Transcript Antenatal Care - howMed Lectures

Antenatal Care
Dr. NUSRAT NOOR
Obstetrics/Gynecology
Background
Antenatal period presents opportunities for reaching
pregnant women with interventions that may be vital to
their health and well-being and that of their infants, for
example:
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detect potential complications of pregnancy and delivery
promote good nutrition, hygiene and rest
provide family planning information
management of STIs
tetanus immunization
HIV counseling and ART prophylaxis
malaria prophylaxis
Aims Of Antenatal Care
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To prevent, detect and manage those
factors that adversely affect the health of
the baby
To provide advice, reassurance, education
and support for the woman and her family
To deal with the ‘minor ailments’ of
pregnancy
To provide general health screening
Classification Of
Antenatal Care

Shared Care
1.
Hospital Maternity Team
2.
General Practitioner (GP)
3.
Community Midwives
Community-Base
Care
Hospital-Based
Care
Advice, Reassurance & Education

Reassurance & explanation on
pregnancy symptoms:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Nausea
Heartburn
Constipation
Shortness Of Breath
Dizziness
Swelling
Back-ache
Abdominal Discomfort
Headaches

Information regarding:
1.
Smoking
2.
Alcohol Consumption
3.
Drugs (Both LEGAL and ILLEGAL)
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2nd trimester:
- (BPD, HC, AC, FL ± 10 days).
AC
BPD
FL
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3rd trimester:
- Much less accurate.
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Confirmation of the pregnancy
1.
The symptom of the pregnancy
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2.
Breast tenderness
Nausea
Amenorrhea
Urinary Frequency
Positive urinary or serum pregnancy test
are usually sufficient confirmation of a
pregnancy.
3.
Dating Pregnancy, confirms the
pregnancy and accurately dates it.
Dating Pregnancy
A.
Menstrual EDD
B.
Dating by ultrasound
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Benefits of a dating scan:
1.
2.
3.
4.
5.
Accurate dating women with irregular menstrual cycles or
poor recollection of LMP.
Reduced incidence in induction of labor for ‘prolonged
pregnancy’
Maximizing the potential for serum screening to detect
fetal abnormalities
Early detection of multiple pregnancies
Detection of otherwise asymptomatic failed intrauterine
pregnancy
Booking History
1.
Past Medial History
2.
Past Obstetric History
3.
Previous Gynaecological History
4.
Family History
5.
Social History
Booking Examination
 Full Physical Examination:
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Cardiovascular

Respiratory Systems
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Abdominal
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Pelvic Examination
Breast Examination
 Examination for most
healthy women :
1.
Accurate measurement of blood pressure
2.
Abdominal examination to record the size of
the uterus
3.
Recognition of any abdominal scars
indicative of previous surgery
4.
Measurement of height and weight for
calculation of the BMI.
Women with a low BMI are at greater risk
of fetal growth restriction and obese women
are at greater risk of fetal growth restriction
and obese women are at significantly greater
risk of most obstetric complications, including
gestitational diabetes, pre-eclampsia, need for
emergency caesarean section and anaesthetic
difficulties.
5.
Urine examaniation: asymptomatic bacteriuria
is more likely to ascend and cause
pyelonephritis in pregnancy.
This causes significant maternal morbidity, but
also predisposes to pregnancy loss and
preterm labour.
All women at booking should have a
midstream urine sent for culture or be tested
with a dipstick which recognizes nitrates, the
presence of which sensitivity predicts the
presence of significant bacteria.
Booking Investigation
1.
Full Blood Count
2.
Blood Group & Red Cell Antibodies
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Women found to be rhesus negative will be
offered prophylactic anti-D administration at 28
and 34 weeks’ gestation to prevent rhesus isoimmunization and future HDN.
Other possible iso-immunization events, such as
threatened miscarriage after 12 weeks’ gestation,
antepartum haemorrhage and delivery of the
baby, may require additional anti-D prophylaxis in
rhesus-negative women.
3.
Rubella
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4.
Women who are found to be rubella nonimmune should be strongly advised to avoid
infectious contacts and should undergo rubella
immunization after the current pregnancy to
protect themselves for the future.
Hepatitis B
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Vertical transmission to the fetus may occur,
mostly during labour, and horizontal
transmission to staff or the newborn infant can
follow contact with body fluids.
A baby born to a hepatitis B carrier should be
actively and passively immunized at delivery.
5.
Human Immunodeficiency Virus
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6.
In known HIV-positive mothers, the use of
antiretroviral agents, elective Caesarean section
and avoidance of breastfeeding reduces vertical
transmission rates from approximately 30% to
less than 5%.
The Department of Health guidelines now
recommend that all pregnant women should be
offered an HIV test at booking.
Syphilis
Haemoglobin Studies
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Tests for thalassaemia and sickle cell
disease are usually reserved for women
who have an ethnic background and those
from the Middle East.
Gestational Diabetes
1.
Random Blood Sugar
2.
Fasting Blood Sugar
3.
Formal Oral Glucose Tolerance
Background
WHO recommends a minimum of four antenatal
visits based on a review of the effectiveness of
different models of antenatal care.
WHO guidelines are specific on the content of
antenatal care visits, which should include:
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blood pressure measurement
urine testing for bacteriuria & proteinuria
blood testing to detect syphilis & severe anemia
weight/height measurement (optional)
International Goals & Targets
Special emphasis must be placed on
prenatal and postnatal care and care for
newborns, particularly for those living in
areas without access to services
Antenatal Care (ROSA)
Antenatal Care
Sri Lanka
95
Maldives
81
India
60
Bangladesh
49
Pakistan
43
Nepal
28
Afghanistan
16
South Asia
54
0
20
40
60
% w om en aged 15-49 years attended at least once
during pregnancy by skilled health personnel
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100
Pattern Of Follow Up Visits
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4 weekly appointments from 20 weeks until
32 weeks
Followed by fortnightly visits 32 weeks to
36 weeks and weekly visits.
The minimum number of ‘visits’
recommended by the Royal College of
Obstetricians and Gynaecologists is 5,
occurring at 12, 20, 28-32, 36 and 40-41
weeks.
Content Of Follow Up Visits
 General questions regarding maternal well-
being.
 Enquiry regarding fetal movements (24
weeks).
 Measurement of blood pressure (a screen for
pregnancy-related hypertensive disorders).
 Urinalysis, particularly for protein, blood and
glucose: this is used to help detect infection,
pre-eclampsia and gestational diabetes.
 Examination for oedema:
Oedema is common in pregnancy and is
mostly an insensitive marker of preeclempsia. Oedema of the hands and face is
somewhat more important as a warning
feature of pre-eclampsia.
 Abdominal palpation for fundal height:
If repeated symphysis–fundal height
measurement are made throughout a
pregnancy, the detection of fetal growth
problems and abnormalities of liquor volume
increased.
 Auscultation of the fetal heart:
There is no evidence that this practice is of
any benefit in a woman confident in the
movements of her baby; however, it provides
considerable reassurance and will
occasionally detect an otherwise
unrecognized intrauterine fetal death.
 A full blood count and red cell antibody
screen is repeated at 28 and 36 weeks.
 Depending on the screening policy of the
particular unit, women at 28 weeks may be
tested for gestational diabetes.
 From
36 weeks, the lie of the fetus
(longitudinal, transverse or oblique), its
presentation (cephalic or breech) and the
degree of engagement of the presenting part
should be assessed and recorded.
It is often at this appointment that a decision
is made regarding the mode of delivery (i.e.
vaginal delivery or planned Caeserean
section).
 At
41 weeks’ gestation, a discussion
regarding the merits of induction of labour for
prolonged pregnancy should occur.
An association between prolonged pregnancy
and increased perinatal morbidity and
mortality means that women are usually
advised that delivery of the baby should
occur by 42 completed weeks’ gestation.
This will usually mean organizing a date for
induction of labour at approximately 12 days
past the EDD.
Antenatal complications
dealt with in
customized antenatal clinics
 Endocrine (diabetes, thyroid, prolactin and
other endocrinopathies)
 Miscellaneous medical disorders (e.g.
secondary hypertension, autoimmune disease)
 Haematology (thrombophilias, bleeding
disorder)
 Substance Misuse
 Preterm labour
 Multiple gestation
 Teenage pregnancy
Everyday Pregnancy Issues!
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Supplements:
“Should I be taking anything?”
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When to start and stop!
 Trace elements:
 Folate, calcium,
 Iron (+ vit.C),
multivitamins.
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Dietary supplements:
 Protein drinks.
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Listeria
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Avoid chilled, ready -to-eat foods:
 Soft cheeses.
 Takeaway chicken sandwiches.
 Cold meats.
 Pre-prepared or stored salads.
 Raw seafood.
 Smoked salmon & smoked oysters (can
OK).
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EXERCISE
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Reduced weight gain.
More rapid weight loss after
pregnancy.
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Improved mood.
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Improved sleep patterns.
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Some studies have shown:
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Faster labour.
Less need for induction.
Less likely to need epidural.
Fewer operative births.
Exercise does NOT increase risk of
miscarriage.
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Exercise commonsense:
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Take frequent breaks.
Avoid exercise in extremely hot weather.
Avoid unstable ground (joints more lax).
Avoid contact sports.
Avoid lifting weights over head.
And weights that strain lower back
muscles.
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Air Travel
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Travel must be completed by 36th
week.
Medical clearance needed for twins &
complicated pregnancy.
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Preventing DVT
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Support stockings.
Hydration.
Ankle rolls, walks around plane.
Baby aspirin.
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Stretch marks
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Related to type of collagen
ie genetic.
May have link with pelvic floor & perineal
“stretchiness”
Goanna oil, emu oil, olive oil,vitamin E and
other expensive topicals…..
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Fetal movements
- what is normal?
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Vaginal Discharge
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Normally increases with gestation.
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Exclude rupture of membranes.
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Canesten pessaries OK for thrush.
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“Uncomfortables”
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Can’t sleep!
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Swollen feet!
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Backache!
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“sick of being pregnant”!
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Shoes won’t fit,
rings too tight...
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85% of pregnancies have
oedema.
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Rest and elevate!
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Carpal tunnel.
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My back hurts……...
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Posture:
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Don’t slouch!, do not bend from waist.
Choose chair with back support.
Bra with support.
Hot pack & panadol.
Elastic brace supports.
Physiotherapy review.
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Is my baby too big?!
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Fundal height = gestation +/- 2 cm.
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Engagement of fetal head.
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Liquor vs EFW.
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Assessing fetal size at term.
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I AM SICK OF BEING
PREGNANT!!!!!
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Check CTG & AFI when 7 days post EDD.
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Post dates IOL= 10 days after EDD.
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“Natural IOL” - does it work?
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Curry, chilli, castor oil, etc..
Warm bath!
Cervical sweep!
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Thank you
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