These recommendations have been developed with the following aims.

·       They cover the clinical antenatal care that all healthy women with an uncomplicated singleton pregnancy should receive and baseline care for all pregnancies.

·       It does not cover the additional care that women at increased risk of complications should be offered.

The Good Clinical Practice Recommendation does not, however, override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian.

The good clinical practice recommendations can be divided into two parts forcare of a routine antenatal patient

a)              Basic essential care recommended for all pregnant women

b)              Additional care and investigations to be preferably offered if available for routine antenatal care of normal healthy woman

The advantages of hospital delivery should be stressed upon. Ideally, all pregnant women must at least have a trained birth attendant.

Basic essential care recommended for all pregnant womenat all levels

·       All pregnant women must be counseled for regular Antenatal visits minimum one visit in first trimester, monthly visits till 30weeks , every 2 weekly till 36 weeks and weekly visits till delivery

·       Blood investigations for Hb, Blood grouping and Rh Typing,VDRL, Blood sugar

-R, and a Routine Urine examination withalbumin & sugar should be done.

·       A repeat Hb and Urine Sugar to be done in third trimester

·       Immunization with 2 doses of Td/TT

·       Iron, Folic Acid and Calcium Supplements

·       At least one Ultrasound for congenital anomalies should bedone before 20 weeks of pregnancy. Delivery by a doctor or a trained birth attendant

·       Education on nutrition, diet and hygiene

·       Education in breast feeding and birth spacing andcontraception methods.

Additional care and investigations to be preferably offered if available for routine ante-natal care of normal healthy woman. Besides the basic essential ANC the following should be preferably offeredif easily available:

·       Preconception counseling and care

·       Counseling for HIV, HbsAg and HCV testing

·       Counseling and screening for Thalassemia, Down'ssyndrome

·       Repeat blood for Hb, Blood sugar screening and UrineEvoluation in each trimester

·       Ultrasound evaluation once in each trimester and Institutional delivery recommended

·       Additional screening for infections, growth retardation, thyroid dysfunctions

The care should be woman-centered care and informed decision making.

1.     Provision and organization of care Who provides care?

o   Auxiliary Nurse Midwife (ANM) and I or doctor.

o   There should be continuityof care throughout theanfenatal period.

o   A system of clear referral should be there

o   A system of clear referral should be there

o   The antenatal record should be meticulous and systematic.

o   A schedule of antenatal appointments should be determined. -

2.               Gestational age assessment: IMP and ultrasound

o   Pregnant women should be offered an early ultrasound scan to determinegestational age (in lieu of last menstrual period [LMP] for all cases) and to detectmultiple pregnancies whenever possible. This will ensure consistency ofgestafional age assessments, improve the performance of serum screening forDown's syndrome and reduce the need for induction of labour after 41 weeks.

3.               Lifestyle considerations

·            Working during pregnancy

o   Pregnant women should be informed of their maternity rights and benefits.

o   The majority of women can be reassured that it is safe to continue working duringpregnancy provided there are no medical or obstetrical complications.

·            Nutritional supplements

o   Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to l2 weeks' gestation, reduces the risk of having a baby with neural tube defects(anencephaly, spina bifida). The recommended dose is 400 micrograms per day.

o   Iron, protein and calcium supplementation should be offered routinely to all pregnant women. This is because there is high incidence of anemia, hypoproteinemia and osteopenia in the Indian population due to poor diet and repeated pregnancies.

·            Prescribed medicines

o   Prescription medicines during pregnancy should be limited to circumstances where the benefit outweighs the risk.

·            Exercise in pregnancy

o   Pregnant women should be informed that a moderate course of exerciseduring pregnancy is not associated with adverse outcomes.

·            Sexual intercourse in pregnancy

o   Pregnant woman should be informed that sexual intercourse in pregnancyis not known to be associated with any adverse outcomes.

·            Alcohol and smoking in pregnancy

o   Due to increased fetal risks. It is suggested that women should avoidalcohol consumption when pregnant.

o   Pregnant women should be informed about the specific risks of smoking/tobacco use during pregnancy (such as the risk of having a baby with low birthweight, IUGR and preterm) and should be encouraged to quit.

·            Travel during pregnancy

o   Travel is safe. However patient should be counseled regarding risks of longdistance travel, especially the risk of DVI with long flights.

o   Pregnant women should be informed that, if they are planning to travelabroad, they should discuss considerations such as flying, vaccinations and travelinsurance with their doctor.

4.  Clinical examination of pregnant women

·       Measurement of weight

o   Maternal weight and height should be measured at the first antenatalappointment, and the woman's BMI calculated.

o   Regular weight check during pregnancy should be done with everyANCvisit.

·       Blood Pressure Measurements

o   Routine   evaluation   of   blood   pressure   at   every ANC visit and moreimportantly, look for even minimal rise in BP or fluctuations. These are predictivefor the development of IUGR and PIH.

o   Large double cuff for obese women should be used for accurate readings.

·       Pelvic examination

o   Routine antenatal pelvic examination does not accurately assessgestational age, nor does it accurately predict preterm birth or cephalopelvicdisproportion. It is recommended when ultrasound facilities for gestational age arenot available.

·       Abdominal examination

o   Every ANC visit after the first trimester should include abdominalexamination for checking that thèuterine size is corresponding with period ofgestations. Early IUGR can be detected by inappropriate growth. Multiplepregnancy, hydramnios etc can be suspected if there is excessive growth.

·       Domestic violence

o   In our country, there is a high incidence of domestic violence, even whenthe woman is pregnant. Healthcare professionals need to be alert to the symptomsor signs of domestic violence and women should be given the opportunity todisclose domestic violence in an environment in which they feel secure.

5.          Screening for hematological conditions

·       Anaemia

o   Pregnant women should be offered screening for anaemia.Screening should take place early in pregnancy (at the first appointment) and at 28weeks when other blood screening tests are being performed. This allows enoughtime for treatment if anaemia is detected. Haemoglobin levels outside the normalrange for pregnancy (that is, 10 g/dl at first contact) should be investigated.

o   In our country there are ethnic groups who are at risk for Thalessemia.Whenever possible testing for it and evaluation of the fetus if needed should beoffered

·       Blood grouping

o   Women should be offered testing for blood group and RhD status in earlypregnancy.

o   It is recommended that post partum anti-D prophylaxis is offered to all nonsensitizedpregnant women who are RhD negative.

o   Women should be screened for Rh antibodies at first visit and again at 28weeks and if positive they should be offered referral to a specialist centre forfurther investigation and advice on subsequent ANC.

6.          Screening for fetal anomalies

·       Screening for structural anomalies

o   Pregnant women should be offered an ultrasound scan to screen forstructural anomalies, preferably between 18 and 20 weeks' gestation. Thereshould be care taken to adhere to all aspects of the PC-PNDT Act and under nocircumstances should the pregnant lady be informed about the sex of the child.

·       Screening for Down's syndrome

o   Pregnant women may be offered screening for Down's syndrome with atest which provides the current standard of a detection rate above 60% and afalse-positive rate of less than 5%. The following tests meet this standard:

-            From lito 14 weeks

-        Nuchal translucency (NT)

-        The combined test (NT, hCG and PAPP-A)

-            From l4to20weeks

-        The triple test (hCG, AFP and uE3)

-        The quadruple test (hCG, AFP, uE3, inhibin A)

-            From 11 tol4weeksandl4to20weeks

-        The integrated test (NT, PAPP-A + hCG, AFP, uE3, inhibin A)

-        The serum integrated test (PAPP-A + hCG, AFP, uE3, inhibin A).

These tests are recommended wherever possible, and not mandatory as theremay financial and logistic problems in these tests being made availableeverywhere, especially in remote rural areas.

7.          Screening for infections

o   Asymptomatic bacteriuria

•           Pregnant women should be offered routine screening for asymptomatic bacteriuria by midstream routine urine examination. Urine culture should be askedwhere indicated. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth.

o   HBsAg

o   HIV

o   VDRL

•                   Bacterial Vaginosis

o   Recurrent vaginal infections and high incidence of preterm labour are interlinked, and hence whenever possible and feasible pregnant women should have a vaginal smear to r/o possibility of bacterial vaginosis.

8.          Screening for clinical conditions

•                   Pre-eclampsia

o   At first contact a woman's level of risk for pre-eclampsia should be evaluated so that a plan for her subsequent schedule of antenatal appointments can be formulated. The likelihood of developing pre-eclampsia during a pregnancy is increased in women who:

-            are nulliparous

-            are aged 35 or older

-            have a family history of pre-eclampsia - have a prior history of pre-eclampsia - obese women

-            have multiple pregnancy or pre-existing vascular disease (e.g. hypertension or diabetes).

o   With every ANC visit, blood pressure is measured in pregnancy and if possible, urine sample should be tested at the same time for proteinuria.

o   Pregnant women should be informed of the symptoms of advanced preeclampsia because these may be associated with poorer pregnancy outcomes for the mother and/or baby or both. Symptoms include headache; problems with vision, such as blurring or flashing before the eyes; abdominal pain just below the ribs; vomiting and sudden swelling of face, hands or feet.

•                   Gestational diabetes mellitus

o   Ideally, every pregnant woman must be offered routine screening for gestational diabetes mellitus by blood sugar estimations in every pregnant woman. However, financial and logistic problems may not be able to support this on routine basis. Hence, a urine sugar examination during ANC visit will help in identifying normal women at risk. Also, identify women with risk factors and these women should be screened thoroughly.

o   Whenever possible, a glucose challenge test using 75gm glucose load, is the ideal method of screening for gestational diabetes.

•                   Thyroid deficiency

o   In our country thyroid deficiency is endemic in many areas, especially in the northern regions. Thyroid screening should preferably -be done at least once, especially in all pregnant women hailing from these areas

9.          Immunization during pregnancy

o   All pregnant women should be immunized against tetanus and diphtheria (Id Vaccine) as per the recent WHO guidelines. However, places where Td is not available, immunization should be with IF.

o   2 doses of Td/ TT should be given 4-6 weeks apart to all pregnant women during the ANC period after 16 weeks onwards.

o   Rubella, Yellow Fever and all vaccines with live virus should be avoided.

10.      Diet and hygiene during Pregnancy

o   Adequate information of a balanced diet should be provided to all pregnant women.

o   Pictorial charts and if possible suggested nutrients should- be given to all pregnant women with advice on improvements in daily diet needs.

o   Care should be taken to see that there is enough, proteins, carbohydrates, calcium, iron and fats in the daily diet and if not, the woman should be advised appropriately by the ANM's or the doctor.

o   Pregnant women should be informed of primary

o   infection prevention measures, such as:

-            Washing hands before handling food

-            Thoroughly washing all fruit and vegetables before eating

-            Thoroughly cooking raw meats and fish.

-            Wearing gloves and thoroughly washing hands after handling soil and farming

-            Avoiding cat/cow faeces in litter or in soil.

11.      Fetal growth and well-being

5.     Abdominal palpation for fetal presentation

6.     Measurement of symphysis-fundal distance

7.     Auscultation of fetal heart

8.     Routine monitoring of fetal movements

o   All pregnant women should be fold about the importance of fetal movements. They should be advised to report to the ANM or the doctor if they donot feel any movements for 12 hours or more.

12.      Management of common symptoms of pregnancy

·            Nausea and vomiting in early pregnancy

o   Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously by end of first trimester and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, non-pharmacological agents or safe anti-emetics. In hyper-emesis hospital admission may be needed.

•                   Heartburn

o   Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification.

o   Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification.

•                   Constipation

o   Women with constipation in pregnancy should be offered information regarding diet modification, such as. is a pgol (psylium husk) supplementation and medication if needed.

•                   Hemorrhoids

o   In the absence of evidence of the effectiveness of treatments for hemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard hemorrhoid creams should be considered.

I.                Varicose veins

o   Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.

•                   Vaginal discharge

o   Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If this is associated with itch, soreness, offensive smell or pain on passing urine there may be an infective cause. In these cases, evaluation and treatment should be considered.

o   A 7 day course of a topical co-trimazole is an effective treatment and should be considered for vaginal Candidal infections in pregnant women.

·            Backache

o   Backache is a common problem which only increases as the pregnancy advances. Women should be informed that exercising in wafer, massage therapy and group or individual back care classes might help to ease backache during pregnancy.

13.      Education on breast feeding and infant care

o   When ever possible all pregnant women should be taken around the post-natal ward and allowed to interact with just delivered women to under stand and be prepared for normal labour.

o   When ever possible the pregnant women should be taught how to breast feed their babies and to look after the hygiene.

o   The proper care to be followed after breast feeding, burping the in fantand how to position the infant when sleeping should all be taught to the women during the ANC period itself.

o   Pre-pregnancy classes on labour and infant care can be offered whenever possible.

14.      Contraception and birth spacing

o   The importance of birth spacing should be stressed and they should be informed about all the methods that can be safely used during the post-partum period when they are breast feeding their babies. Effective contraception with risks, advantages and benefits must be explained. They should also be explained about the difference between spacing and permanent methods.

o   At the first post-natal visit, IUCD / Injectable contraceptive / POP/Implant / preference for IL should all be offered as the basket of choices. All these should be offered with adequate counseling and proper selection according to the WHO criteria for each method. Importance of LAM should be stressed for all women and breast feeding should be encouraged.

Schedule and content of Antenatal appointments

The schedule below, which has been determined by the purpose of each appointment, presents the recommended number of antenatal care appointments for women who are healthy and whose pregnancies remain uncomplicated in the antenatal period

Focused antenatal care (ANC):The four-visit ANC model outlined in WHO clinical guidelines

Goals

Activities

Rapid assessment and management for emergency signs, give appropriate treatment, and refer to hospital if needed,

The patients with high risk pregnancy should be referred to LEVEL 3 or LEVEL 4 for better management and care;

•           Elderly primi (30 yrs and over)

•           Short stature (< 140 cms)

•           Malpresentation (breech, transverse lie)

•           APH, Threatened abortion

•           Pre-eclampsia, Eclampsia, IUGR

•           Anaemia

•           Twins, Hydramnios

•           Previous still birth, IUD, MROP

•           Grand multipara/Rh incompatibility

•           Postdate pregnancy

•           Previous caesarean or instrumental delivery

•           Pregnancy with heart disease, renal disease, diabetes, tuberculosis

Investigations to be done in high risk pregnancies

•           In Rh -v e mother (Rh +ve father)

•           ICTat 1st visit, 28 wks and 34 wks

•           In BOH TORCH - 1gM and lgG

•           Anti phospholipid antibody— 1gM and IgG

•           Down syndrome: Triple test at 15 wks of pregnancy (MSAFP, B-HCG & urinary 03)

•           CVS,    amniocentesis    &    cordocentesis    for    various            chromosomal     fetal malformations

Nausea and Vomiting of Pregnancy

•           Morning sickness in pregnancy is common medical condition where there is mild nausea and vomiting.

•           Excessive and severe form of morning sickness during pregnancy is called as Hyperemesis Gravidarum.

CAUSES

•           Hormones Excess of HCG and Oestrogens

•           Psychogenic Emotional factors.

•           Dietary deficiency BI BóVitamins,

•           Decreased gastric motility are the more common theories.

•           "HG" Hyperemesis Gravidarum is more common in first pregnancy, first trimester, and with positive family history, multiple gestation and, H Mole,

•           Gynaecological Twisted Ovarian cyst Red degeneration of fibroid uterus, Fatty liver of pregnancy.

TREATMENT OF NAUSEA AND VOMITING, (Valid for all levels of health care)

•           Most cases of nausea and vomiting are mild and do not require any treatment. It usually resolves with sixteen to twenty week and is not associated with a poor pregnancy outcome. However persistent vomiting and severe nausea can progress to Hyperemesis Gravidarum, if the woman is unable to maintain adequate hydration, fluid and electrolyte balance as nutritional status may be jeopardized. Hospital admission becomes necessity and intravenous fluid administration is urgently required.

•           Aim of treatment in Nausea and Vomiting

•           Dietary intake,

•           Life style modifications and

•           Reassurance should be encouraged and women should be counselled to eat whatever they like to take.

•           To feel better, eat and drink enough so that she does not loose weight. • Treatment may not eliminate nausea and vomiting completely. • Dietary changes

•           Avoiding food and not eating at all, actually makes the nausea worse.

•           Try eating before or as soon as you feel hungry, to avoid any empty stomach which aggravates nausea.

•           Eat snacks frequently and have small meals six small meals a day. Rich in proteins, and carbohydrates, and low in fat. Brushing of teeth after eating may help preventing symptoms.

•           Drink cold, clear and carbonated or sour fluids, Ginger and lemon fluids.

•           Avoid triggers

•           Avoid spicy foods, High sugar foods, perfumes, chemicals and coffee and smoke. Visual and physical motions flickering lights and driving,

MEDICATIONS

•           Medications that reduce the nausea and vomiting are definitely effective in some women and are safe to take during pregnancy.

•           Doxylamine Succinate 10 mgs is an Hi receptor antagonist found to be effective in treatment of NV of pregnancy. Pyridoxine 10 mgs vitamin B6 can reduce the symptoms of mild to moderate nausea.

•           Anti-histaminesare safe for nausea and vomitingcommoniy used but causes drowsiness.

•           Promethazine (Phenergan) 25mgs injectable 2-3 times intramuscularly thrice a day. May cause. drowsiness and dry mouth.

•           Metoclopramide (Region) It speeds of emptying of stomach and thus may help to reduce nausea and vomiting.

•           Vitaminsvit Bi, B6, B12, vit C as nutritional supporti 00 mgs i/v in drip. •

Intravenous fluids

•           Fluids and Nutrition If unable to hold down food or liquids, treatment will have to start with intravenous fluids.

•           Level 3(100 bedded Community Health Center)

•           If the patient's symptoms are not relieved or diagnosis is not confirmed and the patient is sick refer to level no. 3 to get the ultrasound of pelvic organs and whole abdomen and treatment of the medical causes like gastroenteritis and cholecystitis.

•           Level 4(100 or more bedded District Hospital)

•           All patients with complications or patients having surgical causes should be referred to level 4 for treatment of complications like diabetic ketoacidosis or electrolyte imbalance and ureamia and other surgical treatment.

Complications

•           Neurological serious complications like Wernick's encephalopathy, peripheral neuritis, central pontine myeiinolysis, rupture of oesophagus and jaundice can occur.

Prevention

•           Early, energetic and effective management of simple vomiting of pregnancy can reduce the further development of Hyperemesis Gravidarum.