Transcript ANTENATAL CARE - Al-Kindy College of Medicine

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 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:
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- assessment and management of maternal risk
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- assessment of fetal risk
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- 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.
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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.
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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.
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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
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• Laboratory tests:
• Routine baseline investigations:
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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.
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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:
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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:
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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:
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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:
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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 breastfeeding.
• 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.
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• 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.
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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
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• 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;
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Surgical
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Medical
• Factors unfavourable for vaginal delivery at 41-42 weeks:
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High head
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Suspicious CTG
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Reduced amniotic fluid
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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.