Antenatal Care

Definition of Antenatal care

comprehensive health supervision of a pregnant woman before delivery

Or it is planned examination, observation and guidance given to the pregnant woman from conception till the time of labor.

GoalsTo reduce maternal and perinatal

mortality and morbidity rates

To improve the physical and mental health of women and children

Importance of Antenatal Care

To ensure that the pregnant woman and her fetus are in the best possible health.

To detect early and treat properly complications

Offering education for parenthood

To prepare the woman for labor, lactation and care of her infant

Schedule for Antenatal Visits:

The first visit or initial visit should be made as early is pregnancy as possible.

Return Visits:Once every month till 28 w.Once every 2 weeks till the 36 wOnce every week, till labor.

Frequency of antenatal appointments

NulliparousNulliparous with an uncomplicated pregnancy, a schedule of 10 appointments.

ParousParous with an uncomplicated pregnancy, a schedule of 7 appointments.

Assessment

History Examination Investigation

History

Personal historyFamily history Medical and surgical history Menstrual history Obstetrical history History of present pregnancy

Fetal kick count

The pregnant woman reports at least 10 movements in 12 hours.

Absence of fetal movements precedes intrauterine fetal death by 48 hours.

Physical Examinations

Height of over 150 cm indication of an average-sized pelvis

The approximate weight gain during pregnancy is 12 kg.; 2kg in the first 20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term).

Symphysis–fundal height should be measured and recorded at each antenatal appointment from 24 weeks.

Fetal presentation should be assessed by abdominal palpation at 36 weeks.

Fetal heart sound is heard by sonicaid as early as 10thweek of pregnancy.

Fetal heart sound is heard by Pinard' s fetal stethoscope after the 20thweek of pregnancy.

Breech presentation at term

ECV. If is not possible to schedule at 37 weeks

then ?!

Pregnancy after 41 weeks

Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping.

42 weeks ?!

Investigations(in clinic):

Urine should be tested for ketones and protein.

Health Teaching during the First Trimester

Physiological changes during pregnancy

Weight gain Fresh air and sunshine Rest and sleep Diet Daily activities Exercises and relaxation Hygiene Teeth Bladder and bowel Sexual counseling

Smoking : Medications Infection Irradiation Occupational and

environmental hazards Travel Follow up Minor discomforts Signs of Potential

Complications

Common Discomforts of Pregnancy, Etiology, and Relief Measures: Urinary frequencyRELIEF MEASURES:

Decrease fluid intake at night. Maintain fluid intake during day. Void when feel the urge.

Fatigue

RELIEF MEASURES:

Rest frequency.

Go to bed earlier.

Sleep difficulties RELIEF MEASURES:

Rest frequencyDecrease fluid intake at night

Nasal stuffiness and epistaxis

ETIOLGY: Elevated estrogen levels RELIEF MEASURES :

Avoid decongestants.Use humidifiers, and normal saline drops.

Ptyalism (excessive salivation)

ETIOLGY: UnknownRELIEF MEASURES:

Perform frequent mouth care.Chew gum.Decrease fluid intake at night.Maintain fluid intake during day.

Nausea and vomiting

•most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks.•that nausea and vomiting are not usually associated with a poor pregnancy outcome.

•non-pharmacological:non-pharmacological:•ginger•P6 (wrist) acupressure

•pharmacological:pharmacological:•antihistamines.

Nausea and vomiting

RELIEF MEASURES:Avoid food or smells that exacerbate condition.Eat dry crackers or toast before rising in

morning. Eat small, frequent meals.Avoid sudden movements. Get out of bed slowlyBreath fresh air to help relieve nausea.

Heartburn RELIEF MEASURES:

Eat small, more frequent meals.Use antacids.Avoid overeating and spicy foods.

Dependent edema

Avoid standing for long periods. Elevate legs when laying or sitting. Avoid tight stockings.

Varicosities

Rest in sims' position. Elevate legs regularly. Avoid crossing legs. Avoid long periods of standing

Hemorrhoids

RELIEF MEASURES:Maintain regular bowel habits.Use prescribed stool softeners.Apply topical or anesthetic ointments to area.

Constipation

RELIEF MEASURES:Maintain regular bowel habits.Increase fiber in diet.Increase fluids.Find iron preparation that is least constipating

Backache

RELIEF MEASURES:Wear shoes with low heels.Walk with pelvis tilted forward.Use firmer mattress.Perform pelvic rocking or tilting

Leg cramps RELIEF MEASURES:

Extend affected leg and dorsiflex the foot.Elevate lower legs frequently.Apply heat to muscles.

Faintness

RELIEF MEASURES:•Rise slowly from sitting to standing.•Evaluate hemoglobin and hematocrit.•Avoid hot environments

ScreeningScreening

Asymptomatic Bacteriuria

Women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis.

Gestational age assessment

New Pregnant women should be offered an early ultrasound scan between 10 weeks 0 days and 13 weeks 6 days to determine gestational age gestational age and to detect multiple pregnanciesdetect multiple pregnancies.

New Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84 mm, the gestational age should be estimated using head head circumference.circumference.

Screening for fetal anomalies

New The 'combined test' (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down's syndrome between 11 weeks 0 days and 13 weeks 6 days.

For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.

Screening for gestational diabetes

New risk factors for gestational diabetes :

body mass index above 30 kg/m2

previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes (refer to 'Diabetes in pregnancy family history of diabetes (first-degree relative with diabetes) family origin with a high prevalence of diabetes:

South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)

black Caribbean Middle Eastern (specifically women whose country of family origin is Saudi Arabia,

United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).

Screening for haematological conditions

New Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks).

Anaemia

Screening shouldtake place early in pregnancy (at the booking appointment).

at 28 weeks when other blood screening tests are being performed.

At 36 weeks.

Normal range: 11 g/100 ml 11 g/100 ml at first contact and 10.5 10.5

g/100 g/100 ml at 28 weeks) should be investigated and iron supplementation considered .

Blood grouping and red-cell alloantibodies

Women should be offered testing for blood group and rhesus D status in early pregnancy.

To give anti-D at 28 weeks and post delivery if the baby (+)

Hepatitis B virus

Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal interventions can be offered to infected women to decrease the risk of mother-to-child transmission.

Hepatitis C virus

Pregnant women should notnot be offered routine screening for hepatitis C virus because there is insufficient evidence to support its clinical and cost effectiveness.

Rubella

Rubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies.

Nutritional SupplementsNutritional Supplements

Folic Acid

Start before conception and throughout the first 12 weeks.

reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bifida).

The recommended dose is 400 micrograms per day.

Vitamin D

New women at greatest risk are following advice to take this daily supplement. These include:

women of South Asian, African, Caribbean or Middle Eastern family origin women who have limited exposure to sunlight, such as women who are

predominantly housebound, or usually remain covered when outdoors women who eat a diet particularly low in vitamin D, such as women who

consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal

women with a pre-pregnancy body mass index above 30 kg/m2.

Vitamin A

Vitamin A supplementation (intake above 700 micrograms700 micrograms) might be teratogenic and should therefore be avoided

Iron

Iron supplementation should notnot be offered routinely to all pregnant women. It does not benefit the mother's or the baby's health and may have unpleasant maternal side effects.

Antenatal care

Pre conception counselling Smoking Alcohol Drugs Diet Exercise Folic acid

Pre conception counseling

Family history

Personal history

Past obstetric history

Folic acid

Rubella status

First visit LMP EDD POH MH PMH Drugs Allergies

First visit Smoking Alcohol FH Advise Exemption card Referral

Low risk pregnancies 12-14/52 hosp visit

Routine blood testsBlood group + rhesus factorFbc + haemoglobinopathies if indicatedRandon blood sugarTreponemal antibodyHep bHiv pappa

Low risk pregnancies

Hosp visit 12-14/52

History

Nuchal transluceny scan

Low risk pregnancy 15 weeks

Serum AFP and downs screening

If booking scan not done before 14 weeks

Low risk pregnancy 23 weeks – anomally scan 26 weeks – midwife/gp 28 weeks – fbc + antibodies 30 weeks – midwife/gp 34/36/38/40 weeks – midwife/gp 41 weeks - hosp

Exercise

Non – contact sport only after 16/52

Intensity decreased by 25%

HR under 140/min

Core temp < 38

Strenuous exercise limited to 15-20 mins

Antenatal visits Weight gain 12-15kg in total BP dias. >90 or increase > 20 from first visit is

significant Urinalysis watch for protein glucose uti Fetal movements Uterine size Fetal lie presentation

Common discomforts Pelvic pains – ligamental stretch Urinary frequency - ? Uti Ankle swelling – ivc compression Varicosities – support stockings Heartburn – posture antacids Constipation – fluids, fibre, fybogel

Common discomforts

Low back pain – posture and relaxin

Dental decay – see dentist

Skin changes – chloasma

Itch – iron def, cholestasis antihistamines

Stretach marks - moisturisers

First trimester

Ectopic pregSharp pain

Irregular vaginal bleeding

Abdo tenderness

Dizziness or fainting

Ectopic pregnancy

Diagnosis

Pos preg test

Serial hcg levels they increase more slowly

Progesterone level lower than normal

Ultra sound scan vaginally/abdominally

Ectopic pregnancy risk factors PID Previous tubal preg or tubal surgery Endometriosis IUD Multiple induced abortions Drugs that stimulate ovulation

Ectopic pregnancy treatment

Tube not ruptured

Methotrexate

Salpinostomy flushng the tube out

Laparoscopic removal

Ectopic pregnancy treatment

Tube ruptured

Laparoscopic removal of embryo and tube

Miscarriage

Symptoms

Pv bleeding

Colicky pain

Refer to EPAU

hyperemesis

1 in 300 preg

Weeks 8-20

Cause unknown – high oestrogen & hcg

More commom multiple preg obesity first babies

Treatment Exclude other causes Drink small amounts frequently Diet high in cho and proteins Admit for iv fluids if severe, dehydrated or

electrolyte imbalance Drugs -

Anaemia

SymptomsFatigue weaknessPallorDizziness or faintingSOBpalpitations

Anaemia

Treatment

Diet

Pregaday

Does not alter outcome in most cases

Infection in pregnancy

Chicken pox – only 2% of infections age > 20yrs 3% risk of fetal damage in first 20/52 If mum’s rash develops 1/52 before delivery or to 4/52 after

baby can get sever infection needs protection No risk between 20/52 and term If no history of cp check varicella antibodies If non immune needs VZ Ig no later than 10 days from exposure

Infections in pregmnancy Rubella – 2-10/52 90% chance of featal damage Toxoplasma gondii 89% adults not immune If fetus infected 10% chance of fetal damage Avoid kittens particularly litter trays Eat well cooked meat Wash vegetables Listeria – soft cheeses, pate. Cookchill foods

Pre eclampsia

Raised BP

Proteinura

XS swelling

Pre eclampsia

3-4% pregnancies

!% very severe

50,000 deaths world wide

Pre eclampsia Risk factors

Young mothers teenagersOlder mothers > 35 yrsFamily historyFirst pregnancyNew fatherDiabeteshypertension

Pre eclampsia Serious adverse effects

FitsStrokePulmonary oedemaKidney failureLiver damageD I C

Pre eclampsia Warning signs

Raised bpProteinuriaXs swellingHeadcaheFlashing lightsVomiting Upper abdo pain

Pre eclampsia Treatment

Lower bpMagnesium sulphateDeliver babyAspirinMetabolic syndrome

Gestational diabetes Plenty of insulin, but insulin malfunctioning Macrosomia > 4500g Problems with labour and delivery Newborn has low blood sugar Increased risk stillbirth Proper management prevents increased risk

ofcomplications

Risk factors Incidence 1%-3% pregnancies Family history Obesity Maternal age > 30 yrs Previous large baby Prior icidence of gestational diabetes Ethnic group – south asians, mexican american

Treatment

Control blood sugar

Exercise

Diet

Blood glucose monitoring

A few will need insulin

Intra uterine growth retardation

Birth weigth < 2500g

Causes Smoking

Poor nutrition

Placental factors

Maternal ill health

Risk factors Smoking Drug and alcohol use Severe malnutrition Maternal high bp, or pre eclampsia Infections – cmv, rubella, toxoplasma Chronic maternal disease – diabetes,

rheumatological

Diagnosis

Fundal height – 18-34/52 height = distance in cm

Ultra sound – ratio of head circumference to abdo

Treatment Stop smoking Good nutrition Bed rest on left side Fetal movement chart Serial ultrasound scans Volume of amniotic fluid

Hydatidiform mole

Incidence 1 in 2000 preg

Increased risk with age

Abnormalities in sperm chromosome

Abnormalities of egg

Hydatidiform mole

Signs Uterus larger than date

Vaginal bleeding

Diagnosis Ultrasound

Hcg higher than normal

Hydatidiform mole

Treatment

Suction curettage

Monitor hcg for several months due to risk of choriocarcinoma

Postpone preg for a year

APH

Placenta abruptio1% of all deliveriesVaginal bleeding in 3rd trimestreConstant back or abdo painContractions tenderness or rigidity of uterus

Risk factors Smoking Pergnancy induced hypertension Alcohol or drug use Increased maternal age >40 yrs Premature rupture of membranes Injury to mother

Diagnosis

No clear test

May or may not show on ultrasound

Exclusion of other causes of bleeding – placenta

praevia

Treatment

Evaluate maternal well being

Monitor

Evaluate fetal well being

If severe bleeding or fetal distress cesarean

Placenta previa 4-8% placentas low lying Only 10% remain low Marginal – placenta near edge of os Partial – placenta covers cervical opening Total – placent completely covers os All need cesarean

Placenta previa Signs

Painless bright red vaginal bleeding Risk factors

SmokingFirst preg after lscsPrevious placenta previaAdvanced maternal age

Placenta previa

Diagnosis

Ultrasound

Treatment

lscs

Post term pregnancy > 42/52 Risks

Reduced amniotic fluid increased risk of cord compression

Meconium in liquor inhlaed by baby causing pneumonia

Too large baby > 4500g

Management Monitor baby

Too large babyDecreased amniotic fluidDeliver if cervix ripe try oxytocinon If cervix not ripe try prostaglandin gelOtherwise lscs

Pre term labour

Labour before end of 36th week preg

Low birth weight < 2500g

8-12% of all pregnancies

Signs and symptoms

Regular uterine contractions for more than 1 hr

Backache

Intestinal cramping with or without diarrhoea

Spotting or blood tinged discharge

Thin cervix, dilation beyond 1 cm, contractions

Risk factors Smoking alcohol drugs Previous pre term delivery 3 or more 1st trimestre miscarriages Cervical incompetence Placenta previa Serious maternal infection Low maternal weight < 45 kg

Postnatal care Maternal Lochia xs bleeding = pph admit Breasts – engorgement lasts 2-3 days mild temp

fell fluey Nipple pain- camomile creams daktarin if

candidal Mastitis – empty breast flucloxacillin

Postnatal care

Blood pressure

Fundal height

Perineum

Symptoms of depression

Contraceptive advice

Postnatal care Fetal

Method of deliveryLength of gestationWeightFeedingconcerns

Postnatal care Fetal examination

Fontanelles Eyes- cataractSclera – jaundiceHsLungsAbdo - masses

Postnatal care

Fetal examGenitalia Hips Femoral pulsesSpineBirth marks

6 week exam Maternal

Feeding DepressionLochiaContracptionBpAbdo examSmear if due

6 week exam Fetal

According to chs schedule