETIC SCREENING :
Prenatal genetic screening includes screening for chromosomal abnormalities associated with
serious birth defects, screening for direct evidence of congenital structural anomalies, and
screening for haemoglobinopathies and other inherited conditions detectable by biochemical
assay. Universal genetic screening abnormalities and for direct evidence of structural
anomalies is performed in pregnancy in order to make the option of therapeutic abortion
available when severe defects are detected. Typical examples are screening for trisomy 21
(Down's syndrome) and severe neural tube defects. Women aged 35 years and above, and
those who already have an afflicted child are at higher risk.
(4) Mental preparation
Antenatal care does not mean only palpation, blood and urine examination and pelvic
measurements. These are no doubt important aspects of antenatal care. Mental preparation is
as important as physical or material preparation. Sufficient time and opportunity must be
given to the expectant mothers to have a free and frank talk on all aspects of pregnancy and
delivery. This will go a long way in removing her fears about confinement. The "mothercraft"
classes at the MCH Centres help a great deal in achieving this objective.
(5) Family planning
Family planning is related to every phase of the maternity cycle. The mother is
psychologically more receptive to advice on family planning than at other times. Educational
and motivational efforts must be initiated during the antenatal period. If the mother has had 2
or more children, she should be motivated for puerperal sterilization. In this connection, the
All India Postpartum Programme services are available to all expectant mothers in India.
(6) Paediatric component
It is suggested that a paediatrician should be in attendance at all antenatal clinics to pay
attention to the under-fives accompanying the mothers.
ROLE OF NURSE IN PRENATAL CARE:-
1. REGISTRATION- The nurse has to do registration of the prenatal mother. so that to assess
the following condition-
 To assess the health status
 To identify and manage high risk cases
 To estimate EDD more accurately
 To give the first dose of TT (after 12 weeks)
 To help the woman for an early and safe abortion (MTP) if it is required by her
 To start the regular dose of folic acid during the first trimester
2. PRENATAL SERVICES FOR MOTHERS-
Health history
 To identify any complications during previous pregnancies
 To identify any medical/obstetric condition(s) that may complicate this
pregnancy
 Age of the woman • Complications when <16 years/>40 year
 Order of the pregnancy- Ideally should be >3 years
 Symptoms indicating discomfort:-
o nausea and vomiting
o heartburn
o constipation
o frequency of urination
 Symptoms indicating that a complication may be arising:-
o fever
o vaginal discharge/bleeding
o palpitations
o breathlessness at rest
o generalized swelling of the body
o puffiness of the face
o oliguria
o decreased or absent foetal movements
 Previous pregnancies/Obstetric history
o Number of earlier pregnancies/abortions/deliveries
o Number of premature birth(s)/stillbirth(s)/neonatal deaths
o Hypertensive disorders of pregnancy (history of convulsions)
o Prolonged/obstructed labour Malpresentation
o Modes of deliveries(normal/assisted/caesarean section)
o Birth weight of the previous baby
 o Any surgery on the reproductive tract
o Iso-immunization (Rh-ve) in the previous pregnancy
o History of any systemic illness
 Hypertension
 Diabetes
 Heart Disease
 Tuberculosis
 Renal Disease
 Convulsions
 Asthma
 Rashes
 Jaundice
 Family history of systemic illness
 Delivery of twins or delivery of an infant with congenital malformation
 • History of drug intake or allergies
 • History of intake of habit-forming substances (tobacco, alcohol)
Physical examination
3. INVESTIGATION-
The nurse should undergo following investigation-
 CBC Blood grouping & Rh typing
 Urine R/E
 RBS
 VDRL
 HBS Ag
 Ultrasound
 Urine/Stool/Blood(Count)/Hb/Serological/Blood group(Rh also)
 Pap test(if facilities)/ Chest X-Ray and Gonorrhea test(if needed)
4. MAINTENANCE OF RECORDS
5. CALCULATION OF EDD
6. ANTENATAL ADVICE:-
  DIET:-
Diet should be: 1. Nutritious 2. Balanced 3. Light 4. Easily digestible 5. Rich in protein,
mineral and vitamin. 6. Iron & folic acid supplementation.
 REST & SLEEP:-
o Night 8 hours ,Day 2 hours
o Avoid heavy work (especially lifting heavy weights)
o Avoid the supine position (especially in late pregnancy, if it is necessary, a
small pillow under the lower back at the level of the pelvis should be used)
 BOWEL:-
Regular bowel movement may be facilitated by regulation of diet, taking plenty fluid,
vegetable and milk.
 ABSISTENCE:-
Should be avoided in • 1st trimester • last 6 weeks
 TRAVELLING:-
o Travelling by vehicles having jerks is better to be avoided, especially in 1st
trimester and last 6 weeks.
o Air travelling is contraindicated in Placenta praevia, Preeclampsia, Severe
anemia and sickle cell disease.
 IMMUNIZATION:-
o Tetanus toxoid is to be given as a routine. Immunization against tetanus not
only protects the mother but also the neonates. In unprotected women, 0.5 mL
tetanus toxoid is given intramuscularly at 6 weeks interval for 2 such, the first
one to be given between 16 and 24 weeks. Women who are immunized in the
past, a booster dose of 0.5 mL IM is given in the last trimester.
o Live virus vaccines (rubella, measles, mumps, varicella, yellow fever) are
contraindicated.
o Rabies, hepatitis A and B vaccines, toxoids can be given.
 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.
 PERSONAL HYGIENE:-
The nurse should advice the mother regarding the personal hygiene and its importance.
  RADIATION:-
The nurse should advice the mother to avoid the X-rays.
 DRUGS:-
Sedative, Anticoagulant, Hormones & Antibiotics Should Be Avoided.
 DANGER/WARNING SIGNS:-
o High fever
o Pain
o feels too weak to get out of bed
o Fast/difficult breathing
o Decreased or absent foetal movements
o Excessive vomiting (woman is unable to take food/fluids)
o Any bleeding P/V during pregnancy
o Severe headache with blurred vision
o Convulsions or loss of consciousness
 Health education about Breast feeding, Nutrition, Family planning, postnatal exercises
and Child care should be given.
 GENERAL ADVICE:-
o The patient should be persuaded to attend for antenatal check-up positively on
the schedule date of visit.
o She is instructed to report to 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.
o 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 1 hour—suggestive of onset of labor.
 Sudden gush of watery fluid per vagina- suggestive of premature
rupture of the membranes.
 Active vaginal bleeding, however slight it may be.

IMPORTANCE OF ANTENATAL CARE:-

 High risk cases are identified.
 Medical disorders and obstetric complications are sorted out at the earliest.
  Pregnancy is regularly supervised: - Casual antenatal visit or inadequate care is
worse than no care at all. Efficacy of prenatal care depends on the quality of care
given to the woman.

 Antenatal care is said to be the strategy; the intranatal care is the tactic in
obstetrics. One is indispensable from the other to achieve a good result. Care should
be thorough and based on individual woman’s need.
 Acceptance of advice: During pregnancy, advice regarding diet, drugs, and family
planning guidance and immunization schedule are better followed than in the
nonpregnant state.
 It is an opportunity to make the patient realize that childbirth is a physiological
process and to boost up the psychology so that the patient finds herself confident
during the ordeal of labor.

 The net effect is marked reduction in maternal mortality and morbidity.

Similarly, there is significant reduction in perinatal mortality and morbidity.

CONCLUSION:-
The value of antenatal supervision is so much tested and recognized that it is needless to
stress its importance. A successful obstetric outcome depends on continued careful
supervision which starts in pregnancy and ends in puerperal period.