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Ante Natal Care

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.

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Ante Natal Care

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  1. Ante Natal Care

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

  3. Aim To deliver a healthy baby from a healthy mother.

  4. Objectives: • Promote, protect & maintain health of pregnant woman. • Detect high risk cases & provide special attention. • To foresee complications & prevent them.

  5. 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.

  6. 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

  7. When should prenatal care start?

  8. IDEALLY, a woman planning to have a child should have a medical evaluation before she becomes pregnant.

  9. Frequency of ANC’s • First check up by 45 days • Monthly till 28 weeks • Fortnightly till 36 weeks • Weekly till EDD • Admission around EDD

  10. 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

  11. Methods: • History taking • Examination • Immunization & hematinic prophylaxis • Investigations • Advice: diet warning signals

  12. History • LMP/ EDD: previous menstrual history (3 cycles) • Conception: spontaneous/ assisted • Pregnancy Confirmation: time & method • Supervision of Pregnancy

  13. Age: Teenage pregnancy: CPD Anemia PIH Elderly primi:Down’s syndrome PIH GDM Anemia

  14. Husband’s Occupation: Socio-economic status Risk of STD/ AIDS • Previous Obstetric History: Recurrent Pregnancy Loss Preterm Labor APH PPH Labor complications

  15. Married Life: Previous pregnancies Low fecundity group • Past History: Allergy to drugs Previous operations Known medical disorders h/o blood transfusion

  16. Family History: Hypertension Diabetes Hemophilias Twins

  17. Examination • Height: < 145 cm  CPD • Weight: total weight gain: 10 – 12 kg 1st trimester : 1 – 2 kg 2nd trimester : 5 kg 3rd trimester : 5 kg

  18. Excessive Wt.:> 0.5 kg/ wk > 2 kg/ month seen in: Hydramnios Diabetes Twins PIH (earliest sign)

  19. If initial wt < 40 kg:↑ chances of IUGR • No ↑ in weight: IUD IUGR

  20. Gait: polio spinal abnormalities • Pallor • Pedal edema • Thyroid enlargement • Vital Signs: pulse, BP • CVS, RS

  21. Abdominal examination • Inspection: Striae Gravidarum, Linea albicans/ nigra Previous Scar Lie: longitudinal/ transverse • Palpation: Grips: fundal, lateral, 1st & 2nd pelvic • Auscultation: FHS

  22. Vaginal Examination Indications to do p/v in pregnancy: • Assess the pelvis at term • 1st trimester: • To confirm diagnosis of pregnancy • If uterus corresponds to POG • Intra/ extra-uterine pregnancy • Cervical length

  23. First Trimester • Ideally with in 45 days • Confirm pregnancy with tests: History taking (incl. LMP – EDD) Complete examination Urine test • Vital signs

  24. Routine investigations: Blood:ABO, Rh HIV, HBsAg, VDRL Hb. Urine:Protein Sugar Pus cells Culture & sensitivity

  25. USG: • Confirm pregnancy • Intra/ extra – uterine • Single/ multiple gestation • Viable/ non viable • Cervical length (after 12 weeks)

  26. 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

  27. 2ND Trimester (13 – 28 weeks) • 1 ANC / month till 28 weeks • History: quickening complications: PIH IUGR Hydramnios Anemia UTI Fever, etc

  28. 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 previousdose) • USG: fetal anomaly scan

  29. 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)

  30. Plan Delivery: Time Mode: Vaginal: spontaneous/ induced Abdominal

  31. Warning Signs of Pregnancy: • Bleeding p/v: Ectopic pregnancy Abortion Vesicular mole APH • White/ excessive watery discharge: Candidiasis Trichomoniasis Bacterial vaginosis Prom Circumvalate placenta

  32. Persistent ↑ / ↓ fetal movements: Fetal distress • Breathlessness:Heart disease Hydramnios Twins PIH • Headache: PIH

  33. Visual disturbances: PIH • Epigastric pain: PIH Heart Disease PTL • Burning micturition: UTI • Excessive vomiting: Hyperemesis g. Vesicular mole

  34. Thank You

  35. Nutrition and Micronutrients in Pregnancy

  36. Nutritional Interventions in Pregnancy • Nutrition • Micronutrients • Folic Acid • Iron • Iodine • Calcium • Zinc • Vitamin A • Vitamin D • Vitamin K • Copper • Selenium • Magnesium

  37. Nutritional Interventions in Pregnancy What is Their Effect on Pregnancy outcome?

  38. 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.

  39. 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

  40. 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.

  41. - Vitamin A Vertical transmission of HIV, Maternal anemia, Infection, Maternal mortality. • Vitamin D neonatal hypocalcaemia. • Vitamin K haemorrhage. • Copper anaemia, anencephaly, LBW • SeleniumNTD, dysfunction of brain & CVS, abortion. • Magnesium blood coagulability, toxaemia, preterm birth.

  42. 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

  43. 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

  44. 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.

  45. 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

  46. Routine vs. Selective iron supplementation: • Routine iron & folate supplementationwhere nutritional anemia is prevalent • Recommended dose: 60 mg elemental iron+ 500 g folic acid

  47. 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 atpreconception up to mid-pregnancy period

  48. 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.

  49. 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

  50. Zinc and pregnancy outcome Zinc – involved in: • 300 enzymes, • nucleoprotein, • DNA and protein synthesis, • cell division. Serum zinc levelsin pregnant women: • Normal range: 7-10 mol/l •  • No change • 

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