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…