Antenatal care began as a social service in Paris in 1788 for women who had the double inconvenience of being both pregnant and destitute. The problem of disposal seems to have been a more pressing objective than treatment or preventive care.

Antenatal clinics constitute screening clinics because they are often the only time a healthy young women will visit her doctor. It may be the first time a woman has been physically examined in her life. Breast palpation and cervical smears should be included in routine examination during such visits. Incidental diseases such as diabetes, HIV and renal disorders should be detected at a very early stage and the necessary treatment be given. General advice and education should be given when ever possible to both mother and father on what to expect and do in pregnancy and labour and about the care of the infant.

Aims of Antenatal Care

• Assessment and management of maternal risk and symptoms
• Assessment and management of fetal risk
• Prenatal diagnosis and management of fetal abnormality
• Diagnosis and management of perinatal complications
• Decision regarding timing and mode of delivery
• Parental education regarding pregnancy and childbirth
• Parental education regarding child rearing

Schedule of Antenatal visits during pregnancy:

A pregnant woman must have at least 3 antenatal visits during pregnancy other than registration. First before 16-20 weeks, second at 32 weeks and third at 36 weeks. The traditional pattern, a monthly examination until 28 weeks, then fortnightly until 38 weeks and weekly thereafter, has much to recommend it.

Booking visits (8-14 weeks): - The main aim of a booking visit (registration visit; enrolment visit) is to obtain a comprehensive history, to establish the gestational age and identify maternal and fetal risk factors. Enquiry about maternal age is one of the oldest sceening test in the history of antenatal care. The mother's age is particularly important because of increased risk of chromosomal abnormalities with maternal age, while the incidence of spontaneous abortion is also higher among older women.

Table 1. shows a checklist of the most common problems that can be identified at a booking visit. It is important that women are given an opportunity to discuss problems at an early stage in the pregnancy and that remedial action is initiated. Acceptance of the pregnancy, emotional support, and strengthening of the women's social network help to promote health of the mother and prospective baby.

Menstrual History

For the majority of pregnancies, the most important question is "how old is the fetus?" This can be established by knowing the date of the last menstrual period.

• Date of last menstrual period
• Whether it was normal in amount and duration?
• Whether it came at the correct time?
• The cycle length
• Whether O.C had been taken recently?
• When the first symptoms of the pregnancy occurred and how these compared to their time of quickening?

Calculate the expected date of delivery (EDD) using Naegle's rule: 280 days from the first day of the last menstrual period (LMP).This is easily done by adding 7 days to the date of the LMP and then going forward 9 months. This rule is based on a menstrual cycle of 28 days and assumes ovulation occurred mid-cycle. Where the cycle is regularly greater than or less than 28 days the calculation has to be adjusted accordingly, e.g. add a further 7 days for a 35 day cycle and subtract a further 7 days from a 21 day cycle.

Obstetric history

The previous obstetric history has an important bearing on outcome of her present pregnancy. A detailed account of her past pregnancies, date and year of their occurrence, outcome of each pregnancy and any obstetric complications at the time should be documented. Details about the baby i.e. sex, gestational age, mode of delivery, weight at birth, should be asked.

A gravida is a woman who is or has been pregnant, irrespective of the pregnancy outcome. With the establishment of first pregnancy she becomes a primigravida , and with successive pregnancies she becomes a multigravida.

A nulligavida is a woman who is not now and never has been pregnant.

A primipara is a woman who has been delivered only once of a fetus or fetuses who reached viability.

A multipara is a woman who has carried two or more pregnancies to viability. It is the number of pregnancies reaching viability and not the number of fetuses delivered that determines parity.

A nullipara is a woman who has never completed a pregnancy beyond an abortion. She may or may not have had an abortion.

It is customary to describe the patient by her parity and gravidity as G, P. e.g. a G3 P1 would mean the patient is pregnant for the third time but has carried only one pregnancy to viability.

Contraceptive History

• Details of method used
• If hormonal, when was the pill discontinued?
• Was the pregnancy planned?
• Length of time trying to conceive.

Family history

Hypertension

Diabetes in 1st degree relative

Genetic disorder

Twins

Social history

Marital status

Working

Alcohol intake

Smoking

Home and Family Situation

General recommendations at the booking visit

Prenatal diagnosis

The facilities for prenatal diagnosis and screening should be explained if available for high-risk patients.

Diet, smoking and alcohol

A good balanced diet should be advocated, within the mothers' purchasing power. The routine use of iron and folic acid supplements to prevent anemia is now less common than formerly. As many women, have poor iron reserves in pregnancy iron should be routinely prescribed.

Exercise and work

Most mothers should be encouraged to see pregnancy as a healthy state and normal activity, both domestic and recreational, should be continued. Outside employment usually continues till term- increasingly women, especially professional groups continue to work until term. They should make efforts to ensure adequate rest.

Coitus

Intercourse is not contraindicated in pregnancy.

Drugs

Mother should be advised to refrain from taking any medicine unless authorized by her physician.

Bowel action

Constipation is common in pregnancy and should not be a cause for concern. A diet high in fruit and vegetables helps and mild laxatives may be taken as required.

Visits in the last 2 trimesters

The 2nd trimester is usually a quite time when attention is focused upon:

• The observation for gestational age and occurrence of multiple pregnancies.
• Uterine irritability, amniotic fluid volume, occurrence of IUGR
• Early detection of anemia and hypertension

Visits in the last trimester: Attention is focused upon:

• Fetal age, growth and maturity
• Fetal well being
• Maternal complications of pregnancy and maternal well- being
• Mechanics of pregnancy
• Preparation for labour-induced labor
• Education for pregnancy, labour, breast feeding, infant care and counseling in family planning

At each visit the precise gestational age should be calculated. If the date of the LMP is certain; if there are reliable observations in early pregnancy; if USG has been performed before the 28th week; and if all observations are in agreement, the calculation is a matter of routine. If not, the clinician must weigh the evidence and make the best estimate, as it is against the gestational age than most other observations are assessed.

The assessment of fetal well-being is important and can be done by measurement of fetal movements by study of fetal heart, antenatal cardiograph, non-stress test and by the bio-physical profile. However, under field conditions a simple yet accurate assessment can be done by identification of risk factors and simple clinical observation of weight gain, fetal movements and uterine height.

Physical Examination of the Pregnant Woman

The patient's height and weight are recorded at the first visit and a respiratory and cardiovascular examination performed to exclude any complications in these systems. There is an increased risk of perinatal complications with a maternal weight <45 or >100kg.

Maternal weight needs to be recorded only at booking; with the exception of patients in whom nutrition is of concern. Lack of weight gain in pregnancy or excessive weight gain may provide an indication of impaired placental function and possible fetal compromise. Failure to gain weight in pregnancy at a rate of approximately 272g/week from the 20th to 36th week is associated with a trebling of perinatal mortality, due to prematurety. Excessive gain in weight (of 635g or more per week) in the same period is associated with a trebling of perinatal mortality due to pre eclampsia. One should estimate the amount of weight gain since last visit [0.5kg/week for the number of weeks since last visit] and compare with the actual weight gain

Examination:

Abdominal Examination: Make sure that the patient looks comfortable, is lying semi-recumbent and has a sheet covering her waist and legs. One must examine from the woman's right side.

Inspection: Assess shape and size of the uterus, any obvious asymmetry of the abdomen, and fetal movements. Look for surgical scars.

Palpation: Firstly, measure the fundal height by placing the ulnar border of the left hand gently in the fundus of the uterus, and measuring with a tape in cm to the symphysis pubis. The measurement in cm should give an estimation of gestational age in weeks i.e. +/- 2 cm from 20-38 weeks. The bladder must be emptied before any measurement. A full bladder can make the fundal height 3 cm higher.

Then palpate for fetal poles to determine presentation and lie.

To establish head engagement in 3 rd trimester, it is better to gently palpate with both hands facing down over the abdomen as shown in the Fig. 2.

After you have palpated the uterus, gently palpate for kidney tenderness and liver and spleen enlargement..

Measure fundal height from top of symphysis pubis:

• 12 weeks: Palpable abdominally just at the symphysis pubis
• 16 weeks: Palpable midway between the symphysis and the umbilicus
• 20 weeks: Palpable at the umbilicus
• 20 to 32 weeks: Height in centimeters above symphysis parallels gestational age in weeks.

Auscultation: One should auscultate for fetal heart with a foetoscope. Normal fetal heart rate is 120-160 beats/min. Heart rates above 160/min or less than 120/min indicates fetal abnormality. In essentially all pregnancies the fetal heart sounds can be auscultated between 16 and 19 weeks using a Dee Lee stethoscope. By 22 weeks the fetal heart sounds are audible in pregnant women.

Blood Pressure: Measure B.P in the semi-recumbent posture (45 0­). The diastolic blood pressure is taken at Kortokoff (IV) (muffling) and not V (disappearance) of sound. Taking Kortohoff V, some women may have diastolic B.P of zero.

Edema: Edema is characterized by pus of face, swollen fingers and swelling of abdominal pain. (Stethoscope will leave an impression). Pre-tibial edema is checked by pressure for 15 seconds and seen if a pit is formed.

Breast examination: The real value of breast exam is to pick up any suspicious masses. The 5-year survival in breast cancer detected in pregnancy is 50% of that in age-matched non-pregnant women. Detection of inverted or retracted nipples is done and the womann advised accordingly.

Thyroid: Examination of thyroid gland is an essential part of the first assessment. Although rarely found, a goiter could be present.

A typical exam at each antenatal visit should include:

• B.P
• Check for edema, fingers, pre tibial
• Symphysis Fundal height
• Presentation
• Lie
• Engagement
• Fetal heart auscultation

Investigation

Booking [8-14 weeks]

• Blood
• Hemoglobin and full blood count
• Microbiological: hepatitis B
• VDRL for syphilis
• Rubella
• USG: A mid trimester scan provides the most detailed study of the fetus and uterine contents. It is the most comprehensive examination an individual will ever receive for the remainder of her life. The aim of this scan is to provide an accurate measurement of the gestational age if an early scan has not been improved by measurement of biparietal diameter,

1. First trimester: crown-rump length predicts the estimated date of confinement .to within 7 or 10 days.
2. Second trimester: Biparietal diameter (BPD) or femur length predicts EDC to within 7 to 10 days.
3. Third trimester: Scans postponed to this time period are not very helpful in predicting the EDC and are accurate only to within 3 weeks either way.

Carry out detailed anatomical survey to rule out any structural abnormalities.

Establish presence of multiple pregnancy and determine chorionicity locate to placenta .

Advice Given During Pregnancy

1. Iron and folic acid to be taken for at least 100 days.
2. Two injections of T.T to be taken 4-6 weeks apart; first dose whenever the patient comes for antenatal visit. Only one dose of T.T is required if previous childbirth was within three years.
3. To avoid hard and strenuous activity She should take extra meals including fruits, vegetables, carbohydrates and proteins
4. Should sleep for 8 to 10 hours at night and 2 hours in day time
5. She should immediately consult the obstetrician if she has any of the following whether during the day or night (box).

Delay could have severe implications for both mother and the baby.

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• Acute leg pain and swelling
• Vaginal bleeding
• Abdominal pain including contractions
• Severe or continuous headache
• Swelling of face or fingers
• Persistent vomiting
• Chills and fever
• Dysuria
• Cessation or marked change in frequency or intensity of fetal movements
• Collapse including convulsions.
• Escape of fluid from vagina

Internal examination

A pelvic examination is usually not necessary unless specifically indicated or prior to induction of labor. To perform a digital pelvic examination, ask the patient to lie comfortably on her back, usually with a tilt and the knees down up with the ankles together . Both hands should be gloved, the fingers of the left hand gently part the labia ,with the index and forefinger of right hand gently introduced within the vagina. This may be advanced till cervix is reached. In later pregnancy, the cervical length and consistency will provide information on the stage of labor. [Bishop's score] and this allows an assessment of favorability for induction of labor.

A digital examination should not be performed with suspected placenta previa [risk of precipitating hemorrhage] or when there is preterm rupture of membranes [risk of introducing infection]. Same applies when consent is withheld .

Advice on Use of Various Vaccines During Pregnancy:

Live Virus Vaccine

Measles: contraindicated

Mumps :contraindicated

Poliomyelitis: not routine; increased risk of exposure

Yellow fever----travel to high risk areas only

Inactivated Bacterial Vaccine

Cholera: to meet international travel requirements

Pneumococcus: same as non pregnant

Plague: selective vaccination of exposed persons

Typhoid: travel to endemic areas

Hyper Immune Globulin

Hepatitis B: post exposure prophylaxis; give along with Hepatitis B vaccine initially, then vaccine alone at 1 and 6 months

Rabies: post-exposure prophylaxis

Tetanus: post-exposure prophylaxis

Varicella: Consider for post exposure (within 96 hours)

Inactive Virus Vaccines

Influenza: Underlying Disease

Rabies: same as non pregnant

Hepatitis B: at high risk and negative for B antigen

Toxoids

Tetanus: diphtheria - same as non pregnant

Pooled immune serum globulins

Hepatitis A: post-exposure prophylaxis

Measles: post-exposure prophylaxis

Recommended Intervals for Routine and Indicated Tests and Procedures During Prenatal Care

TIME (WK)	ASSESSMENT
Initial	Hemoglobin Urinalysis, including microscopic examination and infection screen Blood group and D type Antibody screen Rubella antibody titer Syphilis screen Cervical cytology Hepatitis B virus screen
8-18	Ultrasound Amniocentesis Chorionic villous sampling
16-18	Maternal serum alpha-fetoprotein
26-28	Diabetes screening Repeat hemoglobin or hematocrit
28	Repeat antibody test for un sensitized D-negative patients Prophylactic administration of anti-D immune globulin Repeat hemoglobin