Antenatal Care

Lifestyle Issues
Health Education Pre-conception counseling and antenatal care important for improving a womans health before and during pregnancy Pre- and peri-conceptional folic acid supplementation can prevent recurrence of fetal NTDs Birth & Parenting Education Provided in the second half of pregnancy Primigravid women - six 2-hour sessions over 6 weeks Aim to provide information on pregnancy, labour, birth, breast feeding and early parenting Social & Psychological Support Maternity Leave In Australia, the full entitlement including unpaid leave is 12 months duration in Government organisations Vary considerably in the public sector - inform women to consult their HR ofcer Additional entitlements - maternity allowance, family payments (eg. baby bonus) Paternity leave - 1 week around birth of child Seatbelts The lap belt should be worn low under the abdomen and over both anterior and superior iliac spines and the symphysis pubis If a shoulder harness is used the straps should be placed so that they pass diagonally across the body between the breasts Placental abruption and fetal death may occur if the lap belt is over the abdominal wall and an accident or sudden stop occurs Air Travel In an uncomplicated pregnancy, there is no indication not to travel unless the women is at or past her expected delivery date Exercise 30 minutes of moderate exercies/day is recommended for pregnant women in the absence of medical or obstetric complications

Do not exercise in the supine position after the rst trimester - may cause hypotension secondary to IVC obstruction Avoid contact sports or activities with increased risk of falling Occupational Work Physically demanding work and prolonged standing are associated with preterm birth and reduced birth weight - also shit and night work Long working hours and preterm birth are not associated Avoid exposure to toxic chemicals and radiation Sexual Activity Intercourse is not contraindicated at any time during normal pregnancy It is best avoided when the membranes have ruptured prematurely or when antepartum haemorrhage has occurred In women with threatened miscarriage, advise against intercourse for several days after symptoms and signs have disappeared Diet Small increase in energy requirements during pregnancy - 71-120kcal/day Birth weight of the baby is related to maternal nutrition Protein requirements increase in the nal 12 weeks of pregnancy with 12g of nitrogen required for growth of maternal and fetal tissue Additional folate, riboavin and polyunsaturated fatty acids promote fetal wellbeing Three serves of dairy per day is recommended Weight Average weight gain is 10-14kg Low pre-pregnancy weight (<50kg) increases the risk of IUGR Excess weight gain during pregnancy is associated with larger infants Obesity increases the risk of: Gestational diabetes HTN Dystocia Thromboembolic disease after C-section Weight-reducing efforts should not be commenced or continued during pregnancy Alcohol Teratogenic Large amounts cause fetal alcohol syndrome: Pre- and postnatal growth restriction Dysmorphic facial features Mental retardation Five or more drinks per week throughout pregnancy is the threshold for increased risk of fetal anomalies

Smoking Increased frequency of low-birth-weight infants, prematurity and spontaneous abortion Placental abruption, fetal death in utero, PROM and SIDS may also occur The incidence of congenital malformations is not increased with maternal smoking Drugs Marijuana - IUGR, prematurity, delayed mental development Cocaine: Maternal complications - stroke, seizures, AMI, arrhythmia Fetal complications - IUGR, prematurity, abortion, placental abruption, NEC, abnormal behavioural development Opiates - maternal withdrawal is associated with spontaneous abortion, hypoxia, passage of meconium, fetal death in utero, hyperactivity of the newborn Maternal stabilisation during pregnancy on methadone Amphetamines - IUGR, placental abruption Dental Care Periodontal disease in pregnancy is a risk factor for prematurity and low birth weight Can be prevented by professional cleaning of teeth Pets Pregnant women should be advised domestic cats may have toxoplasma infection If transmitted to the fetus it can result in mental retardation, seizures and blindness and infant death

Branching of the villous structure of the placenta to maximise the surface area for maternal fetal exchange at the terminal villi Clinical & Laboratory Diagnosis !HCG test conrm diagnosis - urine and serum The EDD is calculated as 40 weeks from the rst day of the LMP Early U/S determination of gestation is more reliable Common early symptoms of pregnancy: Fatigue Breast tenderness Nausea Frequency of urination Minor Complications Urinary frequency Pelvic pressure Insomnia Lower backache Nausea and vomiting - manage with frequent small, low-fat meals, eating dry CHO before rising and oral thiamin Hyperemesis gravidarum - severe N/V that can lead to dehydration requiring uids and metoclopramide Routine Investigations FBE Blood group and anti-D RBC antibody screen Serology - syphilis, HBV, HCV, HIV, rubella MSU for culture and sensistivity First Trimester Ultrasound To establish gestational age, investigate vaginal bleeding and screen for Down syndrome Live fetus is demonstrated by identifying a fetal heartbeat from 6-7 weeks gestation Determine if the pregnancy is intrauterine or ectopic and if it is singleton or multiple Down syndrome - fetal nuchal translucency together with rst-trimester biochemical assay of the two hormones (free !HCG and pregnancy-associated plasma protein A - PAPPA) 85-90% detection rate for trisomy-21 and can be used as population screening for mother who have chosen to have this test

First Trimester Care

Development of the Embryo, Fetus & Placenta Blastocyst forms at the 32-cell stage after fertilisation and consists of: Inner cell mass, the precursor of the embryo Trophectoderm overlying the embryonic pole that interacts with the uterine lining to facilitate implantation 7-14 days after conception By the end of the rst 8 weeks (embryonic period) all essential structures are present Neural plate begins developing during the 3rd week and the heart begins beating ~21-22 days post-fertilisation These structures grow and develop during the fetal period from week 9 till birth Placental growth and development involves: Growth of the cytotrophoblast with invasion of the maternal spiral arteries to increase the maternal blood supply to the placenta

Diagnostic Tests Chorionic villous sampling at 10-13 weeks involves a transvaginal or transabdominal sample of chorionic villi for genetic testing To identify chromosomal abnormalities and some hereditary conditions Models of Care for Pregnancy & Education Home birth with midwife or doctor Birth centre attached to a hospital Shared care with family practitioner at a private or public hospital Team midwifery care Private obstetric consultant care

At each subsequent visit the woman is asked about her general wellbeing and fetal activity Screening & Investigations Woman should be offered maternal serum screening (!HCG, AFP and oestradiol) if no nuchal fold translucency risk assessment is performed in the rst trimester Performed at 15-20 weeks and has a 70% pick up rate for Down syndrome but a 5% false-positive rate If the calculated risk is >1:250 the woman should be referred for genetic counselling and amniocentesis for fetal karyotyping Amniocentesis - performed at 14-18 weeks and offered to any woman at increased risk of chromosomal abnormality Risk of miscarriage - 0.5-1% Gestational diabetes screening: Mid-second trimester Oral 50g glucose load with measurement of the blood glucose concentration at 1 hour If abnormal, a full 2-hour GTT is performed 18-week U/S to check anatomy of the fetus, number of fetuses, conrm the gestational age of the fetus After 20 weeks U/S is unreliable in conrming gestational age Also used to assess fetal wellbeing if there is any evidence of delayed growth or maternal/fetal compromise 26-week FBE and Rh antibody screen If no anti-D detected in an Rh-negative woman, they should receive 650IU of anti-D IgG at 28 and 34 weeks Minor Second Trimester Complications Nausea and vomiting - usually resolved early in second trimester Constipation due to increased progesterone Relief measures include increased uid and bre intake, exercise, mild laxatives or stool softeners Varicosities due to progesterone-mediated smooth muscle relaxation of the veins, increased blood volume, stasis and increased pelvic pressure Management - frequent position changes, elevation of legs, exercise, avoiding lengthy periods of standing, support stockings Headaches - often worse in those with a pre-pregnancy history of migraine Consider anaemia and hypoglycaemia Management - rest, hydration, simple analgesia, cold packs

Second Trimester Care

Common Clinical Presentations A woman at 26 weeks gestation in her rst pregnancy is referred to the antenatal clinic by her GP for apparent slowing of fetal growth A 37-year-old woman at 16 weeks gestation asks if her age poses any risk to her pregnancy A 22-year-old woman at 24 weeks gestation presents to the antenatal clinic with a history of a previous intrauterine death A pregnant woman who has a long-term history of essential hypertension presents to the antenatal clinic at 25 weeks gestation Procedure At Each Antenatal Visit I. BP is checked - <140/90 is normal II. Mother is asked of fetal movements are often and regular and if there has been any sudden changes in fetal activity A. In the third trimester she should feel the baby roll over and kick several times/day III. Symphysis-fundal height (SFH) is measured - fundal height (cm) +/- 3 = weeks of gestation A. Fetal size and growth, lie, presentation and descent of presenting part are assessed B. Fetal HR checked - U/S or Pinard stethoscope IV. Urine is tested for proteinuria and signs of infection V. Information about pregnancy and motherhood is provided A. Assess need for social support to ease mothers transition and ability to cope Follow-Up Antenatal Care In the second trimester of pregnancy up to 28 weeks gestation, a woman will have regular monthly antenatal check-ups

Third Trimester Care

Common Clinical Presentations A 25-year-old woman at 34 weeks gestation in her rst pregnancy wishes to discuss how she will manage pain during labour and birth A 30-year-old woman at 32 weeks gestation in her second pregnancy wishes to talk about having her baby naturally after a previous elective caesarean as the baby was very small A 37-year-old woman at 41 weeks gestation in her rst pregnancy presents and is now 7 days beyond her expected date of delivery Principles of Management Monitor the progress of pregnancy Provide advice, reassurance and education about pregnancy, labour and planning for a parenting role Consider factors inuencing the overall health and wellbeing of women and their families Identify women at risk of maternal and fetal complications during pregnancy Manage any obstetric and/or medical problems arising during pregnancy including socioeconomic and psychological factors Antenatal visits are fortnightly from 28-36 weeks and then weekly to 41 weeks Blood pressure of most importance - pre-eclampsia most common in third trimester Education should be focussed on preparation for labour Consider the prevention and management of major perineal trauma antenatal pelvic oor exercises reduce longer-term problems with anal and stress incontinence and genital prolapse Assessment of antenatal and postnatal depression Birth plan for labour and birth care written at ~36-37 weeks Include analgesia, support persons, wishes for medical intervention Advise women to stay home until contractions are regular and becoming more frequent (once every 7-10 minutes) She should contact her health service when her membranes rupture, she is bleeding, experiencing reduced fetal movements or is feeling distressed Minor Third Trimester Complications Gastro-oesophageal reux due to sphincter relaxation - advise frequent smaller meals, avoidance of caffeine and spicy foods and use antacids if severe Increasing difculty with breathing due to enlarging uterus, especially at night Sleeping in lateral position may help Oedema and potential median nerve compression leading to carpal tunnel syndrome Management: Oedema - support stockings, regular exercise

CTS - physiotherapy, wrist splints Supine hypotension due to aortocaval compression Postural hypotension due to obstructed venous return from the lower limbs Urinary frequency with increased pressure on the bladder Loin pain secondary to varying degrees of ureteric obstruction Back and pelvic pain from descent of fetal head and relaxation of pelvic ligaments Management - sleeping in lateral position, massage, heat packs, pelvic rock exercise

Physiology Breast enlargement and colostrum production Irregular uterine contractions become more frequent Cervical ripening and assumption of a more anterior position Increased amount of discharge or the loss of a discrete mucous plug (show) Oestrogens role in promoting labour: Increases development of gap junctions between myometrial cells causing more coordinated contractions Production of prostaglandins from the membranes