Ensuring proper ante-natal care is crucial for the well-being of both the mother and the baby during pregnancy. Regular check-ups, timely investigations, and appropriate interventions can help identify and address any potential risks or complications. In this article, we will provide a step-by-step guide to the ante-natal management of a normal pregnancy, highlighting the key aspects of each visit and the recommended tests and actions.
First Visit (Preferably in the First Trimester):
During the initial visit, the healthcare provider focuses on gathering essential information and conducting preliminary examinations. Here are the key components:
Age and Last Menstrual Period (LMP):
The healthcare provider will inquire about the woman's age and the date of her last menstrual period to estimate the gestational age accurately.
Ask and Examine:
Parity and obstetric history: Inquiring about previous pregnancies and any obstetric complications.
Medical history: Assessing for medical illnesses such as diabetes, hypertension, cardiac problems, epilepsy, or other chronic conditions.
Family history: Exploring the presence of genetic disorders, multiple pregnancies, infections (including tuberculosis), diabetes, or hypertension in the family.
Personal history: Discussing tobacco/alcohol intake.
Complaints: Addressing any excessive nausea and vomiting or vaginal bleeding.
Physical examination: Assessing height, weight, and calculating BMI. Checking for pallor, jaundice, pedal edema. Evaluating pulse, blood pressure, respiratory and cardiovascular functions. Conducting a thorough abdominal and pelvic examination, including P/S (per speculum) and P/V (per vaginum) examinations if necessary.
Essential tests: Hemoglobin levels to assess for anemia.
Desirable tests: ABO and Rh grouping, VDRL/RPR, HIV, HBsAg, and thyroid function tests. WHO OGTT/DIPSI test for the diagnosis of gestational diabetes mellitus (GDM).
Optional tests: Aneuploidy screen by ultrasound (USG) and double marker if adequate counseling facilities are available.
Provide a protection card or ANC card and register the woman on the RCH (Reproductive and Child Health) portal to generate an RCH number.
Give a filled MCH (Maternal and Child Health) protection card and a safe motherhood booklet.
Prescribe daily intake of folic acid tablets.
Administer the first dose of tetanus toxoid.
Second Visit (Second Trimester):
During the second visit, the healthcare provider focuses on monitoring the progress of the pregnancy and assessing the well-being of the mother and baby. Here are the key components:
Ask and Examine:
Inquire about any complaints since the last visit, quickening/fetal movements, and medication adherence.
Perform a physical examination, including weight measurement, assessment for pallor and pedal edema, and palpation of the abdomen to determine the fundal height.
Essential tests: Hemoglobin levels and urine albumin assessment.
Desirable tests: Level II USG between 18-20 weeks for the detection of gross congenital malformations. Repeat WHO OGTT/DIPSI test if >24 weeks and at least 4 weeks have elapsed since the first test.
Optional tests: Quadruple test (if available and with adequate counseling facilities).
Prescribe iron and folic acid (IFA) tablets and calcium carbonate with vitamin D tablets according to the woman's Hb levels.
Administer a single dose of albendazole.
Ensure compliance with investigations and treatment.
Discuss birth preparedness.
Administer the second dose of tetanus toxoid at least four weeks after the first dose.
Third (28 - 34 weeks) and Fourth Visit (36 - 40 weeks):
During these visits, the healthcare provider focuses on monitoring the progress of the pregnancy, assessing fetal well-being, and preparing for delivery. Here are the key components:
Ask and Examine:
Repeat the inquiries and examinations performed during the previous visits.
Auscultate fetal heart sounds.
Measure abdominal girth and symphysiofundal height to assess fetal growth and position.
Repeat essential tests: Hemoglobin levels and urine albumin assessment.
Optional test: USG for fetal growth and liquor volume if needed.
Continue the prescribed IFA and calcium tablets and ensure compliance.
Provide parenteral iron sucrose therapy if the patient is non-compliant or has Hb levels below 9g% (with specific dosage guidelines).
Refer patients with Hb levels below 7g% to a higher center.
Refer to a higher center if there is a discrepancy between fundal height and period of gestation.
Educate patients about the following danger signs and the importance of seeking medical attention if any of these occur:
Abnormal vaginal discharge
Palpitations, easy fatigability, and breathlessness
Decreased or absent fetal movements
Leaking of watery fluid per vaginum
Severe headache, blurring of vision, or convulsions
Decreased urine output or burning sensation during urination
Counseling at All Levels for High-Risk Pregnancy:
Highlight the importance of counseling for women with high-risk pregnancies, including those with medical illnesses, previous caesarean section, past obstetric mishaps, malnutrition, high blood pressure, gestational diabetes, multiple pregnancies, and other risk factors. Emphasize the need for tailored care and increased monitoring.
Guide women on birth preparedness, including:
Timing and place of the next ANC visit based on risk factors.
Rest, nutrition, balanced diet, and exercise.
Counselling for HIV testing.
Familiarity with danger signs.
Encouragement of institutional delivery.
Assessment of Fundal Height & Its Correlation with Gestational Age:
Explain the significance of measuring fundal height to estimate gestational age and monitor fetal growth.
Identification of the Following:
Facility for delivery.
Support persons and birth companion.
Means of transport in case of emergencies.
Blood donors (if required).
Proper ante-natal management of normal pregnancies plays a vital role in ensuring the health and well-being of both the mother and the baby. Regular visits, appropriate investigations, and timely interventions help identify and address any potential risks or complications. By following the guidelines outlined in this comprehensive guide, healthcare providers can provide optimal care and support to pregnant women, contributing to positive pregnancy outcomes.
Note: The guidelines and recommendations mentioned in this article are based on expert opinions, available scientific evidence, and the guidelines provided by the Indian Council of Medical Research and the Department of Health Research, Ministry of Health & Family Welfare, Government of India.