DEFINITION
Systematic supervision of women during pregnancy to monitor the progress of fetal growth and to ascertain the well-being of the mother and the fetus, also to detect pregnancy-related complications at the earliest.
OBJECTIVES OF ANTENATAL CARE
- To promote, protect, and maintain the health of mother during pregnancy
- To detect high-risk cases and give them proper attention
- To foresee complications and prevent them
- To ensure that antenatal care (ANC) is used as opportunity to detect and treat the existing health issues in pregnant females
- To make sure that services are available to manage obstetric emergencies
- To protect pregnant women and their families for the eventuality of any emergency
- To remove anxiety associated with pregnancy and delivery
- To teach the mother about the elements of child care, nutrition, personal hygiene, and environmental sanitation
- To reduce maternal and infant mortality and morbidity
- To sensitize the mother about the need of spacing the birth and family planning
- To attend the under-fives accompanying the mother.
COMPONENTS OF ANTENATAL CARE
- Antenatal visits
- Prenatal advises
- Specific health protection
- Mental preparation
- Family planning.
PROTOCOLS OF ANTENATAL VISITS
Every country's ANC protocols are different. Based on the base-line health of the pregnant females, following are the antenatal protocols by Indian Health Governing Bodies. They are divided into:
- Essential components of ANC checkup
- Desirable component of ANC checkup.Antenatal care starts from the first visit of the pregnant female by the healthcare provider.
Schedule of essential antenatal visits are:
- Below 12 weeks of pregnancy
- Between 14 weeks and 26 weeks of pregnancy
- Between 28 weeks and 34 weeks of pregnancy
- About 36 weeks till term.
Schedule of desired antenatal visits is:
- From conception till 28 weeks: Monthly visits
- About 28–36 weeks: Fortnightly visits
PRENATAL ADVICE
History taking: Detailed history of pregnant female to be taken under following headings:
- Pregnancy scoring:
- Gravida: Number of times patient has become pregnant
- Parity: Living number of existing children
- Abortion: Number of times abortions occurred
- Any kind of complication in previous pregnancies.
- History of medical, surgical, or obstetric complication that may affect the present pregnancy
- Any familial disease that may affect the current pregnancy
- Menstrual history to calculate the expected date of delivery (EDD) by Naegele's formula (EDD = 1st date of last menstrual period + 9 months 7 days)
- History of drug allergies or any drug intake.
PHYSICAL EXAMINATION
Weight: Prepregnancy weight has to be recorded.
- Total weight gain during pregnancy for a normal pregnancy should be 10–12 kg.
- First trimester: 1–2 kg
- Second trimester: 2–3 kg
- Third trimester: 5–7 kg.
- In obese patients:
- Body mass index > 30, weight gains should be 6–8 kg
- Body mass index > 35, weight gain should be 3–4 kg.
- Excessive weight gain that is more than 3 kg per month or more than 500 g per week, preeclampsia, gestational diabetes mellitus (GDM), and twin pregnancies should be ruled out.
Pallor
To rule out anemia, pallor should be checked at lower palpebral conjunctiva, nails, tongue, oral mucosa, and palms. If pregnant female is pale of anemic, its causes should be determined by laboratory investigations and treatment should be started.
Edema
Physiological edema of pregnancy is seen in normotensive pregnant females. It is of pitting type, nontender, extends generally till ankle which appears in evening and disappears by morning is not related to albuminuria.
Pathological Edema
Pathological edema is edema above the ankle/hand/face/abdominal wall/vulva. It could be pitting or nonpitting and tender. It does not disappear completely after taking rest. If there is a presence of pathological edema, then hypertension, anemia, hypothyroidism, and filariasis should be ruled out.
Blood Pressure Monitoring
Regular blood pressure (BP) monitoring should be done in seated position with feet supported. BP should be taken in both the arms in 1st antenatal visit. The right arm should be used thereafter if there is no significant difference between the readings between left and right. Any BP of more than or equal to 140/90 over several readings is considered hypertension during pregnancy.
Breast Examination
Thorough breast examination should be carried out to rule out any existing breast lump. Also, nipple examination should be done to rule out flat, retracted nipple, or 3skin infection of areola. In case of retracted or flat nipples, corrective measures should be taught to the pregnant female to facilitate breastfeeding upon birth.
SPECIFIC HEALTH PROTECTION
Tetanus Toxoid
According to Ministry of Health and Family Welfare of India, administration of two dosage of tetanus toxoid (0.5 mL IM) is mandatory. The first dose should be given as soon as the pregnancy is registered. The second dose should be given 4–6 weeks apart preferably at least 1 month before the EDD. If a woman receives the first dose after 38 weeks of pregnancy, then the second dose may be given in postnatal period after a gap of 4 weeks. If a woman has been previously immunized with two doses of TT during her previous pregnancy within past 3 years, then she should be given only 1 dose of TT in present pregnancy.
Flu Vaccination
Flu vaccination should be given to all the pregnant women who are at risk of the disease.
Tetanus, Diphtheria, and Pertussis
According to the latest international recommendations, pregnant women should be given 1 dose of tetanus, diphtheria, and pertussis vaccination intramuscular (IM) in between 27 weeks and 36 weeks of pregnancy.
Folic Acid Supplementation
All women in the reproductive age group should be advised to have folic acid (recommended dose: 400 µg) for 2–3 months preconception and continue during pregnancy in the first 12 weeks to reduce the incidence of neural tube defect in the fetus.
Iron-folic Acid Supplementation
- Prophylactic dosage: All pregnant females should be given one tablet of iron-folic acid (IFA) (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days starting after the first trimester.
- Therapeutic dosage: If hemoglobin is less than 11 g/dL, then the patient needs to take two IFA tablets per day for 3 months and also investigation should be carried out and specific treatment should be given.
MENTAL PREPARATION
Pregnant woman should be talked to about the normal changes during pregnancy, mode of delivery, process of delivery, breastfeeding, and newborn care. Healthcare provider should also educate the family members of the pregnant woman to give supportive care as and when required.
FAMILY PLANNING
During antenatal checkups, pregnant women should be counseled about the spacing between births and various methods of family planning—temporary and permanent. She should be given the cafeteria choice of family planning methods and she should be helped to choose one in order to keep her health and her children's health in good condition.