Ante Natal Care

Ante Natal Care (ANC)

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

AIMS 

There are three main purposes to antenatal care:

1. health promotion, health education 

• Identify high risk pregnant woman 

2. preparation for labor and puerperium 

• Social and psychological support 

3. parenthood and surveillance of risk. 

• (providing appropriate surveillance for all pregnancies in the hope of identifying the small number that develop complications, with the aim of optimizing the outcomes for both the mother and her baby). 

Outcome of Antenatal Care 

Outcome or impact : 
To reduce maternal and neonatal mortality and morbidity rates.

FACTORS AFFECTING PREGNANT WOMEN:

1. Demographic and Biological Factors 
2. Socioeconomic Factors 
3. Psycho-social Factors 
4. Health Services Factors 
5. Environmental Factors

Assessment and physical examination

ANC

Care is often based on a traditional arrangement of antenatal visits. The schedule varies, with the initial, or ‘booking’ visit, ideally between 8 and 10 weeks, with subsequent visits 4-weekly until 30 weeks; 2-weekly until 36 weeks and then weekly thereafter.

The booking visit 

• The purpose of the antenatal booking visit is to detect any risk factors that may indicate the necessity of extra surveillance above that provided to ‘low-risk’ women. It is also an opportunity to identify any social difficulties and to discuss the parents’ own wishes for the pregnancy and delivery. 
• Past obstetric history 
• Medical and surgical history 
• Family history 
• History of present pregnancy 
• Social and drug history 
• Mental health 
• Examination

History

• Welcome the woman, and ensure a quite place where she can express concerns and anxiety without being overheard by other people. 
• Personal and social history: This include: woman’s name, age, occupation, address, and phone number. marital status, duration of marriage, Religion , Nationality and language, Housing and finance 

Menstrual history 

• Duration of menstruation. 
• Cycle length. 
• Regularity of the cycle 
• LNMP (last normal menstrual period) 
• EDD (expected date of delivery) 
• Duration of pregnancy equql to 280 days since first day of LMP, 266 days from day of ovulation. 
• By adding 9 months and 7 days to first day of LMP we can calculate EDD, provided regular 28 days cycle length. If for example cycle length of a regular cycle is 21 days we add 9 months only. On the other hand sh has a regular cycle of 35 days we add 9 months and 14 days to LMP.

Current problems with pregnancy : 

Ask the patient if she has any current problem, such as: 

- Nausea & vomiting. 
- Abdominal pain. 
- Headache. 
- Urinary complaints. 
- Vaginal bleeding. 
- Edema. 
- Backache. 
- Heartburn. 
- Constipation.

Obstetrical history: 

This provides essential information about the previous pregnancies that may alert the care provider to possible problems in the present pregnancy. Which includes:

• Gravida, para, abortion, and 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.

Medical and 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, and cervical cerclagc. 
• Accidents involving 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:
- D.M. 
- Hypertension. 
- Heart disease. 
- Cancer. 
- Anemia.

Physical examination 

Physical examination is important to: 

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

General Examination 

It should be started from the moment the pregnant woman walks into the examination room. 
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.

Vital signs: 

• Blood pressure:

1.  It is taken to ascertain normality and provide a baseline reading for a comparison throughout the pregnancy. 
2. 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.

• Pulse:

1. The normal pulse rate = 60-90 BPM. 
2. Tachycardia is associated with anxiety, hyperthyrodism, or infection.

• Respiratory rate:

1. The normal is 16-24 BPM. 
2. Tachypnea may indicate respiratory infection, or cardiac disease.

• Temperature: 

1. normal temperature during pregnancy is 36.2C to 37.6C. 
2. Increased temperature suggests infection.

Cardiovascular system: 

• 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.

Musculoskeletal system 

• 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.

Height & weight:

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. 

Recommendation for weight gain during pregnancy are often made based on the woman’s body mass index.

Observe the neck for enlarged thyroid gland and scars of previous operations.

• 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.

Abdomen: 

• The size of the abdomen is inspected for:

- the height of the fundus, which determines the period of the gestation. 
- multiple pregnancy.

• The shape of the abdomen is inspected for: 

- fetal lie & position. 
- the abdomen is longer if the fetal lie is longitudinal as occurs in 99.5% of cases. 
- 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.

1-Inspection: 
The nurse should look at the following: 

1. Skin changes such as linea nigra, striae gravidarum and scars of previous operations. 
2. The size of the abdomen is inspected for: 
3. Height of the fundus, which determines the period of gestation. 
4. Multiple pregnancy and polyhydramnios will enlarge both the length and breadth of the uterus. 
5. A large fetus increases only the length of the uterus.
6. Contour of the abdominal wall is observed for pendulous abdomen, lightening protrusion of umbilicus and full bladder 

2-Palpation :
The uterus will be palpable per abdomen after the 12th week of gestation
Abdominal palpation includes 

1. Estimation of the period of gestation. This is done by determination of fundal height.
2. Calculations: 

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

1. 12 weeks :the uterus fills the pelvis so that the fundus of the uterus is palpable at the symphysis pubis . 
2. 16 weeks, the uterus is midway between the symphysis pubis and the umbilicus. 
3. 20 weeks, it reaches the umbilicus 

Skin  

• Pallor of the skin my indicate anemia. 
• Jaundice may indicate hepatic disease. 
• Chloasma and linea nigra related to pregnancy. 
• Striae graviderum should be noted. 
• Nail beds should be pink with instant capillary return.

Legs:

• Legs should be noted for edema. 
• They should be observed for varicose veins 
• The calf must be observed for reddened areas which may be caused by phlebitis and white areas which could be caused by deep vein thrombosis. 
• Ask the woman to report tenderness during examination. 
• The legs should be observed for unequal length or muscle wasting which may be an indication of pelvic abnormalities. 

Breast

Assess breast size, symmetry, condition of nipple, and the presence of colostrum.

Gastrointestinal systems  

1. 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

     2. Intestine

• Assess for the bowel sound. Assess for constipation or diarrhea.

     3.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.

     4.Vaginal bleeding:

•  Vaginal bleeding at any time during pregnancy should be reported to the obstetrician to investigate its origin.

Laboratory data 

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

Ultrasound  

Is perform

• estimate the gestational age. 
• Check amniotic fluid volume. 
• Check the position of the placenta. 
• Detect the multi-fetal pregnancy. 
• The position of the baby.

Fetal kick count: 

• The pregnant woman reports at least 10 movements in 12 hours. 
• Absence of fetal movements precedes intrauterine fetal death by 48 hours.

Schedule of antenatal care: 

• 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

Services at subsequent visits: 

• the nurse inquires about physical changes that are related directly to the pregnancy, such as the woman’s perception of fetal movement, any exposure to contagious illness, medical treatment and therapy prescribed for non-pregnancy problems since the last visit, 

• prescribed medications that were not prescribed as a part of the women’s prenatal care. 

health education: 

• Follow up: 

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

Health promotion during pregnancy begins with reviewing health hare.

Hygiene: 

• 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, maxilla, and breast due to increased discharge and sweating. 
• Vaginal douches should avoided except in case of excessive secretion or infection.

Danger signs of pregnancy 

1. Vaginal bleeding including spotting. 
2. Persistent abdominal pain. 
3. Sever & persistent vomiting. 
4. Sudden gush of fluid from vagina. 
5. Absence or decrease fetal movement. 
6. Sever headache. 
7. Edema of hands, face, legs & feet. 
8. Fever above 100 F( greater than 37.7 C). 
9. Dizziness, blurred vision, double vision & spots before eyes. 
10. Painful urination.

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. 

 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.

Purpose:

1. To develop a good posture. 
2. To reduce constipation & insomnia. 
3. To alleviate comfortableness, postural back ache& fatigue. 
4. To ensure good muscles tone& strength pelvic supports. 
5. To develop good breathing habits, ensure good oxygen supply to the fetus. 
6. to prevent circulatory stasis in lower extremities, promote circulation, lessen the possibility of venous thrombosis

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.

Contraindications: 

• Vaginal bleeding. 
• Sever anemia. 
• History of preterm labor, 
• Extreme over or under weight. 
• Hypertension, heart, lung, thyroid diseases

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 hypo-tension 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