Antenatal Care

Nail Obeidat Assistant Professor KAUH/ JUST 27/9/2010

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Definition

Careful, systematic assessment and follow up of a pregnant patient to assure the best health of the mother and her fetus.

Objectives & Benefits

To prevent and identify maternal or fetal problems that adversely affect pregnancy outcome. To educate the patient about pregnancy, labour-delivery, and parenting as well as about ways she can improve her health. To promote adequate psychological support from her partner, family and caregivers.
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How often should pts be seen?

First visit in early pregnancy. Then every 4 weeks until 28 weeks. Then every 2 weeks until 36 weeks. Then weekly until delivery. For high risk patients, individualized and more visits.
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First visit
History: Medical problems (DM, HT, others). Surgical, previous operations, complications and need for transfusion. Family hx- inherited problems (medical diseases, congenital anomalies, cystic fibrosis, hemophilia..).
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Social hx- psychosocial background and lifestyle, smoking, alcohol Obstetric- EDC, recurrent problems (fetal & neonatal death, preterm deliveries, IUGR, macrocosmic babies, anomalies, abruptio, HT, PET, GDM, PPH, thromboembolism.). Gynaecologic- infertility treatment, PID, ectopic pregnancy, STDs).
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How is GA determined?
Accurate estimation is vital & mandatory. First day of the last normal menstrual period. Regular and normal periods?

Oral contraceptive pills? Lactation?

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Ultrasonic estimation of EDC

1st trimester: - The best & most accurate. - Measure crown-rump (CRL 5 days).

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2nd trimester: - (BPD, HC, AC, FL 10 days).

BPD FL
3rd trimester: - Much less accurate.

AC

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Physical examination:

General & full examination. Obstetric examination.

Pelvic examination? Only If indicated.

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Routine laboratory tests

Hemoglobin/ hematocrit (low, high - why?). Blood type & Rh ( Rh-negative women). Antibody screen (Kell, Duffy, E, S.). Urinanalysis: screen for bacteruria. Urine culture, if indicated.
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Cont lab tests

Rubella titer: - Highly contagious disease. - Congenital rubella syndrome is now rare. - ~ 10-15% are seronegative. - Mothers who are seronegative should be immunized 2-3 months before conception or in the postpartum period.
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Contlab tests
Hepatitis screen: - Hepatitis B-sAg: transmit to the fetus mainly during birth. - Many of those babies become carrier & can develop chronic hepatitis. - Hep B Ig & vaccine within 12 hrs of life. - ?Hepatitis C.
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Contlab tests
Serologic tests for syphilis (VDRL). - In our country not mandatory. HIV antibody (with consent). - not in our country. Blood sugar, random. ?Pap smear.
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Revisits
History: Brief history to uncover any new problems. Ask about pain, contractions, vaginal discharge, fetal movements Specific questions, those with medical problems or known complications. Counseling for those desiring sterilization.

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Contrevisits
Physical examination: Weight & blood pressure. Examine the gravid uterus. Measure fundal height (IUGR). Determine fetal lie & presentation (3rd trim). Estimate fetal weight (small vs large baby). Auscultate fetal heart tones (sunicade). Pelvic examination, if indicated.
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Conrevisits
Laboratory tests: Hematocrit/ hemaglobin, Repeat at 28 & 36 weeks, or if indicated. Urine dipstick on each revisit, Presence of significant proteinuria (PET) Presence of glucosuria (GDM). Presence of leukocytes (UTI).

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Contrevisits
Antibody screen, if Rh-negative women Repeat at 28 & 34 weeks, if negative Give Anti-D immune globulin. Glucose screen, glucose tolerance test At 26-28 weeks. Repeat at 32 weeks, in high risk patients. Screening for group B streptococcus (GPS), Low vaginal swab (LVS) at 35-37 weeks. Significant reduction of early onset GBS neonatal infection.
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Ultrasound during ANC

1st trimester: Diagnose pregnancy. Assure accurate dating. Fetal number. Fetal viability. Adnexial mass. Screen for chromosomal anomalies; Nuchal translucency & nasal bone.

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2nd trimester: Detailed anomaly scan (18-20 weeks). Placental localization.

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3rd trimester: When indicated (high risk pregnancy), Growth & fetal welfare parameters. Regular/ serial U/S: High risk pregnancy. Poor obstetric history. New problem during ANC (IUGR, PET, GDM).

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Then,
Pregnancy is classified to be low or high risk. Scoring system for risk assessment.

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Important signs!
Vaginal bleeding. Abdominal or pelvic pain. Uterine contractions from 20-36 weeks. Leaking of fluid from vagina. Decrease in fetal movements. Severe headache or blurring of vision. Persistent vomiting. Fever. Swelling of hands or face.

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Complications of pregnancy can be prevented or minimized by good ANC!

Anemia due to iron or folic acid deficiency. Urinary tract infections and pyelonephritis. Pregnancy induced hypertension & PET. Preterm labour and delivery. Intrauterine growth restriction.

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Cont
Sexually transmitted diseases. Rh isoimmunization. Fetal macrosomia. Hypoxia or fetal death from post-term birth. Breech presentation at term.

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Everyday Pregnancy Issues!

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Supplements: Should I be taking anything?

When to start and stop! Trace elements: Folate, calcium, Iron (+ vit.C), multivitamins. Dietary supplements: Protein drinks.
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Listeria
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
Reduced weight gain. More rapid weight loss after pregnancy. Improved mood. Improved sleep patterns.
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Some studies have shown:

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:
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
Travel must be completed by 36th week. Medical clearance needed for twins & complicated pregnancy.

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Preventing DVT
Support stockings. Hydration. Ankle rolls, walks around plane. Baby aspirin.

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Stretch marks
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
Normally increases with gestation. Exclude rupture of membranes. Canesten pessaries OK for thrush.

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Uncomfortables
Cant sleep! Swollen feet! Backache! sick of being pregnant!
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Shoes wont fit, rings too tight...

85% of pregnancies have oedema. Rest and elevate! Carpal tunnel.

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My back hurts...
Posture:
Dont 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?!

Fundal height = gestation +/- 2 cm. Engagement of fetal head. Liquor vs EFW. Assessing fetal size at term.
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I AM SICK OF BEING PREGNANT!!!!!

Check CTG & AFI when 7 days post EDC. Post dates IOL= 10 days after EDC. Natural IOL - does it work?
Curry, chilli, castor oil, etc.. Warm bath! Cervical sweep!
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Thank you

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