NORMAL PREGNANCY

Prenatal Care

The woman enters pregnancy with an optimal state of health

Objectives of Prenatal care

Delivery of a healthy infant

Maintenance of health of the mother

Pre-conceptional counseling and care to optimize maternal health-conceptionally

Counsel the couple about pregnancy, its course, outcome well before the time of actual conception. Identify high risk factors by detailed obstetric, medical, family and personal history. Evaluate base level health status such as weight (over weight or under weight), blood pressure - and treat appropriately. Evaluate nutritional status such as anemia - and treat appropriately. Rubella and Hepatitis immunization in non-immunized women. Patients with medical complications such as diabetes, hypertension or epilepsy Educate about the effects of the disease on pregnancy and pregnancy on the disease. Stabilize pre-existing diseases by intervention. Avoid pregnancy in extreme situations. Encourage strongly to stop smoking, alcohol intake and other abusive drugs. Give specialized care to addicted woman. Screen for inheritable genetic diseases before conception. Investigate for history of recurrent fetal loss, or with family history of congenital abnormalities and counsel the couples appropriately.

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Antenatal or Prenatal period

Duration of pregnancy Estimated date of delivery (EDD) or due date 280 days (40 weeks) from the first day of last menstrual period (LMP). 9 calendar months plus 7 days from the start of LMP in a woman with 28 days cycle and ovulation on day 14-15.

Diagnosis of pregnancy

Symptoms

Confirmation of diagnosis by Serum/ urine hCG

Obstetric examination

Pelvic / abdominal examination

Ultrasonography

Presumptive symptoms

Amenorrhea: Strongly suggestive of pregnancy. Breast changes: Tenderness and tingling in very early pregnancy. Breast enlargement and nodularity in the second month of pregnancy. Enlargement and more deep pigmentation of nipples and areolae. Nausea (with or without vomiting) or morning sickness: May begin as early as the first missed menstrual period. Frequent urination: Due to pressure put on bladder by enlarging uterus. Tiredness and Fatigue: One of the earliest symptoms of pregnancy. Sensation of fetal movements or quickening (feeling of life): begins between 18th -20th week.

Clinical evidence
Levels of Human gonadotropins (hCG) in urine and serum
Name of the Test Two site sandwich immunoassay (membrane elisa/ card test) Sensitivity 30 50 mIU/ ml Post conceptional age when positive On first day of missed period

hCG is detectable in serum in approx. 5% of patients, 8 days after conception and in more than 98% of patients by day 11.

Obstetric examination
Ultrasonography Routine scan: Done at 18-22 weeks First trimester scan: Done in cases with multiple pregnancy loss, missed abortion, elderly primigravida, vaginal bleeding Other scans are done if indicated
Changes evident on Ultrasonogaphy Chorionic gestational sac Embryo apparent in gestational sac Fetal heart activity Embryonic movements Duration of pregnancy when demonstrated 5 weeks After 6 weeks After 6 weeks By 7th week

Biometry and targeted imaging: Done at 18-22 weeks This is done to check Whether corresponding to date Dating Fetal growth profile Any anomaly Placental site If not done during this time, do it at the earliest.

Enlargement of abdomen
Duration of pregnancy Till 12th week End of 12 week
th

Fundal height Uterus is in pelvis. Felt as suprapubic bulge. Above symphysis pubis Midway between symphysis pubis and umbilicus At the level of umbilicus Should correspond in centimeters (within 2 cm.) to the gestational age in weeks

16th week 24 week

th

20th 37th week

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Look for Landmarks in Normal Pregnancy

Changes Regular and rhythmic uterine contractions elicited during bimanual examination Softening of cervix especially pronounced surrounding the external os. Bluish discoloration of anterior vaginal mucosa Sensation of separation between uterus and cervix Upper part of body of uterus is enlarged by growing fetus Lower part is empty and extremely soft Cervix is firm Duration of pregnancy when demonstrated Between 4-8 weeks 6 weeks Between 6-8 weeks Between 6-10 weeks Sign Palmers sign Goodells sign Chadwick sign Hegars sign

Palpable pulsations in the lateral uterine vessels Palpable fetal parts Active fetal movements Fetal heart rate (FHR) varies between140-160 per minute but gradually settles down to 120-140 per minute as the pregnancy advances. Knobby feel of the uterus (can be mistaken for uterine fibroids)

8 weeks 20th week 20th week 10th week with ultrasound fetal heart monitor 20-24 weeks with an ordinary stethoscope Upto 20 weeks

Osianders sign Internal and external ballotment Active fetal movements Fetal heart sound (FHS)

Piskaceks sign

Antenatal Care
Systematic supervision (examination and advice) of a woman during pregnancy is called antenatal (parental) care. The care should start from the beginning of pregnancy and end at delivery. Antenatal care comprises of: Careful history taking and examinations (general and obstetrical) Advice given to the pregnant women

Aims and objectives

Screen the high risk cases. Detect any complications and treat them at the earliest. Continued medical surveillance and prophylaxis. Educate mother about the physiology and labor to remove fear and improve psychology. Discuss with the couple about care of the newborn. Motivate couple about the need of family planning and give appropriate advice to couple seeking medical termination of pregnancy.

Schedule for Antenatal visits

Schedule for Antenatal visits The first visit should ideally be within the time of second missed period

History taking History of present complaints Obstetric history Menstrual history Past medical / surgical history Family history Personal history

Examination General examination: Built, nutrition, height, weight, pallor, jaundice, edema, B.P. etc. Obstetric examination: Abdominal & Vaginal examination

Routine investigations Blood examination Hemoglobin and hematocrit ABO & Rh grouping VDRL Hepatitis B virus ELISA for HIV (after counseling) Routine urine examination for Protein Sugar Pus cells Culture and sensitivity* Ultrasound scan at 18-20 weeks

* Culture and sensitivity test is done with Clean catch specimen of midstream urine. To collect the midstream urine - clean the vulva and
collect the urine in a clean container during the middle of the act of urination.

Screening for blood glucose

Investigations need to be done: Fasting blood sugar Post prandial blood sugar GCT (Glucose challenge test) at 24-28 weeks (If available) In GCT, blood glucose is measured 1 hour after a 50-gram glucose drink. Values more than 140 mg/dL (7.8 mmol/L) are considered abnormal. Glycosylated hemoglobin (Hb Alc), if available Screening is done in the patients with: Positive family history of diabetes (parents or sibling), including uncles, aunts and grand parents Persistent glycosuria Having a previous birth of an overweight baby of 4kg or more Previous stillbirth Previous unexplained perinatal loss Presence of polyhydramnios or recurrent vaginal candidiasis in present pregnancy Age over 30 Obesity

Investigations in special situations

Serological tests for rubella (In situations like repeated pregnancy loss, congenital anomalies)

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Schedule for the optimal subsequent antenatal visits

Duration of pregnancy Up to 28 weeks Up to 36 weeks After 36 weeks till EDD Interval of Ante-natal visits At interval of 4 weeks At interval of 2 weeks Every week

Minimum antenatal visits

The visit may be curtailed to at least four in the developing countries (as per WHO recommendation).
Frequency of visits First visit Second visit Third visit Fourth visit Duration of pregnancy During second trimester at around 16 weeks Between 24-28 weeks At 32 weeks At 36 weeks

Important: Convince the woman to attend for antenatal check up positively on the scheduled date of visit.

ANTENATEL ADVICE
8

Dietary advice Dietary supplementation Bowel

Rest and sleep

Antenatal advice

Coitus

Care of breast Tetanus immunization

Smoking, Alcohol, other drugs

Dietary advice
Advise diet with consideration to socioeconomic condition, food habits and taste of the individual. Give reasonable and realistic instructions to individual woman. Advise adequate diet so as to produce optimum weight gain (11kg) and to provide: The maintenance of maternal health The needs of the growing fetus The strength and vitality required during labor Successful lactation. The pregnancy diet ideally should: be light, nutritious, easily digestible and rich in protein (Meat, fish, eggs, milk, cheese, curd, beans, and combination of grains with legumes), minerals and vitamins. consist in addition to the principal food, at least half litre of milk (1 liter of milk contains about 1gm of calcium), plenty of green vegetables and fruits. have sufficient amount of cereals, fruits, vegetables, pulses and water. have salt just sufficient to make the food palatable. include supplementary vitamins daily from 20th week onwards.

Recommended dietary supplementation

Iron and folate supplements Prophylactic dose (to all women): one tablet of 100 mg. elemental iron and 0.5 mg folic acid once a day for at least 100 days. Therapeutic dose: If Hb < 11 g/dl. : 100 mg. elemental iron and 0.5 mg folic acid twice per day for 3 months, i.e. at least 200 tablets. Vitamin B12: No supplementation is required with adequate diet of animal origin. Supplements may be required in vegetarians. Calcium: 1-1.5 gm. of calcium is advisable routinely. The dosage may be increased to 2 gm. per day in case of PIH (pregnancy induced hypertension) and deficiency of calcium. 9

Rest and sleep

Continue the usual activities throughout pregnancy. Take about 10 hours of sleep (8 hours at night and 2 hours at noon) on an average, especially in the last 6 weeks.

Bowel
Take plenty of fluids, vegetables, high fibre diet and milk to regulate bowel movement. Natural bulking agents such as Isabgol husk may be advised at bed time.

Care of breast
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 the later months by manipulation.

Coitus
Sexual intercourse is normally not harmful at any time of pregnancy. However, it should be avoided: During the first trimester preferably during the time of missed periods and during the last 6 weeks. If there is any pregnancy complication such as placenta previa, rupture of membranes, preterm labor or premature cervical dilatation.

Smoking, alcohol and drugs

Strongly discourage their use during pregnancy.

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Immunization against Tetanus

Protects both mother and neonates.
Dosage In unprotected women Women immunized in the past 2 doses of 0.5 ml tetanus toxoid intramusculary (IM) A booster dose of 0.5 ml (IM) Time when given At 6 weeks interval, the first one to be given between 16-24 weeks In the last trimester

Prevention of perineal trauma during delivery

Antenatal perineal massage Advise woman to do perineal massage 10 minutes daily beginning in the 34th or 35th week of pregnancy. Method of perineal massage: Introduce 1 or 2 fingers 3 to 4 cm deep into the vagina. Apply and maintain pressure, first downward for 2 minutes and then for 2 minutes to each side of the vaginal entrance.

Monitoring during subsequent Antenatal visits

Vital signs Pulse Temperature Blood pressure: Criterias for the diagnosis of Pregnancy Induced Hypertension (PIH) / Pre-eclampsia - A diastolic blood pressure of 90 mm of Hg or more or - An increase of 15 mm of Hg above basal level and / or - A systolic blood pressure record of 140 mm of Hg or more or - A rise of 30 mm of Hg above basal level if the rise in blood pressure is observed at least on two occasions 6 hours apart. Weight Overall weight gain of a woman during normal pregnancy is 9 to 11 kg. Progressive weight gain indirectly reflects fetal growth. Excessive weight gain indicates fluid retention and it is believed to be the earliest sign of pre-eclampsia. Weight gain should be 0.3 to 0.5 kg per week during the second and third trimester. Urine dip test for protein and glucose Height of uterine fundus above the symphysis pubis Size of fetus Fetal heart sound Fetal activity Presenting part (late in pregnancy) Position, consistency, effacement and dilation of the cervix (starting after 38 weeks) Look for any abnormal symptoms or signs such as Presence of headache Abdominal pain Nausea and vomiting Vaginal bleeding Loss of fluid Dysuria

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To assess the status of the fetus

Growth and development Liquor status

Lie of the fetus Longitudinal lie Transverse lie Oblique lie

Fetal presentation Cephalic Vertex Face Brow Breech presentations Complete breech Incomplete breech Frank breech

Lie of the fetus

Relation of the long axis of the fetus to the long axis of the mother

Longitudinal lie Most common lie (in about 99% pregnancies at term) Fetal head is either up or low

Transverse lie Fetus lies crosswise in the uterus

Oblique lie Unstable situation that may become longitudinal or transverse during the course of labor

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Fetal presentation
Position of the fetus felt through cervix

Cephalic

Vertex (95% of all cephalic presentations)

Breech (3.5% of all pregnancies) Classified according to the position of legs and buttocks which present first Face Brow Complete breech Incomplete breech One hip is not flexed, one foot or knee lies below the breech (i.e. one foot or knee is lowermost in the birth canal) Frank breech

Head is flexed Chin is in contact with the chest Occiput of the fetal head presents

Neck is extended sharply Occiput and back of the fetus touching Face is the presenting part

Head is extended partially Changes into vertex or face presentation during labor

Both legs and hips are flexed

Hips are flexed and legs are extended

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Antenatal advice

Previously affected child

Advanced maternal age (35 years or more at the time of delivery)

Family history of congenital defects (Congenital heart diseases or Neural tube defect)

Pre-gestational maternal diabetes 12

Conditions in which care is required to detect birth defects

Maternal Rubella infection during pregnancy

Maternal seizure disorders

Exposure to alcohol or to certain medications such as anti-seizure medicines

Positive history of any of the above disorders

Refer to higher centre for specialized care

Instruct the woman to come to hospital for consideration of admission in the following circumstances
Symptom A bloody sticky discharge per vaginum Painful contractions every 20 minutes or less continued for at least an hour Bags of waters have broken Sudden gush of watery fluid per vaginum Suggestive of Onset of labor

Preterm, premature rupture of membranes (pPROM if < 37 weeks) or Premature rupture of the membranes (PROM if > 37 weeks of pregnancy) In early pregnancy Miscarriage Ectopic pregnancy In late pregnancy Placenta previa Abruptio placenta Onset of labor

Active vaginal bleeding, however slight

Advice on identification of danger signs

Advise to go to the hospital / health centre immediately, day or night, WITHOUT WAITING if any of the following signs are present Vaginal bleeding Convulsions Severe headaches with blurred vision Fever and too weak to get out of bed Severe abdominal pain Rapid or difficult breathing She should go to the health centre as soon as possible if any of the following signs are present Fever Abdominal pain Feels ill Swelling of fingers, face, legs

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THE BASIC COMPONENT OF THE NEW WHO ANTENATAL CARE MODEL THE FIRST VISIT
Ideally, the first visit should occur in the first trimester or preferably before 12th week of pregnancy. It can help identify women who may be at risk for pregnancy complications e.g. Women involved in the work that requires strenuous activity or lengthy standing positions or Exposure of women to teratogenic agents (heavy metals, toxic chemicals, ionizing radiation) Advise women about these concerns. Identify other problems and provide support such as poverty, young age of the mother, women suffering domestic or gender-based violence, and women living alone. Vaginal examination Only one routine vaginal examination during pregnancy is recommended. It could be postponed until the second visit, if it is not accepted by the woman during the first visit. Identification and treatment of symptomatic sexually transmitted infections (STIs) After the first trimester, do not do vaginal examination in women who report bleeding and refer the patient to a CHC level hospital to exclude placenta praevia or other pathology. Give routine iron supplementation to all women . New WHO model includes only four visits. This involves: General information about pregnancy and delivery and answers to the patients questions. Information on signs of pregnancy-related emergencies and how to deal with them. 14

a) Obtain information on
Personal history Name Age (date of birth) Address Tobacco use (smoking or chewing habit) or use of other harmful substances Educated or not Educational level Economic resources Medical history Specific diseases and conditions: Tuberculosis, heart disease, chronic renal disease, epilepsy, diabetes mellitus STIs (Sexually transmitted infections) HIV status, if known Other specific conditions such as hepatitis, malaria, sickle cell trait Other diseases, past or chronic; allergy(-ies) Operations other than cesarean section Blood transfusions Current use of medicines - specify Period of infertility: duration, cause(s).

Obstetric history Number of previous pregnancies Date (month, year) and outcome of each event (live birth, stillbirth, abortion, ectopic, hydatidiform mole). Specify preterm births and type of abortion, if any Birth weight (if known) Sex Periods of exclusive breast-feeding: For how long? Special maternal complications and events in previous pregnancies, validate by records (if possible): Recurrent early abortion Induced abortion and any associated complications Thrombosis, embolism Hypertension, pre-eclampsia or eclampsia Abruptio placenta Placenta praevia Breech or transverse presentation Obstructed labor, including dystocia Third-degree tears Third stage excessive bleeding Puerperal sepsis Gestational diabetes 15

Obstetrical operations: Cesarean section (indication, if known) Forceps or vacuum extraction Manual/instrumental help in vaginal breech delivery Manual removal of the placenta. Special perinatal (fetal, newborn) complications and events in previous pregnancies, validate by records (if possible): Twins or higher order multiples Low birth weight: <2500 g Intrauterine growth retardation (if validated) Rhesus-antibody affection (erythroblastosis, hydrops) Malformed or chromosomally abnormal child Macrosomic (>4500g) newborn Resuscitation or other treatment of newborn Perinatal, neonatal or infant death (also: later death) History of present pregnancy Date of last menstrual period (LMP); certainty of dates. Habits: smoking/chewing tobacco, alcohol, drugs (frequency and quantity) Any unexpected event (pain, vaginal bleeding, other: specify) History of malaria attacks.

b) Perform physical examination

Check for signs of severe anemia: pale complexion, fingernails, conjunctiva, oral mucosa, tip of tongue and shortness of breath. Record weight (kilograms) and height (metres) to assess the mothers nutritional status.

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Measure blood pressure. Chest and heart auscultation. Measure uterine height (in centimetres). Record the findings on a chart (Figure1). Consider vaginal examination (using a speculum), especially if any of the conditions listed under Assess for referral below are positive and indicate the need for performing a pap smear.

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Weeks of gestations Figure - 1: Uterine height values by weeks of gestation

c) Perform the following tests

Urine: dipstick test for bacteriuria and test for proteinuria in all women Urine for presence of sugar Hemoglobin (Hb) Blood-group typing (ABO and rhesus) Blood: Test for syphilis. If positive, treat.

d) Assess for referral

Determine the expected date of delivery (EDD) based on LMP and all other relevant information. Use 280-day rule (LMP + 280 days). If the following conditions are diagnosed, proceed as recommended: Condition
Diabetes Heart disease Renal disease Epilepsy Drug abuse Signs of severe anemia and Hb <70 g / l HIV positive

Advice
Refer Refer for continued higher level care. Refer for specialized care. Give advice for continued medication. Refer for specialized care. Refer Counsel on safe sex practices as well as on risk to the baby and partner (s), and refer for treatment and prevention of mother - to - child transmission of HIV. Refer to higher level of care. Give advice on the benefits of institutional delivery. Refer for higher level of care. Refer for higher level of care. Refer for higher level of care. Stress on hospital delivery. Refer for evaluation and higher level of care. Refer for nutritional evaluation if BMI <18.5 or >32.3 kg / m.

Family history of genetic disease Primigravida Previous stillbirth Previous growth-retarded fetus (validated IUGR) Eclampsia or pre-eclampsia during previous pregnancy Previous cesarean section High blood pressure (>140/90 mm Hg) Body Mass Index (BMI) (weight in kg/height m)

e) Implement the following interventions

Iron and folate supplements Prophylactic dose: to all women: one tablet of 100 mg. elemental iron and 0.5 mg folic acid once a day for at least 100 days. Therapeutic dose: If Hb < 11 g/dl. : 100 mg. elemental iron and 0.5 mg folic acid twice per day for 3 months, i.e. at least 200 tablets. If test for syphilis is positive: treat. Tetanus toxoid: first injection. 0.5 ml. deep intramuscular (IM). Refer high-risk cases, according to diagnosis made (as mentioned above).

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f) Advice, questions and answers, and scheduling the next appointment

Give advice on safe sex. Emphasize the risk of acquiring or transmitting HIV or STIs without the use of condoms Advise women to stop the use of tobacco (both smoking and chewing), alcohol and other harmful substances. Advise on breast-feeding. Request the woman to record when she notes the first fetal movement. Advise the woman to bring her partner (or a family member or friend) to later ANC visits so that they can support the woman through her pregnancy. Schedule appointment: second visit, at (or close to) 26 weeks: state date and hour.

g) Maintain complete records

THE SECOND VISIT

Personal history: Note any changes or events since first visit. Measure blood pressure

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Measure uterine height Perform a multiple dipstick test for bacteriuria Test for proteinuria in nulliparous women and those women with a history of hypertension or pre-eclampsia/eclampsia Blood test to determine hemoglobin if clinically indicated Important : An unexpectedly large uterus (discovered through abdominal palpation and uterine height measurement) may indicate twins or a pathological condition and the woman should be evaluated at a higher level of care.

a) Obtain information on
Medical history Review relevant issues of medical history as recorded at first visit. Iron intake: check compliance. Note intake of medicines, other than iron, folate. Obstetric history Review relevant issues of obstetric history as recorded at first visit. Present pregnancy: Record symptoms and events since first visit e.g. pain, bleeding, vaginal discharge, signs and symptoms of severe anemia. Other specific symptoms or events. Note abnormal changes in body features or physical capacity e.g. peripheral swelling, shortness of breath observed by the woman herself, her partner or other family members. 18 Fetal movements: felt ? Note time of first recognition. Check-up on habits: smoking, alcohol, other.

b) Perform physical examination

Measure blood pressure. Take uterine height values: record on graph (Figure 1). Check for generalized edema. Other alarming signs of disease: shortness of breath, coughing, etc. Vaginal examination: do only if not done at first examination. Important : Do not perform vaginal examination, if patient is bleeding or spotting and refer to hospital.

c) Perform the following tests

Urine Repeat multiple dipstick test to detect urinary-tract infection; if still positive after being treated at the first visit, refer to hospital. Repeat proteinuria test only if woman is nulliparous or if she has a history of hypertension, pre-eclampsia or eclampsia in a previous pregnancy. Blood Repeat Hemoglobin levels Important: All women with hypertension in the present visit should have a urine test performed to detect for proteinuria.

d) Assess for referral

Look for any of the symptoms / signs Unexpected symptoms Hb <70 g / l If bleeding or spotting Evidence of pre-eclampsia, hypertension and / or proteinuria Suspicion of fetal growth retardation (uterine height values below the 10th percentile-Figure 1) Fetal movements if not felt by the woman What to do Refer as required Refer Refer Refer to higher level of care or a hospital Arrange referral to hospital for evaluation Use hand-held Doppler for detection of fetal heart sound; if negative, refer to hospital

e) Implement the following interventions

Continue iron supplementation. If Hb is <70 g / l, refer. If bacteriuria was treated at first visit and test is still positive, refer.

f) Advice, questions and answers, and scheduling the next appointment

Repeat all the advice given at the first visit. Give time for free communication. Schedule third ANC visit, at (or close to) 32 weeks.

g) Maintain complete records

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THE THIRD VISIT

The third visit should take place in or around 32 weeks. Measure blood pressure. Measure uterine height. Perform urine test to detect bacteriuria. Check hemoglobin. Test for proteinuria in nulliparous women and those with a history of hypertension, pre-eclampsia or eclampsia. Give special attention towards discovery of twins during the external abdominal examination and uterine height measurement. Referrals are based on symptoms and findings which require special intervention.
Symptom / sign High hemoglobin (Hb >130 g / l) in absence of other symptoms The uterine height distance is below expected or as evidenced by the chart curve May indicate may mean poor fetal growth indicative of poor growth What to do? Warranting an extra visit at week 36 to evaluate fetal growth or the need for referral. Referral or hospitalization.

Provide instruction and advice in the event labor starts (e.g. what to do in the event of abdominal pain or leaking of amniotic fluid) Discuss birth spacing and contraceptive options with her and her partner.

a) Obtain information on
Personal history Note any changes or events since second visit.

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Medical history Review relevant issues of medical history as recorded at first and second visits. Note intercurrent diseases, injuries or other conditions since second visit. Iron intake: check compliance. Intake of any medicines other than iron and folate. Obstetric history Review relevant issues of obstetric history as recorded at first visit and as checked at second. Present pregnancy Symptoms and events since second visit: abdominal or back pain (preterm labor ?), bleeding, vaginal discharge (amniotic fluid ?). Other specific symptoms or events. Changes in body features or physical capacity, observed by the woman herself, her partner or other family members. Fetal movements. Check-up on habits: smoking, alcohol, etc.

b) Perform physical examination

Measure blood pressure. Uterine height values: record on graph (Figure 1). Fetal heart sounds: Use hand-held Doppler required only if no fetal movements are seen or the woman feels less fetal movement. Check for generalized edema. Other alarming signs of disease: shortness of breath, cough, etc. If bleeding or spotting: refer Breast examination.

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c) Perform the following tests

Urine Repeat multiple dipstick test to detect urinary-tract infection; if still positive after being treated at a previous visit, refer. Repeat proteinuria test only if the woman is nulliparous or she has a history of hypertension, pre-eclampsia or eclampsia in a previous pregnancy. Blood Hemoglobin estimation in all women.

d) Assess for referral

Reassess risk based on evidence since the second visit and observations made at present visit. Symptoms / sign
Unexpected symptoms If bleeding Evidence of pre-eclampsia, hypertension and /or proteinuria Suspicion of fetal growth retardation (uterine height values below expected or indicative of poor growth as evidenced by the chart curve) Hemoglobin is continuously <7 gm% Hemoglobin is >13 gm% If abnormalities are detected in either fetal growth or blood pressure or if proteinuria is found

What to do
Refer as required. Refer Refer to special unit in the clinic, or a hospital. Refer Refer New appointment no later than 36 weeks to check fetal growth, blood pressure, and the possibility of proteinuria. Refer

e) Implement the following interventions

Continue iron supplementation. If Hb <7 gm%, refer Tetanus toxoid: second injection.

f) Advice, questions and answers, and scheduling the next appointment

Repeat advice given at first and second visits. Give advice on measures to be taken in case of (threatened) labor. Questions and answers: time for free communication. Provide recommendations on lactation, contraception and the importance of the postpartum visit. Schedule appointment: fourth visit, at (or close to) 38 weeks.

g) Maintain complete records

THE FOURTH VISIT

This should be the final visit and should take place between weeks 36 and 38. It is important to discover breech presentation and refer for obstetric evaluation and external cephalic version (ECV). Advise women that if they have not delivered by the end of week 41 (complete 41 weeks or 290 days) to report to the hospital / maternity centre for evaluation. Inform patient again about the benefits of lactation and contraception. Important : An external cephalic version should be attempted at the hospital, but when pelvic-cephalo disproportion is suspected, elective caesarean section should be considered. 21

a) Obtain information on
Personal history Note any changes or events since the third visit. Medical history Review relevant issues of medical history as recorded at first three visits. Note intercurrent diseases, injuries or other conditions since third visit. Iron intake: check compliance. Symptoms and events since third visit: pain, contractions (preterm labour ?), bleeding, vaginal discharge. Other specific symptoms or events. Fetal movements.

Present pregnancy

b) Perform physical examination

Measure blood pressure. Record uterine height values: record on graph. Check for multiple fetuses. Fetal lie, presentation (vertex, breech, transverse). Fetal heart sound(s): hand-held Doppler may be used. Check for generalized edema. Look for other signs of disease: shortness of breath, cough, etc. If bleeding or spotting: refer to hospital.

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c) Perform the following tests

Urine Repeat multiple dispstick test to detect urinary-tract infection; if still positive after being treated at a previous visit, refer to hospital. Repeat proteinuria test only if the woman is nulliparous or she has a history of hypertension, pre-eclampsia or eclampsia in a previous pregnancy.

d) Assess for referral

Reassess risk based on evidence since third visit and observations made at present visit.
Symptoms / sign Any unexpected symptoms Vaginal bleeding Evidence of pre-eclampsia Suspicion of fetal growth retardation(uterine height values below expected) Suspicion of twins Suspicion of breech presentation What to do Refer as required. Refer Refer to special unit in the clinic or a hospital. Refer Arrange for hospital delivery. Refer to evaluate external cephalic version. Hospital delivery is mandatory.

e) Implement the following interventions

Continue iron supplementation. 22

f) Advice, questions and answers, and scheduling the next appointment

Repeat the advice given at previous visits. Give advice on measures to be taken in case of the initiation of labor or leakage of amniotic fluid. Give advice on breast-feeding. Give time for free communication. Schedule appointment for postpartum visit. Provide recommendations on lactation and contraception.

g) Maintain complete records

DANGER SIGNS: (REPORT IMMEDIATELY) Excessive vomiting wherein the woman is unable to take anything orally leading to decreased urinary output Any bleeding per vaginum during pregnancy Severe headache with blurred vision Convulsions or loss of consciousness High fever with or without abdominal pain, and the woman is too weak to get out of the bed (Indicating infection or sepsis) Fast or difficult breathing (dyspnea) Decreased or absent fetal movements Heavy (>500 ml.) vaginal bleeding during and following delivery

IDENTIFICATION OF HIGH RISK PREGNANCY

General history
Low socio economic status
Increases the risk of perinatal morbidity and mortality

Maternal age

Substance abuse

Environmental risks

Younger than 20 years Premature birth Low birth weight Uterine dysfunction Fetal death Neonatal death

Older than 35 years First trimester miscarriage Fetal chromosomal anomalies eg. Trisomy 21, and sex chromosomal anomalies Medical complications such as Hypertension, Diabetes, Preeclapmsia Multiple gestation Higher rate of Cessarean section Fetal morbidity and mortality

Tobacco

Alcohol

Increased fetal morbidity and mortality

Increased fetal morbidity and mortality Fetal Growth Restriction (see chapter on "Substance abuse during pregnancy")

Drugs (Opioids, Coccaine, Marijuana, etc.)

Caffeine

Fetal Growth Restriction Premature labor Abruptio placenta Noxious chemicals

Higher rates of spontaneous abortion

Radiation exposure

Unpleasant symptoms such as headache, nausea, lightheadedness

Previous obstetric history

Factor Parity Nullipara Multipara Risk Pregnancy induced hypertension (PIH) Placenta previa Post partum hemorrhage Increased incidence of dizygotic twins Increased risk of subsequent ectopic pregnancies Increased risk of subsequent preterm delivery

Spontaneous abortion Birth defects Childhood leukemia

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Ectopic pregnancy Preterm delivery Large infant (more than 4000 gm)

May denote uncontrolled glucose intolerance and may be associated with intrapartum complications such as Difficult vaginal delivery Postpartum neonatal complication such as hypoglycemia Increased risk of similar outcome

Perinatal death (stillborn or neonatal death) It may be due to undetected Glucose intolerance Collagen vascular disease Congenital abnormality Chromosomal abnormality Preterm labor Hemolytic diseases Abnormal labor Pregnancy induced hypertension (pre - eclapsia and eclampsia) Previous cesarean section

Increased risk of similar outcome Risk of scar dehiscence

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Medical history
Factor Chronic hypertension (diastolic blood pressure more than 90 mmHg.) Risk Super imposed pre-eclampsia Abruptio placenta Perinatal loss Maternal mortality Myocardial infarction Utero- placental insufficiency Cerebro-vascular accident In Fetus Abnormal development Death Increased risk of developing cardiac diseases in their lifetime

Cardiac diseases

In Mother Heart disease may worsen in pregnancy

Pulmonary diseases

Supply of well oxygenated blood to fetus may be compromised Diseases such as asthma increase the risk of - Preterm delivery - IUGR - Perinatal morbidity and mortality Continuous assessment is necessary Creatinine level must be kept below 1.5 mg./100ml. Congenital anomalies Fetal mortality Neonatal morbidity such as - Respiratory distress syndrome - Macrosomia - Hypoglycemia - Hyperbilirubinemia - Hypocalcemia Untreated Hypothyroidism or Hyperthyroidism may affect pregnancy outcome Treatment of thyroid diseases during pregnancy can affect the fetal thyroid Abruptio placentae Growth restriction Super imposed pre-eclampsia Genetic disorders in mother Fetal malformations Consanguinity: Marriage between close relatives Increased risk of miscarriage Rare recessive genetic diseases in offspring Effect Congenital anomalies Small for age infant Neonatal infection (during vaginal delivery) Congenital anomalies Severe anemia which may lead to death Ethnicity: Indians

Renal diseases Diabetes mellitus

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Thyroid diseases Systemic lupus erythematosus (SLE) Genetic disorders

Sickle cell anemia Thalassemia

Infectious diseases

Infection Cytomegalovirus Herpes simplex Toxoplasmosis (in early pregnancy) Parvovirus

Hepatitis B-virus (HBV) HIV Auto-immune disorders In Mother Recurrent fetal loss Placental infarction Pre-eclampsia early in pregnancy Arterial or venous thrombosis Auto-immune thrombocytopenia

Vertical transmission causing neonatal infection Transmission causing neonatal infection

Physical examination
Factors General examination Short or underweight woman Obesity Perinatal morbidity or mortality Low birth weight infant Preterm delivery Hypertension Diabetes mellitus Wound complication Thrombo-embolism Abortion Premature labor Dysfunctional labor Post-partum hemorrhage Obstruction of labor by cervical or lower uterine segment myomas Unstable fetal lie or compound presentation Premature cervical dilatation causing recurrent pregnancy loss in 2nd term or preterm labor Spontaneous miscarriage Risk

Evaluation of uterus Leiomyomata (Fibroids)

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Incompetent cervix Uterine anomalies

Laboratory studies
Factors Blood type Maternal sensitization of Rhnegative mother (e.g. prior transfusion, previous pregnancy of Rh-positive baby or Chorionic villus sampling) VDRL positive Risk Hemolytic diseases in Rh-positive fetus

Late abortion Stillbirth Congenitally infected fetus Intrauterine infections with premature rupture of membrane and preterm delivery Neonatal eye infection (Ophthalmia neonatorum) Chorio - amnionitis Neonatal sepsis Associated maternal arthritis, rash or peripartum fever

Gonorrhea

Chlamydia

Ophthalmia neonatorum Neonatal pneumonia Post partum endometritis First trimester abortion Fetal infection resulting in severe congenital anomalies

Rubella (Maternal infection in first trimester carries greatest risk for the fetus)

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Complete blood count Anemia (if severe)

In mother Intercurrent infections Preterm labor PIH ( pregnancy induced hypertension) Obstetric shock Abruptio placentae Congestive cardiac failure Puerperal sepsis Failing lactation

In fetus Premature birth IUGR (intrauterine growth retardation) Stillbirth Neonatal anemia High prenatal mortality rate Foetal malformation due to Vit B12 deficiency

Urinalysis and culture Asymptomatic bacteriuria (2-10%) Acute systemic pyelonephritis Gestational diabetes

Symptomatic urinary tract infection (40%) May develop into Acute systemic pyelonephritis (in 25-30% patients) Premature labor and delivery Increased risk of Macrosomia Increased risk of Pre-eclampsia Increased risk of stillbirth Open neural tube defect (80-90% of pregnancies) Multiple gestation Fetal death Abruptio placentae Other fetal congenital defects (e.g. oomphocele, congenital nephrosis)

Screening for neural tube defect High levels of Maternal feto proteins (MSAFP)

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Low levels of MSAFP and estriol and high levels of hCG Low levels of all three markers Hepatitis B Virus (HBV) testing HIV infection Sickle cell anemia

Trisomy 21 (Down syndrome) Trisomy 18 (Edward syndrome) Vertical transmission of HBV that may lead to acute or chronic hepatitis Transmission of infection to fetus in utero, during delivery, after birth and breast feeding Increased incidence of infectious complications such as pyelonephritis, cholecystitis, pneumonia, and skin infections. Spontaneous abortion Pre-eclampsia Preterm labor and delivery IUGR Unexplained fetal death

CHECK YOUR PROGRESS

1. How many minimum antenatal visits are recommended by WHO?

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2.

What are the routine investigations done on first antenatal visit?

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3.

What is quickening and when does it start?

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4.

What is the Immunization schedule for tetanus vaccine?

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5.

What are the risks associated with anemia during pregnancy?

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6.

What is the permissible weight gain per week during 2nd and 3rd trimester of pregnancy?

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7.

In which conditions screening of Blood glucose during pregnancy is required?

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8.

What is the recommended dosage of iron and folic acid supplements during pregnancy?

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9.

Enumerate the conditions when a pregnant woman needs to report to hospital immediately.

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