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Antenatal Check Up: History taking

SBA - Presentation 2 (b). Antenatal Check Up: History taking. Maternal Health Division Ministry of Health & Family Welfare Government of India. History Taking. What is the importance of history taking? Diagnose pregnancy (first visit only)

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Antenatal Check Up: History taking

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  1. SBA - Presentation 2 (b) Antenatal Check Up:History taking Maternal Health Division Ministry of Health & Family Welfare Government of India

  2. History Taking What is the importance of history taking? • Diagnose pregnancy (first visit only) • Identify medical or obstetric complications in present pregnancy • Identify complications during previous pregnancies Antenatal Check Up: History taking

  3. History Taking Points to be taken care of : • Ensure privacy • Ensure calm and quiet atmosphere • Make the woman comfortable and relaxed • Maintain confidentiality • Establish rapport • Record all facts on Mother & Child Protection (MCP) card • Highlight abnormal findings Antenatal Check Up: History taking

  4. History Taking Start with • Age of woman • Order of pregnancy • Birth interval Record LMP (1st day of woman’s last Menstrual period) and calculate Expected Date of Delivery EDD = LMP + 9 months +7 days Antenatal Check Up: History taking

  5. History Taking Ask for symptoms What are normal symptoms during pregnancy? • Nausea & vomiting • Heart burn • Constipation • Increased frequency of urination These symptoms may cause discomfort to the woman Antenatal Check Up: History taking

  6. History Taking What are the symptoms of complications? • Fever • Persistent vomiting with dehydration • Palpitations, tiredness • Breathlessness at rest / on mild exertion • Generalized swelling of body / facial puffiness • Severe headache and/ or blurring of vision • Passing smaller amount of urine or burning micturition • Leaking or bleeding per vaginum • Abnormal vaginal discharge / itching • Decreased or absent fetal movements Antenatal Check Up: History taking

  7. History Taking Obstetric history • No. of previous pregnancies • Date (month / year) • Mode (vaginal / caesarian) • Outcome (live birth, still birth, preterm, abortion, ectopic, vesicular mole) Antenatal Check Up: History taking

  8. History Taking Obstetric history • Any past obstetric complicationsRecurrent pregnancy loss, Post abortal complications, APH, Hypertensive disorders of pregnancy, Malpresentation, Obstructed labor, PPH, Third degree tears, Puerperal sepsis, Thrombo-embolism etc • Any past obstetric proceduresCesarean section, Instrumental delivery, Manual removal of placenta Antenatal Check Up: History taking

  9. History Taking Any current / past systemic illnesses • High BP • Diabetes • Heart disease : Breathlessness on exertion, palpitation • Tuberculosis : Cough> 2 wks , blood in sputum, prolonged fever • Renal disease • Epilepsy : Convulsions • Asthma : Attacks of breathlessness • Jaundice • Malaria Any other history suggestive of RTI / STI ; HIV / AIDS Antenatal Check Up: History taking

  10. History Taking • Family history of systemic illness • Hypertension • Diabetes • Tuberculosis • Thalassemia or repeated blood transfusions • Multiple pregnancies • Intake of alcohol or tobacco or smoking • Drug intake or allergies • Domestic violence Antenatal Check Up: History taking

  11. Indications for referral to 24 x 7 PHC Previous history of : • Stillbirth or neonatal loss • Three or more spontaneous consecutive abortions • Obstructed labor • Premature births, twins or multiple pregnancy • Weight of baby < 2.5 Kg or > 4.5 Kg • Hypertension, pre-eclampsia, or eclampsia • Surgery of reproductive tract (LSCS) • Congenital anomaly of the baby • Treatment for infertility • Rh negative pregnancy Antenatal Check Up: History taking

  12. Indications for referral to 24 x 7 PHC • High fever with or without abdominal pain, too weak to get out of bed • Fast or difficult breathing • Haemoglobin 7–11 g% even after consuming IFA tablets for 30 days • Excessive vomiting, unable to take anything orally • Breathlessness at rest • Reduced urinary output with high BP • High BP (>140/90 mmHg) with or without proteins in the urine Antenatal Check Up: History taking

  13. Indications for referral to FRUs • Malpresentation • Multiple pregnancy • Any bleeding P/V during pregnancy and after delivery (a pad is soaked < 5 minutes) • Severe headache with blurred vision • Haemoglobin <7 g% • Convulsions or loss of consciousness • Decreased or absent foetal movements • Active labour lasting longer than 12 hours in a primipara and more than 8 hours in a multipara • Continuous severe abdominal pain Antenatal Check Up: History taking

  14. Indications for referral to FRUs • Premature rupture of membranes (PROM) before 37 weeks • High BP (>140/90 mmHg) with proteins in the urine, and severe headache with blurred vision or epigastric pain • Temperature more than 38°C • Foul smelling discharge before or after delivery/abortion • Ruptured membranes for more than 18 hours • FHR >160/minute or <120/minute • Perineal tear ( 2nd, 3rd and 4th degree) Antenatal Check Up: History taking

  15. To summarize History taking of an ante-natal woman includes • Recording LMP • Asking for symptoms • Obstetric history • Any current / past systemic illnesses or allergies • Family history of systemic illness • History of Intake of drugs, alcohol, tobacco etc. • History of domestic violence Antenatal Check Up: History taking

  16. Thank you Antenatal Check Up: History taking

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