ANTENATAL CARE Dr Samar Sarsam. It is the clinical assessment of mother and fetus during pregnancy. To obtain the best outcome for both. It is a mixture.

ANTENATAL CAREDr Samar Sarsam

• It is the clinical assessment of mother and fetus during pregnancy. To obtain the best outcome for both. It is a mixture of both art and science. It involves a no. of routine visits on regular bases throughout pregnancy.

• Team work between midwives, general practitioners, and obstetricians will continue to be necessary in effective antenatal care.

• Aims of antenatal care:• - assessment and management of maternal risk• - assessment of fetal risk• - prenatal dx. and management of fetal

abnormalities• management of perinatal complications• timing and mode of delivery• parental education regarding preg. and child birth• education regarding child rearing• so a programme should be based on individual

requirements of both mother and fetus.The women are now able to choose the professional most closely involved with their antenatal care.

• Providers of antenatal care:• community care • shared care• hospital only care

• schedule of visits during preg.• traditional antenatal care was around 14 visits

during preg.• monthly until 32 weeks, then fortnightly until

36 weeks, and weekly until delivery.• Currently the trend is towards reducing the

no. of visits, at the same time establishes clear objectives to be achieved at each visit.

• The visits:• Preconception clinic visit• 8-14 weeks visit• 20-24 weeks visit• 36-38 weeks visit• 41-42 weeks visit

• Preconceptional visit:• Where health education and risk assessment can be

directed towards the planned pregnancy. It may be said that antenatal care should start before pregnancy.

• The main structure of the organs of the embryo is laid down in the first 8 weeks of pregnancy, and it is during this time that major congenital abnormalities arise.

• The patient’s general health and wellbeing can be fully assessed.

• General advice regarding nutrition and the avoidance of teratogens.

• Daily supplementation with 0.5 mg of folic acid, it reduces the risk of neural tube defect by 72% in patient with previous affected preg.

• Pre pregnancy management of the diabetic to ensure optimal control of blood glucose levels during the early weeks of pregnancy has the potential to prevent birth defects.

• A pre-pregnancy counselling might give advice to women with any of the following conditions:

• Women who had unsuccessful pregnancy • Women with some diseases who are anxious to know

whether pregnancy would exacerbate this, or whether the child might be harmed

• Women with a family history of disease• Genetic problems may require special investigations,

including chromosomal studies.

• High risk pregnancy:• -maternal health conditions• -maternal problems develop during preg.• -disorders of preg.• -fetal complications•

• BOOKING VISIT 8-14 WEEKS• First trimester is a critical period in

determining the outcome of preg• History, gestational age, fetal & maternal risks

• physical examination•

• Laboratory tests: • Routine baseline investigations:• blood tests: Hb, full blood count, if Hb below 8.5 gm

we send for blood film and transferrin and ferritin RBCfolate and B12 assays, Hb electrophoresis ( thalasemia and sickle cell anemia )or women at particular risk ( Mediterranean, afro-Caribbean & Asian )

• Blood group, Rh factor and antibody screen • microbiological: rubella, hepatitis B, syphilis (VDRL ),HIV• other tests: (not routine tests)• infections such as varicella zoster, cytomegalovirus,

toxoplasmosis which may affect the fetus adversely are not routinely screened we depend on history.

• Serum -fetoprotein at 16-18 weeks• Blood glucose screen.

• urine tests:• glucose, ketones, proteins, bacterial activity • vaginal speculum examination:• done only if indicated: if vaginal discharge, do

high vaginal swab. • if cervical smear not done, or was abnormal.• -Cervical cytology.• -Cervical culture for:• Neisseria gonorrhoea• Group B streptococci• Chlamydia trachomatis • Mycoplasma hominis

• Ultrasound:• Confirm gestation by measuring crown rump

length. Dx. multiple pregnancy, monochorionic twins.

• Abnormalities as anencephaly ( structural abnormality ), nuchal translucency in fetal chromosome abnormality.

• Subsequent antenatal visits:• The success of antenatal care depends on repeated

careful observations of both mother and fetus to detect any abnormality or potential problems as early as possible.

• Each visit:• HISTORY• Age, diet, occupation, smoking, gestational age calculated

according to Naegeles rule (280 days from LMP, crown rump length, biparietal diameter, femur length, fetal abdominal circumference, and femur length).

• History of contraception, menstrual irregularity• Obstetrical history, parity and gravida, no. of abortions,

preterm labor, perinatal death, fetal malformation, mode of delivery, third stage complications, puerperium.

• Medical problems as hypertension D.M, heart disease, surgical problems.

• Physical examination:• Height, wt (complications occur with wt lower than 45kg

and wt over 100kg)• General examination B.P, P.R, edema, anemia, heart, chest,

breast examination• Abdominal examination, fundal height, lie, engagement,

fetal heart, to asses fetal growth and malpresentation• Gestational age estimate and fundal height

measurements (from 22 weeks until term, fundal height measured in centimetres )

• -The fetal heart should also be auscultated• -Examination of the abdomen: Beginning at 24 weeks to

identify the attitude, lie, presentation and position of the fetus and the volume of amniotic fluid.

• Vaginal examination late in pregnancy often provides valuable information:

• Confirmation of the presenting part.• Station of the presenting part.• Clinical estimation of pelvic capacity and its general

configuration.• Consistency, effacement and dilatation of the cervix.• Investigations:Urine and Blood• Screening:• It allows us to place women into low or high risk groups• Biochemical screening tests:• include serum oesteriol, alpha fetoprotein, hCG,

inhibin.• Ultrasound as screening and diagnosing• To confirm the dx. We need invasive tests. • Doppler ultrasound may be needed

• Diet:• There is no need for a large increase in calorie

value of the diet; 2400 calories is recommended, protein should be increased, carbohydrates can be reduced slightly to compensate for the increased calorie value of the protein.

• The amount of calcium required daily by an adult is 0.5g; during pregnancy the amount is increased to 1.5g.

• If calcium intake is judged to be deficient, a half- litre of milk, providing 500-600mg, should be taken daily.

• Vitamins and iron supplementation:• The daily absorption of iron from an ordinary diet is about

1.2mg, while the requirement during pregnancy average 3.5mg. An iron supplementation is therefore often given. The preparation commonly used is ferrous sulphate 200mg three times daily, 300mg of ferrous gluconate, or 100mg of ferrous fumarate.

• During pregnancy megaloblastic anemia from deficiency of folic acid may occur,

• a daily dose of 0.5mg of folic acid is required. Higher therapeutic doses (5mg/day) are usually reserved for prophylaxis against neural tube defect.

• Routine multivitamin supplementation is not recommended unless the maternal diet is questionable or if she is at nutritional risk e.g. multiple gestation, complete vegetarians, and epileptics.

• Exercise: Exercise is beneficial during pregnancy because it helps to maintain a feeling of wellbeing. Although violent exercise should be avoided during pregnancy, the woman should be encouraged to continue all ordinary activities.

• Preparation for lactation: • The best preparation for lactation is to ensure that the

expectant mother is aware of the normal course of events following delivery and is mentally prepared for breast- feeding.

• Attention is given during antenatal examination to the nipples. A poorly developed, retracted or inverted nipple cannot be drawn into the infant’s mouth, and may be traumatised because the baby cannot fix onto the nipple properly. If the nipples are retracted some advocate the mother to wear glass or plastic nipple shells during the day, and at night during the latter part of pregnancy.

• There should be no attempt to harden the nipples with spirit only ordinary washing is necessary. Dry skin on the nipples may be treated with an occasional application of lanolin. The breasts should be supported by a well fitting brassiere, which does not press upon the nipples.

•

• MID TRIMESTER VISIT 20-24 WEEKS• Examination, general examination, gestation, fetal

growth • Blood tests:• Hb , antibodies, repeat blood sugar in screening for

D.M• Urine test• Ultrasound: gestation, placenta, amniotic fluid, fetal

abnormalities, multiple preg.• In high risk patients we do Doppler ultrasound of the

uterine arteries to identify risk of pre-eclampsia and intra uterine growth restriction

• We may need invasive methods as amniocentesis, cordocentesis.

•

• ANTENATAL VISIT IN SECOND HALF OF PREGNANCY • Asses maternal health• Fetal growth and well being• Dealing with any complication as hypertension, ante

partum hge.• Women education • Plans for birth• Post delivery contraception• Breast feeding• Labor pain

• 36-38 WEEKS VISIT• It is to anticipate any problem regarding delivery, fetal

or maternal as • hypertension, D.M, fetal distress, ante partum hge.

and others• Presentation, position of the fetus• Adequacy of the pelvis• Fetal well being• Time and place of delivery• Contraception•

• POST DATE VISIT• Accurate dating• Time of delivery, the need for induction of labor which is

usually performed at 42 weeks • The way of induction of labor;• Surgical• Medical• Factors unfavourable for vaginal delivery at 41-42 weeks:• High head• Suspicious CTG• Reduced amniotic fluid• Low Bishop score

• MAJOR SYMPTOMS REQUIRING URGENT INVESTIGATION:

• -vaginal bleeding• -abdominal pain, uterine contractions• -premature rupture of membranes• -headache, unwell• -Cessation of fetal movement• -collapse, including convulsions• -acute leg pain and swelling

• SPECIAL PROBLEMS:

• -Problems among teenagers, they are single unsupported, greater risk to have pre-eclampsia

• -Drug abuse, other social problems• -Problems in ethnic minority groups, some diseases are

specific to certain ethnic groups such as sickle cell disease in Afro-Caribbean population, thalassaemia in Mediterranean population, glycogen storage disorders in the Jewish population.