Antenatal Care

ANTENATAL CARE

DR MYO HLA MYINT

AIMS

To prevent, detect and manage factors that adversely affect the health of mother and baby.

Detection of any psychological or physical problems during pregnancy

Mother Gives birth to HEALTHY baby Couple prepared for the birth and for child

rearing, including receiving info about diet, childcare and family planning

Classification of antenatal care

Shared care

Shared care

Service provided by Hospital maternity team , GP and community midwives.

Women with risk factors

Community Based care

Booking appointment done by community midwives.

Routine scans and investigations requested

Ideally for low risk women

Hospital based care

Highly specialized antenatal care eg : antenatal clinic for women with diabetes,

High risk women

PATTERN OF VISITS

FIRST 28 WEEKS – 4 WEEKS ONCE

28-36 WEEKS – EVERY 2 WEEKS

36 weeks -DELIVERY – once WEEKLY

The Booking Visit

Confirmation of pregnancy ◦ Breast tenderness, nausea, amenorhhea,

urine frequency)

◦ + Urine test

Booking History

Dating the Pregnancy-EDD ◦ time of delivery

◦ LMP-Naegele’s rule OR Ultrasound

For risk assessment – from history taking, physical exam and investigations

Booking History

◦ Personal Info ◦ Past medical History Immunisation history – Rubella, Hep B, Tetanus

Hypertension -epilepsy Kidney Disease -asthma DM -collagen disease Heart Diseases -Thyroid disorders Others

Personal information IC No

Mother’s Name

Race

citizenship

Education level

Occupation

Home Address

Husband’s name

Husband’s occupation

Husband’s working add

LMP

EDD

Gravida _ para _

Age (DOB)

Tel no :

Husband’s IC NO

Husband’s Tel No:

AN

PN

Previous Pregnancy Info

Year of pregnancy

Result of pregnancy

Type of Delivery

Place of delivery

Sex

Birth weight

Child’s condition at

present

Breast feeding/ duration

Complication

◦ Previous Gynaecological History

History of infertility

Recurrent miscarriage

Any gynae surgery

◦ Family History

Type II DM

Thromboembolic disease

◦ Social History

Smoking

Alcohol

Usage of illegal substances-Cocaine,Amphetamine

Domestic Violence

BOOKING EXAMINATION

• Check BMI

• Thyroid exam

Cardiovascular

◦ Measurement of BP

◦ Loud Heart sound

◦ Flow murmur

Respiratory

Breast exam Abdominal exam

◦ Any abdominal scar

◦ Size of uterus

Vaginal exam – cervical smears and vaginal swabs NOT routinely done

-Abdominal exam

◦ ANY abdominal scar

◦ Size of uterus

Vaginal exam – cervical smears and vaginal swabs NOT routinely done

Height of fundus

Booking Investigations

Full blood count – Hemoglobin 10.5-15.0g/dl

◦ Hematocrit normal>35

◦ MCV and MCH

Blood Group and RHESUS Antibodies

Infection screening (Rubella, Hepatitis B, HIV, Syphilis)

Assess screening for MOGTT

Urinalysis – For asymptomatic bacteriuria

COLOUR CODES FOR ANTENATAL CARE

OBJECTIVE: Its Important in managing the pregnant mothers based on their risk factors.

◦ Red – hospital admission

◦ Yellow – To be refered to the O&G Specialist in Hospital/ Health Clinics

◦ Green – To be seen by the Medical Officer in Health Clinics by appointments

◦ White – Can be seen by Community Nurses or Staff nurses in the health clinics

WHITE 1- TO BE DELIVER IN HOSP

WHITE 2-CAN BE DELIVERED AT HOME

RED tag 1. Eclampsia 2. Pre-eclampsia – High blood pressure with albumin urea 1+ or with

symptoms or B.P>160/100 3. Heart disease in pregnancy with signs and symptoms ( Breathless,

palpitation) 4. Breathlessness with light activity ( Activity spt, sweeping and

washing plates) 5. Mother with uncontrolled diabetes 6. Bleeding during pregnancy (inclusive of abortion) 7. Fetal Heartbeat abnormal FHR <110/min at or after 26/52 week FHR >160/mim after 34/52 week ( FHR may be high at term 8. Anaemia with symptoms at any period of gestation 9. Premature contraction of uterus 10. Leaking liquor/ not in labour 11. Asthma - severe

YELLOW

1. Mother HIV positive 2. Mother Hepatitis B positive 3. Blood pressure >140/90 <160/110 mmHg

with urine albumen negative 4. Mother diabetic – Urine yellow or orange 5. No foetal movements felt >32 weeks 6. More than 7 days after EDD

GREEN TAG

1. Rhesus negative

2. Weight of mother at booking <45 kg

3. Associated medical condition – Psychiatric or deformity except diabetes or hypertension

4. H/O Gynaecological surgery

5. Cigarette smoker or alcohol drinker

6. Unsure of dates -LMP

7. H/O recurrent miscarriages =>3 times

8. Bad Obstetric history a. LSCS b. PIH/ Eclampsia/ diabetes c. Perinatal mortality d. Baby’s weight <2.5 kg or >4 kg e. 3rd degree perineum tear f. Retained placenta g. PPH i. Instrumental delivery j. Prolonged labour

9. Multiple pregnancy 10. Blood pressure > 140/90 and urine

albumen negative 11. Haemoglobin <11.0 Gm 12. Urine sugar – green 2 times 13. Urine albumen >1+ 14. Weight gain >2 Kg in 1 week 15. Weight of mother >80 Kg 16. Height of fundus less or more than

POA 17. Breech/ oblique/ transverse lie with

no labour pain > 36/52 weeks of pregnancy

18. Head not engaged at 36/52 weeks of POA for a primigravida

WHITE I -DELIVER AT HOSPITAL

1. Primigravida 2. Age – <18 and >40 years 3. Gravida 6 and above 4. Interval from last delivery <2

years or >5 years 5. Mother’s ( i ) Height <145 cm ( ii ) Single mother ( iii ) Home environment not

suitable

WHITE II -DELIVER AT HOME

1. Gravida 2 to 5 2. No bad obstetrics history 3. No associated medical problem 4. No complication during pregnancy 5. Home environment suitable 6. Height >145 cm 7. Age of mother >18 and <40 8. POA >37 weeks and <41 weeks 9. Married and support by family 10. Estimated baby’s weight >2 kg and <3.5 kg

Content of follow up visits

General Questions on well being

Fetal movements -24 weeks within 12 hours

BP measurements

Urine : Albumin, sugar

Blood : Hb

Weight

Edema

POA, Gestation weeks

Symphysis –fundal height

From 36 weeks-fetal lie, presentation, engagement degree

Fetal Heart sound

Symphsis-fundal height graph

Antenatal imaging and assesment of well being

Ultrasound

CTG

BENEFITS OF SCAN

confirm the fetal viability Provide an accurate estimation of gestational

age Diagnose multiple gestation and chorionicity Identify markers which would indicate

increase risk of fetal chromosome abnormality such as Down’s S

Identify fetuses with gross deformity

ULTRASOUND MEASUREMENT

CROWN- RUMP LENGTH-measures from head to buttocks

FORMULA :::: Gestational age (weeks) = crown-rump length (cm) + 6.5

An ultrasound showing a fetus measured to have a crown-rump length of 1.67 cm, and estimated to have a gestational age of 8 weeks and 1 day

Biparietal diameter

The diameter between the 2 sides of the head.

This is measured after 13 weeks.

FEMUR LENGTH

Measures the longest bone in the body and reflects the longitudinal growth of the fetus

ABDOMINAL CIRCUMFERENCE

The single most important measurement to make in late pregnancy.

It reflects more of fetal size and weight rather than age. Serial measurements are useful in monitoring growth of the fetus.

Diagnostic Ultrasound

In 1st trimester

11-14 weeks ◦ Estimation of gestational age

◦ Multiple pregnancy

◦ Nuchal thickness and measurement and chromosomal abnormalities

2nd trimester

18-22 weeks

Fetal anatomical survey to detect any structural defect

Establish multiple gestation

Locate the placenta –exclude placenta previa

Estimate amniotic fluid volume

Measure cervical length to assess the risk of preterm delivery

3rd trimester

Asses fetal growth ◦ BPD,HC,AC &FL-fetal symmetry ◦ Serial measurements are plotted in graph with normal reference range

Assess fetal well being ◦ Amniotic fluid volume

Maximum vertical pool measured after general survey of uterine contents ◦ <2cm oligohydromnion ◦ >7cm polyhydromnions

Sum of all vertical pool (from 4 quadrants)

◦ Fetal heart rate

Fetal CTG

Fetal growth chart

Doppler Investigation

Waveform from umbilical artery provide information on feto-placental blood flow and placental resistance

Thank you…