ANTENATAL CARE

Medical outpatient supervision all through pregnancy until labour commences Care is provided by: - Midwives - General Medical Practitioners - Obstetricians and Gynaecologists - Other specialists as required

- Physicians (Sub-speciality interests) most often required

AIMS AND OBJECTIVES OF ANTENATAL

Main aim of antenatal care is to ensure a healthy mother and baby at the end of the pregnancy Principle involved is a preventive health measure utilizing investigations and prophylactic and definitive treatment where indicated

The aims and objectives of antenatal care are:

1. Assess the general health and well being of the mother and her fetus and plan appropriately for adequate care in pregnancy, labour and in the puerperium 2. Predict and where possible prevent any fetal or maternal complications developing during pregnancy (prenatal diagnosis and management of fetal abnormality sickle cell anaemia etc) 3. Detect early and manage effectively any maternal or fetal complications developing during pregnancy 4. Prepare the couple (mother and father) to cope with pregnancy, labour and the care of the newborn baby 5. Provide appropriate health screening and health education

Some benefits of Antenatal Care

A. Lack of antenatal care associated with five times increase in perinatal loss in some studies B. Antenatal care is one of the main factors involved in the very low perinatal and maternal morbidity and mortality in developed compared to developing countries C. Women who receive no antenatal care and who have pregnancy complications perform more poorly compared to those who have received antenatal care - Preterm labour

- Intrapartum complications
- Anaemia - Infections

PRINCIPLES OF ANTENATAL CARE PRE- PREGNANCY CARE - Diabetes mellitus - Epilepsy - Cardiac disease - Haematological disorders - Drugs

FIRST VISIT TO THE CLINIC

The visit should be as early as possible in pregnancy, preferably before the 12th week of pregnancy

Objectives:
- Establish gestational age - Early detection of abnormalities (fetal / maternal) - Appropriate intervention measure - diagnosis - treatment

- Advice on medical disorders antedating pregnancy

- Advice on drugs and other habits (e.g. smoking, drinking) considered inimical or harmful to the pregnancy

AT THE FIRST VISIT

DetailedHistory (Obstetric/Gynaecological/Medical/Surgical/Social) Complete Clinical examination: Height and weight Investigations

CALCULATION OF EDD
1. Add 7 days to LMP ( date of delivery)
2. Subtract 3 months from the month of the menses (month of delivery)

INVESTIGATIONS
1. 2. 3. 4. 5. 6. 7. Complete Blood count (CBC) ABO and Rhesus Grouping VDRL Test Hb Electrophoresis (where indicated) Rubella / Hepatitis B / HIV Urine Protein/Sugar/Acetone Midstream urine Microscopy, Culture sensitivity (where indicated) 8. Ultrasonography - Dating of pregnancy - Fetal anomaly - Status of cervix 9. Other Tests (As indicated)

and

SUMMARY OF FINDINGS/DIAGNOSIS

Low Risk High Risk pregnancy

Medications-Folic Acid/ Vitamins Supplementary Iron

Specialised drugs (diabetes/hypertension/ thyroid disease etc)

Detailed discussion

Follow up programme

Schedule of future/follow-up visits

Appointments made for Every 4 weeks until 28 weeks

Then after:

Appointments made for : Every two weeks until 36 weeks Every week from 36th week until delivery

Appointments adjusted to more frequent intervals, if pregnancy is precious or some abnormalities detected Appointment schedules for nullipara and multipara may be different SCHEDULE OF VISITS NEED TO BE MODIFIED ACCORDING TO INDIVIDUAL NEEDS SCHEDULE OF VISITS ALSO VARY IN OTHER LOCATIONS

Plan for action in subsequent visits

First follow up visit
General health of patient investigated through general questions and specific questions relating to the pregnancy/other systems Nausea, vomiting, heart burn, vaginal bleeding, fetal movements Her weight and blood pressure are taken and compared with previous results. Check for oedema: pre-tibial, fingers etc

The urine is tested for protein and sugar

Obstetricexamination performed( multiple/singleton)

OTHER FOLLOW-UP VISITS At each Subsequent visit, steps outlined for first follow - up visits are repeated Obstetric Examination(SFH, Multiple/singleton) Lie, Pres, FHS,

A gradual weight gain is expected A gradual increase in the fundal height is also expected

MANAGEMENT GUIDELINES AT FOLLOW-UP VISITS

1. 20-24-28 WEEKS: Screen for gestational diabetes if indicated 2. 20-24; 32-36 weeks: CBC check 3. Follow up U/S examination is usually carried out - Fetal anomaly scan (18-20 wks) 4. Other tests (as indicated: atypical antibody titre, maternal serum alpha-feto protein screening) At each visit: Apart from routine medications, patient should be reassured, anxieties alleviated and minor discomfort occurring during pregnancy discussed After 36th week of pregnancy, Delivery plans again discussed. Engagement of presenting part checked; pelvic assessment may be performed

Some events of note in pregnancy

1. Average weight gain in pregnancy from 15th38th week of pregnancy is about 0.5 kg per week 2. Blood Pressure - Systolic increase >30mm (over booking BP) - Diastolic increase >15 mm (over booking BP) BP 140/90 (P.I.H etc)

ABNORMALITIES DURING ANTENATAL CARE

Any abnormality detected should be fully investigated

as indicated and as soon as such abnormality is detected.

In line with the objectives of antenatal care, early detection of abnormalities, appropriate investigations and treatment should be emphasized. Admission for specialised treatment may be indicated in

some cases

Look out for

Abnormal weight gain / No weight gain /Rise in blood pressure Rapid increase in fundal height
Fundal height greater than gestational age : Multple pregnancy Fetal macrosomia Gestational diabetes Polyhydramnios/ fetal anomaly Lack of/Sluggish increase in fundal height - static fundal height Fundal height less than gestational age: Fetal growth restriction FGR Intra-uterine growth Restriction (IUGR) Oligohydramnios/PROM Fetal anomaly

EFM- 4 BASIC FEATURES OF FH TRACE

BASELINE VARIABILITY CTG BASELINE VARIABILITY

EFM DECELERATIONS

Decelerationstransient slowing of FHR below the baseline level of more than 15 bpm and lasting for 15 sec. Or more.

Fig 3 Early Decelerations

Fig 4 Late Decelerations

Fig 5 Variable Decelerations

MINOR DISORDERS/QUESTIONS IN PREGNANCY

Diet
Cramps

- Normal Diet
- Reassurance / Calcium

Heartburn
Constipation

- Antacids
- Reassurance Dietary Advice Fluids / Fruits Rarely aperients needed

Syncope/Fainting - Reassurance

Vaginal discharge

Frequency of Micturition Stress incontinence - Treat as indicated/ Reassurance Varicose Vein - Reassurance Haemorrhoids - Treat if troublesome. CrepeBandage for varicose veins Exercise - OK: Advisable Not strenuous Not allowed in premium pregnancy Work/Employment - Ok - Disallowed in premium pregnancies

- Vaginitis Treat as appropriate - Investigate

Travel

-Car -Train

Okay if roads are good and journey

-Air

not long.

Air travel (especially long journeys ) not advisable after 35th week of pregnancy.

Travel of course disallowed if any abnormality of pregnancy e.g. bleeding is present.

Immunisations:
Immunisation against rubella not allowed during pregnancy .
Vaccination against Tetanus toxoid allowed. Sexual Intercourse: No restrictions except in cases of abortions or vaginal bleeding In early / late pregnancy.

Dental care:
Consult the dentist Dental problems more common in pregnancy. Smoking /Alcohol/ DrugsCaution. Stop. OTHERS- Vomitting ,Carpal Tunnel syndrome etc

WHO systematic review of randomised controlled trials of routine antenatal care

MDGuillermo Carrolia, , , MDJos Villarb, PhDGilda Piaggiob, MDDina KhanNeelofurb, MDMetin Glmezoglub, PhDMiranda Mugfordc, MDPisake Lumbiganond, MDUbaldo Farnote, MDPer Bersgjf and for the WHO Antenatal Care Trial Research Group

The objective of routine antenatal care is to deliver effective and appropriate screening, preventive, or treatment interventions.
Thus, the number of visits should be the result of how these effective interventions can be delivered in a timely way during pregnancy. The results of this systematic review suggest that these effective interventions can be provided within fewer visits than presently recommended, without any clinically important increase in the risk of adverse outcomes.

Delivery care

DEFINITION OF LABOUR

Labour is defined as:

Progressive dilatation of the cervix in association with repititive uterine contractions Cervical dilatation without uterine contractions * Cervical Incompetence

Repititive uterine contractions without

progressive dilatation of the cervix * False labour

Disorders of labour

INITIATION OF LABOUR

LABOUR:
*

TERM / PRE-TERM
Spontaneous False labour Braxton Hicks

contractions
* * Induced Augumented

Symptoms and signs of labour

* * * * Onset of painful regular contractions "Show" Rupture of membranes Effacement / dilatation of cervix

STAGES OF LABOUR

THREE Stages well recognised

"FOURTH" Stage also described

COMPONENTS OF NORMAL LABOUR

Powers

Passages
Passenger

Pelvic inlet

FIRST STAGE
From onset of true labour until full cervical dilatation.

Latent / Active phases

* * Active phase: Cervix 3-4 cm dilatation with contractions 3 in 10 minutes Progressive cervical dilatation

Usually descent of the presenting part.

Complications of first stage

* * Fetal distress Prolonged labour

*
* * *

Obstructed labour / ruptured uterus

Bleeding per vaginam Trauma IUFD etc

SECOND STAGE

Commences at full cervical dilatation and with delivery of baby

Main features * * * Painful frequent contractions

ends

Bearing down feeling / Expulsive efforts Delivery of baby

Complications of second stage

*
* * * * * *

Fetal distress
Delay in second stage Deep Transverse Arrest Persistent occipito-posterior position High head Bleeding / trauma Shoulder dystocia

THIRD STAGE
Commences after birth of baby until placenta and membranes delivered.

Main features

* Weaker contractions
* Delivery of placenta & membranes

DURATION OF LABOUR (stages 1-3)

Varies with parity Influenced by various factors

* Age
* The Forces * The Passage Failure in the forces Problems with the passage

* The Passenger-

Difficulties with the passenger

THE MECHANISM OF LABOUR The aim of labour is the delivery of the baby followed by the delivery of the placenta and membranes.
Events involved in the ultimate delivery of the baby include: * Descent * Flexion * Internal Rotation * Extension * Restitution * External Rotation * Delivery

MANAGEMENT OF LABOUR
Initial Assessment 1.History A. Detailed review of prenatal data:

Previous obstetric history (Mother / baby)

Previous gynaecological history

PMH / FSH
History of current pregnancy B. Labour Details Contractions /Show /Bleeding / Liquor etc.

Physical Examination
* General state of patient vital signs T P BP

*
*

Systemic examination
Obstetric examination

Abdomen - Fundal height - Lie / Presentation - Engagement - FHS. singleton / multiple - Contractions

Vaginal Exam - Inspection -Cervix effacement/position/dilatation - Presenting part - Level of presenting part - Pelvic assessment

Investigations CBC Blood Grouping /Cross matching Others SUMMARY OF FINDINGS Diagnosis * * Low Risk - Labour room II Low parity High Risk - Labour room I * PIH / Multiple pregnancy / Prem. labour /APH / IVF etc.

Routine Care In Labour Room

*
* * * * * *

Enema
Bath IV Fluids CTG Nil Per oral Nursing Care Psychological support

*
*

Careful Monitoring (TWO PATIENTS!)

Consent

FIRST STAGE

1.
2. 3.

CTG
Partogram/ Active management of labour Regular VE / Assessment 3 - 4 - 6 hourly (May be more frequent in special cases) I.V.Fluids Analgesia * Pethidine/ Anti-emetic * Epidural

4. 5.

6. 7.

Intervene as required Special cases - Specialist care required * P.I.H. * Eclampsia * Cardiac * APH * Diabetes Mellitus Preparation for delivery

8.

PRIMARY ARREST

10 9 8 7 6 5 4 3 2 1 0 2 4 6 8 10 12

Dilatation

SECONDARY ARREST

10 9 8 7 6 5 4 3 2 1 0 6 8 10 12 14

Dilatation

ARREST IN SECOND STAGE

10 9 8 7 6 5 4 3 2 1 0 6 8 10 12 14 16

Dilatation

SECOND STAGE Delivery of the baby: Maternal position Maternal / fetal monitoring * Normal vaginal delivery * Vaccuum * Forceps * Breech * Anticipate difficulties - shoulder dystocia

Episiotomy
* * * * usually R medio-lateral local anaesthesia pudendal block perineal infiltration

Care of Perineum
Care of Baby Suction

Airways
Paediatrician

THIRD STAGE: A. Mechanism of Placental Separation

Shultze Mechanism of Placental Separation

* Retroplacental clot
* Placenta / membranes dragged downwards * Membranes peel from periphery

* Placenta delivered by inversion

Duncan Mechanism of Placental Separation * Separation at periphery of placenta * Placenta descends to vagina sideways * Maternal surface of placenta appears first at vulva

THIRD STAGE
B. Delivery of the placenta
Signs of placental separation * Descent / Lengthening of umbilical cord * Uterus rises up * Gush of blood (small quantity) * Placenta in vagina

Active management: Brant - Andrews Method

* Ergometrine - 0.5 mg (a)
I:V / I:M / after delivery of baby at MOH

* Methergin - 0.20 mg (b) * Syntometrine / Syntocinon (c) Avoid (a) , (b), (c) if BP in labour

Caution
* * * * Side effects Hypertension Hypertensive cases Cardiac cases

Are the placenta and membranes complete?

Careful examination of placenta / membranes

Problems * Primary PPH * Secondary PPH Repair of Episiotomy / perineal lacerations Care of Perineum

SPECIAL PROBLEMS / COMPLICATIONS DETECTED IN THIRD STAGE - {ANTICIPATE}

* * * * * Vaginal lacerations Cervical lacerations Extension of episiotomy Retained placenta / Parts / Membranes Primary postpartum haemorrhage (Look out for)

Ruptured uterus
Shock Vulval haematoma

FOURTH STAGE: { usually about 1-2 hrs after delivery} Vital signs * BP , Pulse * Full Bladder * Trauma * Uterine Relaxation / Atony * Sudden Collapse / Shock * Could be very serious VULVAL HAEMATOMA.RUPTURED UTERUS After pains * Analgesia TRANSFER TO LYING - IN WARD IF ALL IS WELL

OPERATIVE DELIVERIES Vaginal * Vaccuum * Forceps * Breech Abdominal * Caesarean Section * Indications * Types / Procedures
Preparation for Operative Deliveries * Counselling / Consent - if not already obtained. * Pre-anaesthetic assessment * Analgesia / Anaesthesia 1. Regional 2. General

DEFINITION
The puerperium is that period after delivery during which the pelvic organs return to their non-pregnant state. The period of the puerperium is usually stated as SIX WEEKS (6 weeks) although some of the organs may not have returned completely to their normal non pregnant state. In most women who are not breast feeding (and even in some women who are breast feeding) ovulation is reestablished during the period of the puerperium.

PHYSIOLOGICAL CHANGES IN THE PUERPERIUM 1. General

2. Cardiovascular system
3. Haematological change 4. Urological changes 5. Genital Tract -Breasts -Uterus -Lochia

6. Lactation

Routine Care In The Puerperium

1. Recording of Vital Signs/Palpation of Abdomen Temperature - Slight rise under 38C noted in first 24 hours after delivery

Pulse Blood Pressure Respiratory Rate 2. Breast feeding / Care of breasts State of uterus

3.

Analgesia

-Indications/drugs -Episiotomies/Lacerations -Operative deliveries

-Caesarean sections etc.

4. Mobilisation

5.

Involution of the uterus/Perineal care

Lochia rubra Lochia serosa Lochia alba

6.

Disorders of Micturition Emptying of the bladder Retention of urine In-continence of urine Bowel function Diet Normal diet Sleep disturbances/Depression -Ensure adequate rest during the day and good sheep at night Insomnia inspite of adequate measuresSinister sign Watch out for depression and early puerperal psychosis and treat early.

7. 8. 9.

10.

Immunisations
Anti-D 300mg should be given to the Rhesus D Negative who is not isoimmunized and who has an Rhd Positive baby soon after delivery. Other immunizations depend on local variations.

11.

Physiotherapy/postnatal exercise should be encouraged where facilities are available and where possible. Contribute to good tone of abdominal wall muscles and to good vaginal function.

12.

Contraceptive advice
-Counseling and appropriate contraception before discharge where possible.

13.

Discharge from Hospital

Varies from place to place. After vaginal delivery, discharge home, if all is well, should be between 48 hours and 4 days after delivery. Time of discharge after operative deliveries usually varies also. Discharge home after caesarean section should be between 6-10 days post-operative.

14.

Postpartum Follow-up Check up after delivery should be about 6 weeks after delivery -the end of the puerperal period Extent of check-up varies, but there is an ideal postpartum check up. Cervical Smear (Other Tests)

ABNORMALITIES OF THE PUERPERIUM Puerperal Pyrexia Puerperal pyrexia is defined as a temperature of 38C (100.4F) or higher or any 2 of the first 10 days postpartum with the exclusion of the first 24 hours after delivery. Most of the causes of puerperal pyrexia originate from infections in the genital tract. Causes of Puerperal Pyrexia 1. Genital Tract Infection 2. Urinary Tract Infection 3. Breast Disorders 4. Wound Infections 5. Thrombophlebitis 6. Respiratory Tract Infection 7. Intercurrent Infections

1.

Gentital Tract Infection

Sites of Infection

- Placental bed
- Lacerations of genital tract - Operative wounds Sources of Infection Endogenous Exogenous

Predisposing Factors
Spontaneous/Induced Labour Duration of labour Premature rupture of membranes Multiple vaginal examinations Internal fetal monitoring Anaemia-Severe Mode of Delivery -Vaginal -Operative -Caesarean Sections Caesarean Sections -Elective -Emergency -Indications etc

Pathology/Bacteriology
The organisms causing genital tract infection are quite varied. - Aerobes - Streptococci/Staphylococci - Gram Neg Org- Pseudomonas/Kliebsiella et - Anaerobes - Bacteriodes Clostridium
Others: Chlamydia Trachomatis The infection may be localized to the affected area e.g. perineal, or eventually spread to other pelvic organs. The infection may be mild, moderate or severe with Septicaemia in some cases.

ENDOGENOUS Coliform organisms Enterococci (Streptococcus Faecalis) Anaerobic Streptococci Gonococci Chlamydia Streptococci Groups B,C,D and G Anaerobic Bacteria (Bacteroides SPP) Clostridium perfringens

EXOGENOUS Haemolytic streptococcus, Group A Staphylococcus Aureus

Spread of Infection may follow a variety of pathways

Vagina/Cervix ------> Pelvic cellular tissue Pelvic Cellulitis

Uterus

------> Parametrium (parametritis)

------> Fallopian tubes/Ovaries ------> Pelvic Peritonitis

-------> Acute Salpingo-Oophoritis with pelvic peritonitis

-------> Haematogenous Spread -------> Septicaemia

New Contraceptive Choices

PILLS HAVE CHANGED OVER TIME

New pills are safer due to reduced hormonal dose Typical dosages by year (approximate)
- 1960s: 1970s: 50 mcg of ethinyl estradiol - 1980s: 1990s: 30 mcg of ethinyl estradiol - Present: 20-15 mcg of ethinyl estradiol

DMPA

150mcgm IM 12 weekly +/- 7 days Unsuitable for women planning pregnancy within 2 yrs Amenorrhoea/occasional spotting in 80% by 12 months Bleeding problems mefenamic acid, cox-2, Transamine,Ocs ( Taneepanichskul et al.Contraception 1999)

SUBDERMAL IMPLANTS

Subdermal implants are silastic rods inserted by means of a trochar into the dermal layer of the skin of the upper arm They secrete hormone at a relatively constant rate over their life-span

COMBINED CONTRACEPTIVE RINGS

Silastic rings impregnated with hormones Ethinyl oestradiol dosages from 10-15 mgs Progestogens-various trialed Place in vagina 3 weeks then remove 1 week Effective High patient acceptability

PATCH

Backing layer Middle layer

Release liner

MIRENA (levonorgestrel-releasing intrauterine system) (LNG IUS)

Steroid reservoir levonorgestrel 20 g/day

THE FEMALE CONDOM

Lubricated, loose fitting polyurethane sheath with 2 flexible rings-one size fits all Lines the vagina and covers some of the vulva Effectiveness-85-95%

FEMALE BARRIER CONTRACEPTION

Diaphragms and Caps are rubber barriers placed into the vagina to cover the cervix prior to sex Act as a barrier, keeping the majority of sperm in the vagina where acid conditions kill the sperm in a few hours and preventing access to the uterus and tubes where sperm can live for 5-6 days

LONG-TERM HEALTH IMPACT OF FEMALE STERILIZATION

Decreased ovarian cancer Decreased PID No post-sterilization syndrome Does not increase need for hysterectomy No HIV/STD protection

LONG-TERM HEALTH IMPACT OF VASECTOMY

No association with testicular cancer No association with cardiovascular disease Probably no association with prostate cancer No HIV/STD protection

THANK YOU FOR YOUR ATTENTION