2. Antenatal care By
Dr/ Ayat Masoud Omar

3. Out line Introduction Definition of ANC Goals of antenatal care
Factors affecting mother utilization of ANC
Frequency of antenatal examination
Component of antenatal care

4. Introduction
Every year there are an estimated 200 million pregnancies in the world. Each of these pregnancies is at risk for an adverse outcome for the woman and her infant..
Every minute of every day, a woman dies somewhere as a result of pregnancy or childbirth. This means 1400 women die every day approimately, and for each woman who dies, suffer from long-term illnesses or disabilities.

5. Causes of Maternal Deaths- (maternal mortality)
Direct Causes – 80% Haemorrhage - 24%, Obstructed labour- 8%, Eclampsia -12%, Sepsis - 5% , Unsafe abortion -13%, Other direct causes – 8% (ectopic pregnancy, embolism and anaesthesia-related causes)
Indirect causes - 20%. (E.g. Anaemia, TB, Malaria, HIV/AIDS etc )

6. Timing of Maternal Death •
Antenatal: 24% • Intra-natal: 15% • Postnatal: 61%
While risk can not be totally eliminated, they can be reduced through effective, and acceptable maternity care. To be most effective, health care should begin early in pregnancy and continue at regular intervals

7. So that

8. Safe motherhood program
means ensuring that all women receive the care they need to be safe and healthy through out pregnancy and child birth.
Main Objective of this program :
Support the national goal to reduce MMR and illnesses resulting from complications of pregnancy and childbirth.

10. Definition of ANC
It is a comprehensive medical and psychological supervision of the pregnant women so that the woman will be able to go through pregnancy ,labour and puerperium without complication to woman or her baby

11. Goals of antenatal care
To reduce maternal and perinatal mortality and morbidity rates.
To improve the physical and mental health of women and children.
To prepare the woman for labor, lactation, and care of her infant.
To detect early and treat properly any complicated conditions that could endanger the life or impair the health of the mother or the fetus.

12. Factors affecting mother utilization of ANC
Demographic Factors
Socioeconomic Factors
Psychosocial Factors
Health Services Factors

13. Health care professionals involved in the administration of the prenatal care includes:
(1) Physicians
(2) Nursing personnel
(a) Dietitians.
(b) Laboratory technicians.
(c) Social services.

14. Frequency of antenatal examination
For low risk group:
Every month till 28 weeks, then every 2 weeks till 36 week then every week till the end of pregnancy.
For high risk patients:
Every 2 weeks till 28 week, then every week till 36 week, then hospitalization (or according to the situation).

15. Component of ANC

16. Component of antenatal care
The initial assessment interview can establish the trusting relationship between the nurse and the pregnant woman.
Types of visit
Initial visit/booking
Return visit/follow up

17. Psychological assessment. Nutritional assessment Health education
During the firs visit, assessment and physical examination must be completed. Including:
history.
Physical examination.
Laboratory data.
Psychological assessment.
Nutritional assessment
Health education

18. 1-History
Welcome the woman, and ensure a quite place where she can express concerns and anxiety without being overheard by other people.
Personal and social history:
This include: woman’s name, age, occupation, address, and phone number. marital status, duration of marriage, Religion , Nationality and language, Housing and finance

19. Menstrual history:
A complete menstrual history is important to establish the estimated date of delivery. It includes:
Last menstrual period (LMP).
Age of menarche.
Regularity and frequency of menstrual cycle.
Contraception method.
Any previous treatment of menstrual disorders
Expected date of delivery (EDD) is calculated as followed:
1st day of LMP −3 months +7 days, and change the year.
Example: calculate EDD if LMP was august 30, 2007.
= June 6, 2008.

20. Current problems with pregnancy :
Ask the patient if she has any current problem, such as:
- Nausea & vomiting.
Abdominal pain.
Headache.
Urinary complaints.
Vaginal bleeding.
Edema.
Backache.
Heartburn.
Constipation.

21. Obstetrical history:
**This provides essential information about the previous pregnancies that may alert the care provider to possible problems in the present pregnancy. Which includes:
Gravida, para, abortion, and living children.
Weight of infant at birth & length of gestation.
Labor experience, type of delivery, location of birth, and type of anesthesia.
Maternal or infant complications.

22. Medical history :
Chronic condition such as diabetes mellitus, hypertension, and renal disease can affect the outcome of the pregnancy and must be investigated.
Surgical history
Prior operation
Previous operations such as cesarean section, genital repair, and cervical cerclage.
Accidents involving injury of the bony pelvis

23. Family history:
Family history provides valuable information about the general health of the family, and it may
reveal information about pattern of genetic or congenital anomalies.
Including:
D.M.
Hypertension.
Heart disease.
Cancer.
Anemia.

24. 2-Physical examination
Physical examination is important to:
detect previously undiagnosed physical problems that may affect the pregnancy outcome.
and to establish baseline levels that will guide the treatment of the expectant mother and fetus throughout pregnancy.

25. General Examination
It should be started from the moment the pregnant woman walks into the examination room.
Examine general appearance:
Observe the woman for body build and gait
The face is observed for skin color as pallor and pigmentation as chloasma.
Observe the eyes for edema of the eyelids and color of conjunctiva.
Healthy eyes are bright and clear.

26. Vital signs:
Respiratory rate:
Blood pressure:
Pulse
Temperature:

27. Cardiovascular system:
Venous congestion:
Which can develop into varicosities, venous congestion most commonly noted in the legs, vulva, and rectum.
Edema:
Edema of the extremities or face necessitates further assessment for PIH

28. Musculoskeletal system
Posture and gait:
Body mechanics and changes in posture and gait should be addressed. Body mechanics during pregnancy may produce strain on the muscles of the lower back and legs.

29. Height & weight:
An initial weight is needed to establish a baseline for weight gain throughout pregnancy.
Preconception:
Wt. lower than 45kg, or Ht. under 150 cm is associated with preterm labor, and low birth weight infant.
Wt. higher than 90 kg is associated with increased incidence of gestational diabetes, PIH, cesarean birth, and postpartum infection.
Recommendation for weight gain during pregnancy are often made based on the woman’s body mass index.

30. Pelvic measurement:
to determine whether the diameters are adequate to permit vaginal delivery.

31. Abdominal examination: , inspection, auscultation and palpation
Observe the neck for enlarged thyroid gland and , congested neck vein
Abdominal examination:
, inspection, auscultation and palpation

32. Abdominal examination:

33. Neurological system
Deep tendon reflexes should be evaluated because hyperreflexia is associated with complications of pregnancy.

34. Skin Pallor of the skin my indicate anemia.
Jaundice may indicate hepatic disease.
Chloasma and linea nigra related to pregnancy.
Striae graviderum should be noted.
Nail beds should be pink with instant capillary return.

35. Legs:
* Legs should be noted for edema., varicose veins
* The calf must be observed deep vein thrombosis.
* The legs should be observed for unequal length or may be an indication of pelvic abnormalities.

36. Breast
Assess breast size, symmetry, condition of nipple, and the presence of colostrum.

37. Gastrointestinal systems
Mouth:
The gum may be red, tender, edematous as a result of the effects of increased estrogen. Observe the mouth for:
Dryness or cyanosis of the lips.
Gingivitis of the gums.
Septic focus or caries of the teeth
Intestine:
Assess for the bowel sound.
Assess for constipation or diarrhea.

38. Vaginal discharge:
* Ask the woman about any increase or change of vaginal discharge.
Report to the obstetrician any mucoid loss before the 37th week of pregnancy.
Vaginal bleeding
* Vaginal bleeding at any time during pregnancy should be reported to the obstetrician to investigate its origin.

39. 3-Laboratory data Test Purpose Blood group To determine blood type.
Hgb & Hct
To detect anemia.
Rubella
To determine immunity
Urine analysis
To detect infection or renal disease. protein, glucose, and ketones
Glucose
To screen for gestational diabetes.

40. Ultrasound Is performed to: estimate the gestational age.
Check amniotic fluid volume.
Check the position of the placenta.
Detect the multifetal pregnancy.
The position of the baby.

41. Fetal kick count:
The pregnant woman reports at least 10 movements in 12 hours.
* Absence of fetal movements precedes intrauterine fetal death by 48 hours.

42. Return / subsequent visits:

43.  Services at subsequent visits:
At each subsequent prenatal visit the following assessments are completed:
Weight and blood pressure, which are compared to
baseline values
Urine testing for protein, glucose, ketones, and
Fundal height measurement to assess fetal growth
Assessment for quickening/fetal movement to determine
fetal well-being
Assessment of fetal heart rate (should be 110 to 160 bpm)

44. health education: Follow up:
Advice the mother to follow up according to the schedule of antenatal care that mentioned before, advise the mother to follow up immediately if any danger sings appears, describe the important of follow up to the mother.

45. Health teaching during pregnancy

46. Hygiene:
Daily all over wash is necessary because it is stimulating, refreshing, and relaxing.
Warm shower baths is better than tub bath.
Hot bath should be avoided because they may cause fatigue. &fainting
Regular washing for genital area, axilla, and breast due to increased discharge and sweating.
Vaginal douches should avoided except in case of excessive secretion or infection.

47. Danger signs of pregnancy
Vaginal bleeding including spotting.
Persistent abdominal pain.
Sever & persistent vomiting.
Sudden gush of fluid from vagina.
Absence or decrease fetal movement.
Sever headache.
Edema of hands, face, legs & feet.
Fever above 100 F( greater than 37.7C).
Dizziness, blurred vision, double vision & spots before eyes.
Painful urination.

48. Breast care:
Wear firm, supportive bra with wide straps to spread weight across the shoulder.
Wash breasts with clean tap water (no soap, because that could be drying)..
advise the mother to be mentally prepared for breast feeding
advise the pregnant woman to expresses colostrums during the last trimester of pregnancy to prevent congestion.

49. Dental care:
The teeth should be brushed carefully in the morning and after every meal.
Encourage the woman to see her dentist regularly for routine examination & cleaning.
Encourage the woman to snack on nutritious foods, such as fresh fruit & vegetables to avoid sugar coming in contact with the teeth.
A tooth can be extracted during pregnancy, but local anesthesia is recommended.

50. Dressing:
Woman should avoid wearing tight cloths on the legs, because these could impede lower extremity circulation.
Suggest wearing shoes with a moderate to low heel to minimize backache.
Loose, and light clothes are the most comfortable.

51. Travel: Many women have questions about travel during pregnancy.
Early in normal pregnancy, there are no restrictions.
Late in pregnancy, travel plans should take into consideration the possibility of early labor.

52. Sexual activity:
Sexual intercourse is allowed with moderation, is absolutely safe and normal unless specific problem exist such as: vaginal bleeding or ruptured membrane.
If a woman has a history of abortion, she should avoid sexual intercourse in the early months of pregnancy.

53. Exercises:
Exercise should be simple. Walking is ideal, but long period of walking should be avoided.
The pregnant woman should avoid lifting heavy weights such as: mattresses furniture, as it may lead to abortion.
She should avoid long period of standing because it predisposes her to varicose vein.
She should avoid setting with legs crossed because it will impede circulation.

54. Sleep:
The pregnant woman should lie down to relax or sleep for 1 or 2 hours during the afternoon.
At least 8 hours sleep should be obtained every night & increased towards term,
Advise woman to use natural sedatives such as: warm bath & glass of worm milk.

55. A good sleeping position is sims’ position,.
avoid resting in supine position, as supine hypotension syndrome can develop.

56. Immunization
the nurse instructs the woman to receive immunization against -tetanus to prevent the risk for her and her fetus. Live attenuated vaccines are contraindicated.
Also, it is important that every pregnant mother should receive a tetanus vaccination card with her first tetanus dose and keep it to record subsequent doses

57. Dose
Given
Protection
Immunity
1st Dose
After the 3rd month 0%
2nd Dose
At least 4 weeks after the first shot and 2 weeks before delivery
80%
3 years
3rd Dose
6months after the 2nd dose
Or during the next pregnancy ( within 5 years)
95%
5 years
4th Dose
1 year after the 3rd Dose
Or During the next pregnancy ( within 5 years)
99%
10 years
5th Dose
- 1 year after the 4th Dose
Lifelong

58. Special habits:
Coffee and tea are minimized and smoking is avoided, smoking may result in
Intrauterine growth retardation (IUGR) or premature labor.

59. Diet:
It should be
nutritious
balanced
light
easily digestible
rich in protein, mineral and vitamin
with woman’s choice

60. Daily requirement in pregnancy about 2500 calories.
- Women should be advised to eat more vegetables, fruits, proteins, and vitamins and to minimize their intake of fats.
Purpose:
*Growing fetus.
*Maintain mother health.
*Physical strength & vitality in labor.
*Successful lactation.

61. Calories: The requirements increase from 2200 to 2500 Kcal (Kilocalories) calories. The additional energy required is more than 300 Kcal but is reduced by reduced physical activity Proteins: 2 g/kg of body weight daily more protein is needed The majority is required as in animal form as meat, milk, eggs. Milk is the ideal source.

62. Fats and Carbohydrates:
Fried food, cream, sweets chocolates and sugar should be consumed sensibly to avoid excess weight gain.
Vitamins and Minerals Iron:
Daily requirement is mg.
mg are needed if the woman is large, has twins takes iron irregularly.
Calcium and magnesium in multivitamins reduces iron absorption so iron is best given alone iron is not needed in the first 4 months if there is no anemia.

63. Sodium: There is no evidence that excess salt predisposes to pregnancy induced hypertension but some restriction is required if the woman is hypertensive.
Iodine: Deficiency may lead to congenital goitre and maternal goitre.
Calcium: calcium supplementation is unlikely to be of benefit. Two glasses of milk are sufficient(1.2 g/day)

64. Vitamin A: daily requirement in pregnancy is 5000 I.U.
Vitamin A in excess amount is teratogenic
Vitamin B6 deficiency may cause vomiting
Folic acid: about 1mg (1000 mcg) provides very effective prophylaxis against megaloblastic anemia.
Folic acid supplementation before and early in pregnancy significantly reduces the risk of neural tube defects.(400micro gram up to 12 wks
Vitamin B12: Its deficiency only occurs in strict vegetarians.
Vitamin C: Deficiency leads to postpartum hemorrhage and scurvy (100 mg/d).
Vitamin K: Deficiency leads to postpartum hemorrhage and it may cause hemorrhage in the fetus