Ante Natal Care

Definition

Systematic supervision of a pregnant woman from time of pregnancy till delivery so as to have a healthy mother & baby.

Aim

To deliver a healthy baby from a healthy mother.

Objectives:

• Promote, protect & maintain health of pregnant woman.

• Detect high risk cases & provide special attention.

• To foresee complications & prevent them.

• Remove the fear of labor & delivery.

• Motivate for family planning, incl. MTP.

• Educate about personal hygiene, nutrition and child care.

• ↓ MMR and infant mortality rate.

High Risk Mothers:• Age > 35 yrs

• Grand multi• Short primi (<150 cm)• Mal presentation (at term)• PIH, Anemia, Medical disorders• h/o recurrent pregnancy loss (RPL)• Multiple gestation, hydramnios• Previous surgery, MRP, difficult

labor

When should prenatal care start?

IDEALLY, a woman planning to have a child should have a

medical evaluation before she becomes pregnant.

Frequency of ANC’s

• First check up by 45 days• Monthly till 28 weeks• Fortnightly till 36 weeks• Weekly till EDD• Admission around EDD

DAWN’s rule of 10• 10 ANC’s• 10 kg weight gain• 10 hrs rest and sleep• 10g Hb• 2 doses Inj. TT by 10th month• 10 hrs in labor for primi and < 10 for

multi• 10 APGAR score for baby• 10 months of breast feeding• Infant immunization by 10th month

Methods:

• History taking• Examination• Immunization & hematinic

prophylaxis• Investigations• Advice: diet

warning signals

History

•LMP/ EDD: previous menstrual history (3 cycles)

•Conception: spontaneous/ assisted

•Pregnancy Confirmation: time & method

•Supervision of Pregnancy

•Age:Teenage pregnancy: CPD

AnemiaPIH

Elderly primi:Down’s syndrome

PIHGDMAnemia

• Husband’s Occupation:Socio-economic statusRisk of STD/ AIDS

• Previous Obstetric History:Recurrent Pregnancy

LossPreterm LaborAPHPPHLabor complications

• Married Life:Previous pregnancies

Low fecundity group

• Past History:Allergy to drugs

Previous operationsKnown medical

disordersh/o blood transfusion

•Family History:

HypertensionDiabetesHemophiliasTwins

Examination

• Height: < 145 cm CPD

• Weight:total weight gain: 10 – 12

kg1st trimester : 1 – 2 kg

2nd trimester : 5 kg3rd trimester : 5 kg

• Excessive Wt.: > 0.5 kg/ wk

> 2 kg/ month

seen in: HydramniosDiabetesTwinsPIH (earliest sign)

• If initial wt < 40 kg: ↑ chances of IUGR

•No ↑ in weight: IUD

IUGR

• Gait: poliospinal abnormalities

• Pallor• Pedal edema• Thyroid enlargement• Vital Signs: pulse, BP• CVS, RS

Abdominal examination

• Inspection:Striae Gravidarum, Linea albicans/

nigraPrevious ScarLie: longitudinal/ transverse

• Palpation:Grips: fundal, lateral, 1st & 2nd

pelvic

• Auscultation: FHS

Vaginal Examination

Indications to do p/v in pregnancy:

1. Assess the pelvis at term2. 1st trimester:• To confirm diagnosis of pregnancy• If uterus corresponds to POG• Intra/ extra-uterine pregnancy• Cervical length

First Trimester

• Ideally with in 45 days• Confirm pregnancy with tests:

History taking (incl. LMP – EDD)

Complete examinationUrine test

• Vital signs

•Routine investigations:

Blood: ABO, RhHIV, HBsAg, VDRLHb.

Urine: ProteinSugarPus cellsCulture & sensitivity

USG:

• Confirm pregnancy• Intra/ extra – uterine• Single/ multiple gestation• Viable/ non viable• Cervical length (after 12

weeks)

•Register the patient (booking of the patient):

At least 5 visits with doctor: 1 investigation in 1st trimester, 1 in the second trimester and 3 in the 3rd trimester

2ND Trimester (13 – 28 weeks)

• 1 ANC / month till 28 weeks• History:

quickeningcomplications: PIH

IUGRHydramniosAnemiaUTIFever, etc

• Examination (No p/v)• Weight• Fe & Ca supplements• Immunization: Inj TT (im)

primi: 2 doses, 1 month apart between 16 – 36 weeks

multi: 1 dose (with in 3 years of

previous dose)

• USG: fetal anomaly scan

3rd Trimester (29 – 40 weeks)

• Fortnightly till 36 wks, then wk’ly till EDD

• History:PIH, Anemia, GDM, etc.

• Examination: p/v at term

• USG: Fetal Biometry (BPD, HC, AC, FL)

Fetal Well Being - BPP (FM, FBM, FT, AFI, NST)

•Plan Delivery:Time

Mode:Vaginal: spontaneous/

inducedAbdominal

Warning Signs of Pregnancy:

• Bleeding p/v: Ectopic pregnancyAbortionVesicular moleAPH

• White/ excessive watery discharge:CandidiasisTrichomoniasisBacterial vaginosisPromCircumvalate placenta

• Persistent ↑ / ↓ fetal movements:Fetal distress

• Breathlessness: Heart disease

HydramniosTwinsPIH

• Headache: PIH

• Visual disturbances: PIH

• Epigastric pain: PIH

Heart DiseasePTL

• Burning micturition: UTI

• Excessive vomiting: Hyperemesis g.

Vesicular mole

Thank You

Nutrition and Micronutrients in Pregnancy

Nutritional Interventions in Pregnancy

Nutrition

Micronutrients

• Folic Acid• Iron• Iodine• Calcium • Zinc

Vitamin A

Vitamin D

Vitamin K

Copper

Selenium

Magnesium

Nutritional Interventions in Pregnancy

What is Their Effect on What is Their Effect on Pregnancy outcome?Pregnancy outcome?

Maternal Malnutrition and Pregnancy Outcome

• Periconception : fertility, NTD.

• 1st t trimester : SB, preterm births, early NND

• 2nd & 3rd trimester : birth wt, SGA, preterm birth.

• Birth wt significantly influenced by starvation• PNMR not affected.• No in incidence of malformation.

• Dietary restriction trials in pregnant women: -– Inconclusive results to demonstrate / exclude effect

on fetal growth / any significant effect on other outcomes

• Nutritional supplementation trials: Mixed result – High protein: no evidence of benefit on fetal growth

– Balanced protein and energy: minimal in average birth wt (~30 g) & small in incidence of SGA NB

• Conclusion: -– Women manifesting nutritional deficits can benefit

from a balanced energy/ protein supplementation

Micronutrients & pregnancy outcome

Micronutrient def. Assoc. with adverse pregnancy outcomes?

• Folic Acid NTD• Iron anaemia, haemorrhage.• Iodine cretinism.• Calcium hypertension, pre-

eclampsia.• Zinc anaemia, NTD, LBW,

anencephaly.

- Vitamin A Vertical transmission of HIV, Maternal anemia,

Infection, Maternal mortality.– Vitamin D neonatal hypocalcaemia.– Vitamin K haemorrhage.– Copper anaemia, anencephaly, LBW– Selenium NTD, dysfunction of brain &

CVS, abortion.

– Magnesium blood coagulability, toxaemia, preterm birth.

Folic Acid

• Strong evidence that folic acid periconceptionally prevents NTD

ng evidence that folic acid risk of some other birth defects

• Improves the hematologic indices in women receiving routine iron & folic acid

• USPHS/ CDC recommends for US women– 400 g/day : all women in childbearing age– 1 mg/day : pregnant women– 4 mg/day : women with h/o NTD take folic

acid 1 month prior to conception & during 1st trimester

Nutritional Supplementation & Anemia• WHO definition of severe anemia:

– hemoglobin < 7 g/dl

• Level of risk – Moderate anemia (Hb 7–11 g/dl) : not

– Severe anemia : significant risk

• Severe anemia is associated with:– LBW newborns– Premature newborns PNMR MMR

Anemia and Obstetrical Hemorrhage• Anemia does not cause obstetrical hemorrhage.

• Etiology of obstetric hemorrhage.– Early pregnancy: abortion complications.– Mid/late pregnancy to delivery: APH, atony,

retained placenta, birth canal laceration.

• Primary factors affecting outcome:– Rapid intervention to prevent exsanguination.– Availability of skilled provider, drugs, blood &

fluids.• There is no evidence that levels of hemoglobin

are beneficial in withstanding a hemorrhagic event.

Iron Supplementation

• Iron requirements:– Average non-pregnant adult:

•800 g iron lost/day•+ 500 g iron lost/day during menses

– Pregnant woman: need due to •Expanded blood volume•Fetal and placental requirements•Blood loss during delivery

• Routine vs. Selective iron supplementation:

– Routine iron & folate supplementation where nutritional anemia is prevalent

– Recommended dose: 60 mg elemental iron + 500 g

folic acid

Iodine Supplementation

• Iodine deficiency is a preventable cause of mental impairment

• Iodine supplementation & fortification programs have been largely successful in iodine deficiency conditions

• Population with high levels of mental retardation (e.g.:- Some parts of china):

– Supplementation may be effective at preconception up to mid-pregnancy period

Calcium

Assocn between PIH & calcium supplementation

incidence of PIH.

– Routine supplementation likely to be beneficial in women at high risk of developing PIH or have dietary calcium intake

calcium doses (2 g/day) not associated with adverse events.

Calcium Supplementation

Calcium risk of: • hypertension, pre-eclampsia• low birth weight, chronic hypertension in children

• Other health benefits not related to pregnancy:– Maintaining bone strength– Proper muscle contraction– Blood clotting– Cell membrane function– Healthy teeth

Zinc and pregnancy outcome

Zinc – involved in: • 300 enzymes, • nucleoprotein, • DNA and protein synthesis, • cell division.

Serum zinc levels in pregnant women:– Normal range: 7-10 mol/l – No change

• IUGR ?• Pre-term babies ?• Congenital abnormalities ?• Infection ?• atonic uterine bleeding ?• inefficient labour ?

Vitamin A• Safe vitamin A dosage during

pregnancy/Preventive-10 000IU daily or 25 000IU weekly

• Indications for vitamin A supplementation:– Vertical transmission of HIV (ongoing)– Infant survival– Maternal anemia: positive interaction with iron in

reducing anemia– Infection– Maternal mortality:

• Vitamin A vs. Placebo RR 0.60 (0.37–0.97)• Beta-carotene vs. Placebo RR 0.51 (0.30–0.86)

• Potential adverse effects of vitamin A and related substances:– Total daily dose > 10,000 IU before 7th week of

gestation associated with birth defects: craniofacial, central nervous system, thymic cardiac

• Overall effectiveness and safety of vitamin A supplementation needs to be evaluated

Vitamin D and Vitamin K

• Vitamin D.– Function- for calcium absorption, Neonatal

hypocalcaemia.– No study.– Routinely Administered.

• Vitamin K.– Deficiency associated with haemorrhage?– No study

Copper and pregnancy outcome • Functions - Cu-proenzymes, Cytochrome-c -

oxidase, angiogenesis, connective tissue synthesis.

• Normal range varies - 110 to 210 micro gm/dl.– Peak value- 220-300 micro gm/dl.– Pattern of rise- First/Second trimester.– Postpartum levels- 2 / 4 / 8-12 weeks.

in serum copper during pregnancy in all studies.• No correlation between maternal and foetal

copper levels.• No correlation with abortion, weight, preterm

delivery or other adverse pregnancy outcomes.• Inverse relationship with birth weight.

Selenium and pregnancy outcome

• Functions - antioxidant, co-factor for enzyme glutathione peroxidase, prevents free radical formation, DNA changes.

• Results of four prospective studies: - in serum selenium during pregnancy– Levels in pregnancy - 35-70 ng/ml– Neural tube defects in one study – First trimester miscarriage in one study – Preterm delivery in one study

Magnesium and pregnancy outcome

• Functions: - anticonvulsant. • Deficiency: - blood coagulability,

toxaemia, preterm birth?

• Results of three prospective studies –.– Levels in pregnant women - 1.55-4.92mg/dl .– Inverse correlation with birth weight in one

study.

– Intra uterine growth retardation in one study.

Micronutrients & pregnancy outcome

• Pregnancy outcomes- Not clearly defined.– Fetus - IUGR, SGA, LBW, preterm birth.– Maternal - preterm delivery, ineffective

labour, atonic uterine bleeding.

• Physiology of micronutrients-discrepancies across studies regarding– normal range / peak values / pattern of / .

Limitations of studiesLimitations of studies: -: -

• Maternal micronutrient status- Varied Materials for assessment.

• Time of assessment during pregnancy-– First trimester / Second trimester / Third

trimester / Birth-maternal/cord blood.

• Frequency of assessment- Serial (>2) – 7, mostly once or twice.

• Range of normal values- variable and wide.

Summary of Nutritional Review Findings

• Evidence of nutritional intervention effectiveness exists for: -– Balanced energy / protein supplementation.– Iron supplementation.– Periconceptional folic acid intake.– Iodine use.– Calcium.

• Confirmatory studies to examine effectiveness of other micronutrients are required.

RDA and safety level in adults (WHO)

Fat Soluble vitamins

RDA Safe level of intake

Vitamin A 1000 g Approx 10 x RDA

Vitamin D 5 g Approx 10 x RDA

Vitamin E 10mg Over 100 x RDA

Vitamin K 70-140 g Approx 50 x RDA

Water Soluble vitamins

RDA Safe level of intake

Thiamin 1.4mg Over 100 x RDA

Riboflavin 1.6mg Over 100 x RDA

Niacin 18mg Approx 100 x RDA

Pyridoxin 2.2mg 100 x RDA

Folic Acid 400 g Over 50 x RDA

Vitamin B12 3 g Over 100 x RDA

Vitamin C 60 mg Approx 100 x RDA

CONCLUSION

Insufficient evidence exists• to support micronutrient deficiency during

pregnancy• to associate micronutrient deficiency with

adverse pregnancy outcomes. • on the physiology of micronutrients and adverse

pregnancy outcomes.

Need for rigorous scientific research• to assess maternal micronutrient status and it’s

correlation with pregnancy outcomes.• to identify the normal range of micronutrients

during pregnancy. • for standardised tests to assess maternal

micronutrient status.

• The first rational approach to optimal health has been, and should be, food.

• When food/nutrient intake is inadequate, significant health benefits have been shown to accrue from supplementation.

• However, supplementation must be practised with great circumspection and with due consideration to the desired endpoint as well as to the possibility of doing harm.

• Future developments promise to provide us with a more sound scientific basis both for the– recommendations we make in terms of healthy

eating and – well-defined indications for nutrient

supplementation.

WHAT TO KNOW ABOUT: PRENATAL

CARE, LABOR AND DELIVERY!!

Good Nutrition

Should include: •Whole and organic foods; •Proteins, •fats; •micronutrients such as: calcium,

iron, magnesium, zincvitaminsmoderate salt

restriction, all in a balanced diet.

• cigarette smoking

•alcohol and drug use

• exposure to teratogens.

•excessive physical work

AVOID DURING PREGNANCY

•Pregnancy is a normal physiologic event that may complicated by pathologic processes dangerous to the health of the mother and fetus in only 5-20% .

• INITIAL OFFICE VISIT: Its’ purpose is to identify all risk factors to which the mother and fetus are exposed that may lead to the pathologic processes. This involves:

PRESENT PREGNANCY:

•Medical history- many medical disorders affecting pregnancy: for example, genetic, cardiovascular, gastrointestinal, endocrine disorders as well as a familial history of Diabetes Mellitus and chronic hypertension among other pathologies require careful evaluation and counseling.

• Immunization status of the expecting mother

HISTORY TAKING

• Identify the last menstrual period FRO accurate gestational age of the pregnancy.

• Previous pregnancy: a) Surgical history- C-section, forceps delivery,

breech delivery or normal vaginal birthb) Length of gestation, birth weight, fetal

outcome, mother’s outcome.c) Length of labor, any complications?

physical examination: complete general and pelvic examination must be performed on every new pregnant patient. 

complete immunization scheme against tetanus

basic lab tests:

•blood screening for rh factor, vdrl for sexually transmited diseases

•urine testing, pap’s smear for std

•stool culture for ova and parasites,

• tb test for high risk patient

ultrasound examination

STANDARD SCHEDULE FOR PRENATAL OFFICE VISITS:

1st-32 weeks; once q4w

32-36 weeks; once q2w

36 to delivery; once qw

SUBSEQUENT VISITS TO THE OBSTETRICIAN CAN VARY:

maternal well-being as a sign of fetal well-being

•Maternal weight at beginning of pregnancy compared to maternal height and identification of weight group. Subsequent weight increases should be regulated and recorded.

•Fundal height, fetal heart tones, fetal size and position

•excessive salivation

• abnormal craving

•frequent urination

• varicose veins

•edema, backache,

•leg cramps,

•breast soreness,

•discomfort in the hands.

COMMON COMPLAINTS

•normal pregnancy usually lasts 266 +/- 6 days

•true labor: involves regular uterine contraction

•false labor: quite common in late pregnany contraction is not regular 

•first baby: 8-12 hours average duration,

•subsequent pregnancy duration of labor is less.

PREPARATION FOR LABOR AND DELIVERY. 

just before the beginning of labor, a small amount of red-tinged mucus called “show” may be passed. cervical mucus mixed with blood and possible evidence of cervical dilation and effacement. fetal presentation and position contribute greatly with smooth delivery.

normal labor divided into 3 stages; 

• 1st: begins with onset of labor and ends when dilatation of the cervix is complete (10cm).

• 2nd: full dilatation of the cervix to the birth of the baby

• 3rd: birth/delivery of the infant and the placenta

natural childbirth programs are popular in current era, father-to-be active participant and helps during labor. the lamaze technique for prepared childbirth.

adequate delivery room facilities include well trained personel, anesthesia and resuscitation equipment and medication, as well as the sterile surgical instruments thay may be needed.

PREPARATION FOR DELIVERY:

CARE FOR MOTHER AND INFANT AFTER BIRTH

infant: apgar score at 1st min and 5th mins to evaluate immediate well-being and predict possible future neurological deficit.

mother: promote breast feeding within 30 minutes of delivery. cervix and rest of birth canal should be examined for any abnormal bleeding, repaired for lacerations especially if bleeding. offer emotional support to the mother.

THANK YOU