Quality ANC For ANM

Antenatal Care
Quality
By
Dr. Animesh Das

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 complicated
conditions that could endanger the life or impair
the health of the mother or the fetus.

Presumptive Signs
Of Pregnancy
These signs are least indicative of
pregnancy; they could easily
indicate other conditions.
Signs lead a woman to believe that
she is pregnant

Amenorrhea.
Breast Changes.
Tangling Sensation In Breast.
Chlosma & Linea Nigra.
Abdominal Enlargement.
Striae Gravidarum.
Nausea & Vomiting.
Frequent Urination.
Fatigue.

And
Sensations of fetal movement in
the abdomen. Firstly felt by the
patient at approximately 16 to
20 weeks.

Definitions
It is a planed examination and observation
for the woman from conception till the
birth .
********* OR *********
Antenatal care refers to the care that is
given to an expected mother from time of
conception is confirmed until the
beginning of labor

Assessment
&
physical examination

Complete
History
1st
Appointment
Estimated
Date Of
Delivery
Physical
Examination
Laboratory
Tests
Plan to next
visits
Patient
Education

Assessment
The initial assessment interview can
establish the trusting relationship
between the nurse and the pregnant
woman.
******* & *********
Getting information about the woman’s
physical and psychological health &
guidance for pregnancy .

During the first visit,
assessment and
physical examination
must be completed.

History
Physical examination.
Laboratory data.
Psychological assessment.
Nutritional assessment.

Welcome the woman,
and ensure a quite place
where she can express
concerns and anxiety
without being overheard by
other people.

History
Names of patient, partner, emergency contact
Marital status
Age
Home address
Telephone numbers for day, night, emergency
Education
Occupation
Partner's name and occupation
Pediatrician
Primary care physician
Hospital for delivery
Religion

A Compete Menstrual History Is Important To
Establish The Estimated Date Of Delivery.
Last menstrual period (LMP).
Age of menarche.
Regularity and frequency of menstrual
cycle.
Contraception method.
Any previous treatment of menstrual

EDD
Expected Date of
Delivery

1st day of LMP −3
months
+7 days,
& change the year.

Example
LMP was 9th September,
2013.

Month Day Year
September 9 2013
(-3 ) June 9+7 days +1
----------------------------------------------------
June 16 2014

So,
EDD
Will Be
June 16, 2014.

Obstetrical History
Gravida, Para, Abortion & 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.

Ask For Current Problems
Nausea & Vomiting.
Abdominal pain.
Headache.
Urinary complaints.
Vaginal bleeding.
Edema.
Backache.
Heartburn.
Constipation.

Medical & Surgical History
Chronic condition such as Diabetes Mellitus,
Hypertension, and Renal Disease can affect the
outcome of the pregnancy and must be
investigated.
Prior operation, allergies, and medications
should be documented.
Previous operations such as cesarean section,
genital repair & injury of the bony pelvis

Family History
Family history provides valuable information
about the general health of the family, and it
may reveal information about patters of genetic
or congenital anomalies.
Including:
Diabetes Mellitus.
Hypertension.
Heart disease.
Cancer.
Anemia

Why
Physical Examination
is so necessary ?

To detect previously undiagnosed
physical problems that may affect the
pregnancy outcome.
----------------------------
To establish baseline levels that will
guide the treatment of the expectant
mother and fetus throughout
pregnancy.

General Examination
Examine General Appearance
Observe the woman for stature or 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.

It is taken to ascertain normality and
provide a baseline reading for a
comparison throughout the
pregnancy.
In late pregnancy, raised systolic
pressure of 30 mm Hg or raised
diastolic pressure of 15 mm Hg
above the baseline values on at least
two occasions of 6 or more hours
apart indicates toxemia.

The normal pulse rate
60-90 PM.
Tachycardia is associated with
Anxiety, Hyperthyroidism, or
Infection.

Respiratory Rate
The normal is 16-24 PM.
Tachypnea may indicate
Respiratory Infection
or
Cardiac Disease.

Temperature
Normal temperature during
pregnancy is
36.2 C to 37.6 C.
Increased temperature suggests
infection.

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
signs of pregnancy-induced
hypertension.

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.

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,
pregnancy induced hypertension, cesarean
birth, and postpartum infection

Pelvic Measurement
The bony pelvis is evaluated early in
the pregnancy to determine whether
the diameters are adequate to permit
vaginal delivery.

* Observe complexion for presence of blotches.
* Ensure that the general manner of the
woman indicates vigor and vitality.
* An anemic, depressed, tired or ill woman is
lethargic, not interested in her appearance, and
unenthusiastic about the interview.
* Lack of energy is a temporary state in early
pregnancy, a woman often feels exhausted and
debilitated.
* Discuss the woman's sleeping patterns and
minor disorders and give advice as necessary.
* Report any signs of ill health.

Observe the Neck for
enlarged
Thyroid gland
and
Scars of previous
Operations.

Fetal lie & Position
The abdomen is longer if
the fetal lie is longitudinal
as occurs in 99.5% of
cases.

But
The abdomen is lower
& broad if the lie is
transverse.

Fetal movement is inspected as
evidence of fetal life and position.
Fetal Heart Beat can be heard by
stethoscope after the 20th week, or
Doppler after 8th week. Normal
fetal heart rate is 120-160
beats/min.

The uterus will be
palpable per abdomen
after the 12th week of
gestation

Abdominal Palpation
Estimation of the period
of gestation. This is done
by determination of
fundal height.

Uterus may be Higher than
expected
Large fetus,
Multiple Pregnancy
Polyhydrammnios
Mistaken date of LMP

Uterus may be Lower than
expected
Small fetus,
Intrauterine growth restriction
Oligohydramnios
Mistaken date of LMP.

Fundal Palpation
Fundal palpation is performed
to determine whether it
contains the breech or the
head. This will help to diagnose
the fetal lie and presentation.

Calculation
Of
Gestation
Using Fundal Height

McDonald’s method: Measure
from symphasis pubis to top of
fundus in cm.
Gestation is measurement
+ or – 2 weeks

By
12 Weeks
The uterus fills the pelvis so
that the fundus of the uterus
is palpable at the symphysis
pubis .

By
16 weeks
The uterus is midway
between the symphysis
pubis and the umbilicus.

By
20 weeks,
The uterus reaches the umbilicus

Firm, smooth, and a
hard continuous
structure, it is likely to
be the fetal back

If smaller, knobby,
irregular, protruding, and
moving, it is likely to be
the small body parts
(extremities).

Assess Breast Size
Symmetry Of Both Breast
Condition of nipple.
Presence of colostrum.
Guide For Breast Care

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.

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.

Blood Routine Examination
Blood Group
Urine Analysis
Glucose
Stool Analysis
VDRL

Hemoglobin will be repeated:
At 36 weeks of gestation.
Every 4 weeks if Hb is <9g/dl.
If there is any other clinical
reason.

The pregnant woman
reports at least 10
movements in 12 hours.

Absence of fetal
movements precedes
intrauterine fetal death
by 48 hours

A medical check up every four
weeks up to 28 weeks gestation
Every 2 weeks until 36 weeks
of gestation
Visit each week until delivery

More frequent visits may be
required if there are
abnormalities or
complications or if danger
signs arise during
pregnancy

Please
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.

Health Teaching
During
Pregnancy

Daily all over wash is necessary because it is
stimulating, refreshing, and relaxing.
Warm shower or sponge 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.

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). Daily to remove the colostrum
& reduce the risk of infection.
It is not recommended to massage the breast, this may
stimulate oxytocin hormone secretion and possibly
lead to contraction.
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.

Dental Care
The teeth should be brushed carefully in the
morning and after every meal.
Encourage the woman the 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.

Dressing
Woman should avoid wearing tight cloths such
as belt or constricting bans on the legs, because
these could impede lower extremity circulation.
Suggest wearing shoes with a moderate to low
heel to minimize pelvic tilt & possible backache.
Loose, and light clothes are the most
comfortable.

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.

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.

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.

Guide lines for exercises during pregnancy
Maintain adequate fluid intake.
Warm up slowly, use stretching exercises but avoid over
stretching to prevent injury to ligaments.
Avoid jerking or bouncing exercises.
Be careful of loose throw rugs that could slip& cause
injury.
Exercises on regular basis (three times per week).
After first trimester, avoid exercises that require supine
position.

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, because the
highest level of growth hormone secretion
occurs at sleep.
Advise woman to use natural sedatives such as:
warm bath & glass of worm milk.

A good sleeping position is sims’
position, with the top leg forward. This
puts the weight of the fetus on the bed,
not on the woman, and allows good
circulation in the lower extremities.
avoid resting in supine position, as
supine hypotension syndrome can
develop.

Immunization
The nurse instructs the woman to receive
immunization against -tetanus to prevent the
risk for her and her fetus.
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

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.

Intestinal motility
decreased during
pregnancy as a result of
progesterone.
Iron supplementation.

Management
The food should have amount of fruit &
green vegetables which contain fibers.
Drinking a lot of water.
Exercise & walking.
Laxatives could prescribed by
physician.

Cause
Occur due to the pressure of
the growing uterus on the
bladder.

Management
The problem will resolved when the
uterus rises into the abdomen after the
12th week.
Kegel exercises are some times
recommended to help maintain the
bladder.

Causes
Backache may be due to muscular fatigue and
strain that accompany poor body balance.
It may be due to increased lordosis during
pregnancy in an effort to balance the body.
The pregnancy hormones sometimes soften the
ligaments to such a degree that some support is
needed.

Management
Regular Exercise.
Sit with knee slightly higher than the hips.
The pregnant woman is reassured that
once birth has occurred, the ligaments will
return to their pre-pregnant strength.

Causes
Progesterone hormone relaxes the
cardiac sphincter of the stomach and
allows reflex or bubbling back of
gastric contents into the esophagus.
The pressure of the growing uterus on
the stomach from about 30-40 weeks.

Management
Avoid lying flat.
Sleeping with more pillows and lying on
the right side.
Small frequent meals.
Take antacids.
Taking baking soda in a glass of water is
contraindicated because of the possibility
of retention of sodium and subsequent
edema
Avoid fried ,spicy, and fatty food
Avoid citrus juices

Obstetric disorders can impose a higher toll
on the mother and/or fetus:
Abruptia placentae
Prematurity
Postterm pregnancy
Preeclampsia-eclampsia
Polyhydramnios
Oligohydramnios
Growth restriction
Chromosomal abnormalities

Leading cause of maternal death
Thromboembolic disease
Hypertensive disease
Hemorrhage
Infection
Ectopic pregnancy

Vaginal bleeding
including Spotting.
Persistent Abdominal Pain.
Sever & Persistent Vomiting.
Sudden Gush of fluid from
vagina.

Absence
or
Decrease Fetal
Movement.

Sever Headache.
Dizziness Vision
Blurred Vision
Double Vision.
Spots Before Eyes.

Fever Above 37.7C.
Painful Urination.
High Blood Pressure
Sever Anemia (<7gm/dl)
Edema of hands, face, legs &
feet.

Presence Of Any Of These Signs
Refer The Patient To
Nearest Hospital
Immediately

Quality ANC For ANM

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