1. Introduction to RMNCAH+N
   • Meaning: Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition
   • Goals, continuum of care, and service-delivery platforms
2. Antenatal Care (ANC): Concepts
   • Definition, objectives, importance
   • Early registration and ANC visit schedule
   • Focused ANC and respectful maternity care
3. First ANC Visit
   • Registration, history taking, examination
   • Baseline investigations
   • Risk assessment and birth preparedness
4. Routine ANC Components
   • Monitoring maternal and fetal wellbeing
   • Weight, BP, abdominal examination, fetal heart rate
   • Nutrition, rest, exercise, hygiene, counselling
5. Investigations and Screening
   • Hb, blood group/Rh typing, urine testing
   • HIV, syphilis, hepatitis B screening
   • Blood sugar, ultrasound, anemia and high-risk pregnancy screening
6. Preventive Interventions
   • Iron-folic acid supplementation
   • Calcium supplementation
   • Tetanus-diphtheria vaccination
   • Deworming, malaria prevention where indicated
7. High-Risk Pregnancy and Referral
   • Identification of danger signs
   • Maternal conditions: anemia, hypertension, diabetes, infections
   • Referral pathways and emergency readiness
8. Birth Preparedness and Complication Readiness
   • Place of delivery, skilled birth attendant, transport, blood donor
   • Financial planning and family support
9. ANC Counselling
   • Diet and nutrition
   • Danger signs
   • Institutional delivery, breastfeeding, postpartum family planning
   • Prevention of mother-to-child transmission of HIV
10. RMNCAH+N Programmatic Linkages

• Nutrition services
• Adolescent and reproductive health
• Newborn and child health continuity
• Relevant Indian initiatives such as PMSMA, SUMAN, JSY, JSSK, and Anemia Mukt Bharat

Antenatal Care (ANC) under RMNCAH+N

1. Definition

• Early registration of pregnancy
• Regular maternal and fetal assessment
• Screening for anemia, infections, hypertension, diabetes, and other complications
• Preventive interventions such as iron-folic acid, calcium, tetanus-diphtheria immunization, and deworming
• Nutrition, lifestyle, danger-sign, and birth-preparedness counselling
• Identification, referral, and follow-up of high-risk pregnancy
• Linkage with safe institutional delivery, postnatal care, newborn care, breastfeeding, and family planning

2. ANC in RMNCAH+N

• R - Reproductive health
• M - Maternal health
• N - Newborn health
• C - Child health
• A - Adolescent health
• H - Health
• +N - Nutrition

Goals of ANC

1. Ensure a healthy mother and healthy baby.
2. Detect high-risk pregnancy and complications early.
3. Prevent maternal, fetal, and neonatal morbidity and mortality.
4. Treat or refer complications promptly.
5. Prevent anemia, tetanus, infections, and nutritional deficiencies.
6. Promote institutional delivery and skilled birth attendance.
7. Prepare the woman and family for birth, emergencies, breastfeeding, and postnatal family planning.
8. Ensure respectful, dignified, woman-centred maternity care.

3. Objectives of ANC

A. Maternal objectives

• Confirm pregnancy and estimate gestational age.
• Calculate the expected date of delivery (EDD).
• Assess maternal nutritional and general health status.
• Detect anemia, hypertensive disorders, diabetes, infections, and medical disorders.
• Prevent or treat nutritional deficiencies.
• Identify psychosocial problems, mental-health concerns, substance use, domestic violence, and social support needs.
• Provide health education and counselling.

B. Fetal objectives

• Confirm fetal viability and assess fetal growth.
• Identify multiple pregnancy, growth restriction, congenital anomalies, malpresentation, and fetal distress.
• Monitor fetal movements in later pregnancy.
• Plan referral if fetal or maternal risk is identified.

4. Timing of Registration and ANC Visits

Early registration

• Accurate dating of pregnancy
• Baseline investigations
• Prompt treatment of anemia and infections
• Timely preventive interventions
• Early recognition of high-risk pregnancy
• Better birth planning and continuity of care

Indian public-health schedule

WHO contact model

• First contact: within 12 weeks
• Then at: 20, 26, 30, 34, 36, 38, and 40 weeks

5. Components of the First ANC Visit

A. Registration and records

• Register in the appropriate maternal/RCH record.
• Issue and explain the Mother and Child Protection Card where used.
• Record contact details and address.
• Ensure name-based tracking and follow-up by the health team.
• Record obstetric score:
  • Gravida (G)
  • Para (P)
  • Abortions (A)
  • Living children (L)
• Calculate gestational age and EDD.

B. Estimation of EDD

EDD = First day of LMP + 9 months + 7 days

C. History taking

1. Present pregnancy history

• LMP and menstrual regularity
• Pregnancy confirmation
• Nausea, vomiting, fever, abdominal pain
• Vaginal bleeding or watery discharge
• Abnormal vaginal discharge
• Burning micturition
• Severe headache, visual disturbance, facial swelling
• Palpitations, fatigue, breathlessness
• Convulsions
• Decreased or absent fetal movement after quickening
• Medication use, allergies, radiation exposure, tobacco, alcohol, or other substance use

2. Previous obstetric history

• Previous abortions, ectopic pregnancy, stillbirth, neonatal death
• Preterm birth
• Low-birth-weight baby
• Previous caesarean section or instrumental delivery
• Postpartum haemorrhage
• Eclampsia or pre-eclampsia
• Gestational diabetes
• Previous congenital anomaly
• Rh isoimmunization
• Multiple pregnancy
• Previous baby with developmental delay or inherited disorder

3. Medical and surgical history

• Hypertension
• Diabetes mellitus
• Heart disease
• Renal disease
• Thyroid disease
• Epilepsy
• Asthma
• Tuberculosis
• Hepatitis/jaundice
• HIV and sexually transmitted infections
• Malaria in endemic areas
• Previous surgery, especially uterine surgery

4. Family history

• Hypertension and diabetes
• Twins
• Thalassemia or other hemoglobinopathies
• Congenital anomalies
• Genetic disorders

5. Personal and social history

• Diet and food insecurity
• Tobacco, alcohol, and drugs
• Occupation and excessive physical work
• Domestic violence or lack of family support
• Economic difficulty and access to transport
• Mental-health symptoms, including low mood, anxiety, or suicidal thoughts

6. Physical Examination at ANC

A. General examination

B. Abdominal examination

1. Inspection
   • Abdominal size and shape
   • Scars from previous surgery
   • Striae, skin condition, visible fetal movements
2. Fundal height
   • Measure symphysis-fundal height, usually from 20 weeks onward.
   • Plot serial measurements where a growth chart is used.
   • A discrepancy may suggest wrong dates, multiple pregnancy, polyhydramnios, oligohydramnios, or fetal growth restriction.
3. Palpation
   • Uterine size
   • Fetal lie: longitudinal, transverse, oblique
   • Presentation: cephalic, breech, shoulder
   • Position
   • Engagement of presenting part
   • Tenderness or uterine contractions
4. Auscultation
   • Fetal heart rate, normally about 110-160 beats/minute.
   • Assess after fetal viability, often with Doppler where available.

C. Pelvic examination

• Vaginal bleeding
• Pain or suspected abortion/ectopic pregnancy
• Vaginal infection symptoms
• Suspected rupture of membranes
• Assessment near labour where appropriate
• Cervical screening or other specific indication

7. Investigations in ANC

At booking or first visit

Repeat or follow-up investigations

• Repeat Hb in later pregnancy, particularly where anemia is prevalent.
• Repeat urine protein and blood pressure monitoring at each visit.
• Repeat HIV/syphilis testing based on local policy or ongoing risk.
• Diabetes testing at the recommended gestational period if not done earlier.
• Growth ultrasound or Doppler only when indicated, for example suspected fetal growth restriction, hypertension, decreased fetal movement, or multiple pregnancy.

8. Routine Preventive Interventions

A. Iron-folic acid (IFA) supplementation

Purpose

Common Indian programme approach

• At least 180 IFA tablets during pregnancy are provided under public-health programmes.
• A commonly used tablet contains 60 mg elemental iron plus 500 micrograms folic acid.
• It is generally started after the first trimester or as per local programme protocol, and taken daily.

Counselling for adherence

• Take after meals if gastric irritation occurs.
• Black stools, nausea, constipation, and mild abdominal discomfort can occur.
• Do not stop solely because stools turn black.
• Take with water and a vitamin C-rich food where possible.
• Avoid taking it at the same time as tea, coffee, or calcium, because absorption may be reduced.
• Assess adherence at every visit.

If anemia is detected

• Classify severity by Hb and follow national protocol.
• Look for likely causes: dietary deficiency, malaria where endemic, hemoglobinopathy, worm infestation, chronic disease, or bleeding.
• Severe anemia, symptomatic anemia, late-pregnancy anemia, or anemia with cardiac symptoms requires urgent medical assessment and possible referral.

B. Calcium supplementation

Purpose

Common Indian public-health approach

• 1 g elemental calcium daily, often supplied as two 500 mg doses.
• Usually started from the second trimester, commonly around 14 weeks, and continued until delivery.
• Keep a time gap, commonly at least 2 hours, between calcium and IFA to avoid reducing iron absorption.

C. Tetanus-diphtheria immunization

• Protects the mother against tetanus and diphtheria.
• Prevents maternal and neonatal tetanus.

D. Deworming

E. Malaria prevention

• Promote insecticide-treated bed nets.
• Test fever promptly for malaria.
• Give treatment or intermittent preventive therapy only according to local/national malaria guidelines.

F. Prevention of mother-to-child transmission of HIV

• Offer HIV testing with consent and counselling.
• If HIV-positive, promptly link the woman to antiretroviral therapy and HIV services.
• Plan delivery, newborn prophylaxis, infant testing, and feeding support according to the national programme.

9. Nutrition During Pregnancy

A. Basic dietary advice

• Cereals and millets
• Pulses, beans, nuts, soy products
• Green leafy vegetables
• Other vegetables and fruits
• Milk and milk products
• Eggs, fish, or meat for those who consume them
• Iodized salt
• Adequate safe water

B. Nutrition goals

• Prevent maternal undernutrition, anemia, and micronutrient deficiency.
• Support appropriate weight gain.
• Improve fetal growth.
• Reduce risk of low birth weight.

C. Avoid or limit

• Tobacco in all forms
• Alcohol and recreational drugs
• Unprescribed medicines and herbal products
• Unsafe, unpasteurized foods
• Undercooked meat, eggs, and fish
• Excess caffeine
• Excessively strenuous physical work
• Exposure to second-hand smoke

10. Health Education and Counselling

Topics for every pregnant woman

1. Importance of regular ANC.
2. Compliance with IFA and calcium.
3. Balanced diet and adequate fluids.
4. Rest, sleep, hygiene, and moderate physical activity.
5. Avoidance of tobacco, alcohol, and non-prescribed drugs.
6. Recognition of danger signs.
7. Institutional delivery and skilled birth attendance.
8. Birth preparedness and emergency transport.
9. Breastfeeding, especially early initiation and exclusive breastfeeding for six months.
10. Postpartum contraception.
11. Newborn care, immunization, and postnatal check-ups.
12. Mental wellbeing and family support.

11. Danger Signs During Pregnancy

Major danger signs

• Vaginal bleeding at any stage of pregnancy
• Severe abdominal pain
• Severe or persistent headache
• Blurring of vision, flashing lights, or altered consciousness
• Convulsions/fits
• Sudden swelling of face or hands
• Severe breathlessness, chest pain, or palpitations
• High fever or chills
• Persistent vomiting with inability to retain food or fluids
• Leaking of fluid per vagina before labour
• Foul-smelling vaginal discharge
• Pain/burning during urination with fever or flank pain
• Decreased or absent fetal movements after they have been felt regularly
• Labour pains before 37 weeks
• Severe weakness, fainting, or marked pallor
• Jaundice

12. High-Risk Pregnancy

Definition

A. Maternal demographic and obstetric risks

• Age below 18 years
• Age 35 years or more
• Height less than 145 cm
• Very low body weight or obesity
• Primigravida at advanced age
• Grand multiparity
• Short birth interval, especially less than 2 years
• Previous stillbirth, neonatal death, recurrent abortion, ectopic pregnancy
• Previous preterm birth or low-birth-weight baby
• Previous caesarean section
• Previous postpartum haemorrhage
• Previous eclampsia/pre-eclampsia
• Previous baby with congenital anomaly

B. Current pregnancy risks

• Severe anemia
• Hypertension, pre-eclampsia, or eclampsia
• Diabetes or gestational diabetes
• Heart disease, renal disease, epilepsy, thyroid disease, tuberculosis
• HIV, hepatitis B, syphilis, or other significant infection
• Rh-negative mother
• Multiple pregnancy
• Malpresentation after 36 weeks
• Antepartum hemorrhage
• Placenta previa
• Oligohydramnios or polyhydramnios
• Suspected fetal growth restriction
• Reduced fetal movements
• Preterm labour or premature rupture of membranes

C. Management principles

1. Identify the risk factor early.
2. Explain the risk and plan with the woman and family.
3. Refer to the appropriate facility.
4. Ensure feedback and follow-up after referral.
5. Make a specific birth plan at a suitable institution.
6. Arrange transport, funds, blood donor support where required.
7. Document clearly in maternal records.

13. Birth Preparedness and Complication Readiness

Meaning

Components

1. Place of delivery
   • Preferably an appropriate institution based on risk status.
2. Skilled birth attendant/facility
   • Know where to go and whom to contact.
3. Transport plan
   • Identify vehicle, emergency contact number, and referral route.
4. Financial preparation
   • Arrange money for unforeseen needs, though public schemes may cover many services.
5. Potential blood donor
   • Particularly important in anemic women, placenta previa, previous PPH, or other risk conditions.
6. Companion/support person
   • Identify someone who can accompany the woman.
7. Newborn care preparation
   • Clean clothes, breastfeeding plan, warmth, immunization, and postnatal follow-up.
8. Postpartum family planning
   • Discuss options before delivery.

14. ANC and Referral

Referral is needed for:

• Any danger sign
• Severe anemia or symptomatic anemia
• Hypertension/proteinuria
• Convulsions
• Bleeding per vagina
• Suspected ectopic pregnancy
• Severe abdominal pain
• Fever with pregnancy
• Reduced fetal movements
• Preterm labour or leaking per vagina
• Malpresentation at term
• Multiple pregnancy
• Diabetes, cardiac disease, renal disease, or other major medical illness
• Any high-risk pregnancy beyond the capacity of the current facility

Referral principles

• Stabilize first if required.
• Explain the reason for referral to the woman and family.
• Send records and details of treatment given.
• Inform the receiving facility where feasible.
• Arrange safe transport.
• Follow up whether the woman reached the facility and received care.

15. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)

Introduction

Main features

• Conducted on the 9th day of every month.
• Provides a minimum ANC package including:
  • Clinical examination
  • Relevant investigations
  • Medicines
  • Specialist consultation where available
  • Counselling
  • Identification of high-risk pregnancy
• Focuses especially on women in the second and third trimesters.
• Aims to ensure at least one specialist/physician ANC check-up during pregnancy.
• Involves volunteer private-sector specialists in public facilities.

16. SUMAN and ANC

• Assured, respectful, dignified, and quality maternity care
• No denial of services at public facilities
• Free care for women and newborns
• Reduction of preventable maternal and newborn deaths
• A positive pregnancy and childbirth experience

17. Role of Frontline Workers in ANC

ASHA

• Identify suspected pregnancies early.
• Encourage registration in the first trimester.
• Motivate women for ANC visits, Td, IFA, calcium, PMSMA, and institutional delivery.
• Provide counselling on nutrition, danger signs, and birth preparedness.
• Help arrange referral and transport.
• Track missed ANC visits.
• Support postnatal and newborn follow-up.

ANM / MPW

• Register pregnancy and maintain records.
• Conduct ANC examination and basic tests.
• Provide IFA, calcium, Td, and deworming as per protocol.
• Identify danger signs and high-risk pregnancies.
• Refer appropriately.
• Conduct counselling and follow-up.

Community Health Officer / Primary-care team

• Ensure full ANC package and required investigations.
• Coordinate with ASHAs and Anganwadi workers.
• Identify, track, and refer high-risk pregnancies.
• Link the woman to PHC, CHC, FRU, district hospital, or medical college as needed.
• Ensure PMSMA attendance and completion of ANC services.

18. Short Note: Full ANC Package

• Early registration
• At least the required ANC check-ups/contacts
• Maternal assessment at each visit
• Abdominal and fetal assessment when appropriate
• Essential investigations
• Td immunization
• IFA supplementation
• Calcium supplementation
• Deworming after the first trimester where indicated
• Nutrition and health counselling
• Screening and management/referral of high-risk conditions
• Birth preparedness and complication-readiness counselling
• Linkage to institutional delivery and postnatal services

19. Exam-Friendly Conclusion