2It is the clinical assessment of mother and fetus during pregnancy 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.
3Aims of antenatal care: - assessment and management of maternal risk- assessment of fetal risk- prenatal dx. and management of fetal abnormalitiesmanagement of perinatal complicationstiming and mode of deliveryparental education regarding preg. and child birtheducation regarding child rearingso 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.
4Providers of antenatal care: community careshared carehospital only care
5schedule 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.
7Preconceptional 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.
8Pre 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 pregnancyWomen with some diseases who are anxious to know whether pregnancy would exacerbate this, or whether the child might be harmedWomen with a family history of diseaseGenetic problems may require special investigations, including chromosomal studies.
9High risk pregnancy:-maternal health conditions-maternal problems develop during preg.-disorders of preg.-fetal complications
10BOOKING VISIT 8-14 WEEKSFirst trimester is a critical period in determining the outcome of pregHistory, gestational age, fetal & maternal risksphysical examination
12Laboratory tests:Routine baseline investigations:blood tests: Hb, full blood count, if Hb below 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 screenmicrobiological: rubella, hepatitis B, syphilis (VDRL ),HIVother 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 weeksBlood glucose screen.
13urine tests:glucose, ketones, proteins, bacterial activityvaginal 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 gonorrhoeaGroup B streptococciChlamydia trachomatisMycoplasma hominis
14Ultrasound:Confirm gestation by measuring crown rump length. Dx. multiple pregnancy, monochorionic twins.Abnormalities as anencephaly ( structural abnormality ), nuchal translucency in fetal chromosome abnormality.
15Subsequent 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:HISTORYAge, 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 irregularityObstetrical 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.
16Physical 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 examinationAbdominal examination, fundal height, lie, engagement, fetal heart, to asses fetal growth and malpresentationGestational 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.
17Vaginal 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 BloodScreening:It allows us to place women into low or high risk groupsBiochemical screening tests:include serum oesteriol, alpha fetoprotein, hCG, inhibin.Ultrasound as screening and diagnosingTo confirm the dx. We need invasive tests.Doppler ultrasound may be needed
18Diet: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 mg, should be taken daily.
19Vitamins 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.
20Preparation 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.
21MID TRIMESTER VISIT 20-24 WEEKS Examination, general examination, gestation, fetal growthBlood tests:Hb , antibodies, repeat blood sugar in screening for D.MUrine testUltrasound: 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 restrictionWe may need invasive methods as amniocentesis, cordocentesis.
22ANTENATAL VISIT IN SECOND HALF OF PREGNANCY Asses maternal healthFetal growth and well beingDealing with any complication as hypertension, ante partum hge.Women educationPlans for birthPost delivery contraceptionBreast feedingLabor pain
2336-38 WEEKS VISITIt is to anticipate any problem regarding delivery, fetal or maternal ashypertension, D.M, fetal distress, ante partum hge. and othersPresentation, position of the fetusAdequacy of the pelvisFetal well beingTime and place of deliveryContraception
24POST DATE VISITAccurate datingTime of delivery, the need for induction of labor which is usually performed at 42 weeksThe way of induction of labor;SurgicalMedicalFactors unfavourable for vaginal delivery at weeks:High headSuspicious CTGReduced amniotic fluidLow Bishop score
25MAJOR 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
26SPECIAL 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.