ANTENATAL CARE

BY

Dr. Nuzhat Rasheed

Assistant Professor
Obstetrics & Gynaecology Department Sheikh Zayed Medical College/Hospital Rahim Yar Khan 1

ANTENATAL CARE
Aims Provision of education, reassurance, and support to the woman and her partner Advice on minor problems and symptoms of pregnancy Assessment of maternal fetal risk factors at onset of pregnancy and as they develop throughout pregnancy Provision of prenatal screening and management of abnormalities detected Determination of timing and mode of delivery where complications arise
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BOOKING VISIT

The purpose of the booking visit is to assess the mother and make a plan for her care in pregnancy. This should include the plan for confinement. Booking should normally be in the 1st trimester in order to take full advantage of antenatal care.

HISTORY
A comprehensive history should include; Personal history, Family history, Previous Obstetric and medical /surgical history, History of present pregnancy to the time of that visit High risk markers from past obst, medical/surgical history History of inheritable disease e.g. Haemoglobinopathies, Hepatitis and HIV Advice and support should be given on healthy lifestyles, including diet and exercise. Woman should be made aware of symptoms and consequences associated with antipartum haemorrhage, pre eclampsia, preterm labour, and pre labour rupture of membranes.

EXAMINATION
A Complete physical examination include; Height, weight and blood pressure in the supine lateral position to avoid compression of the inferior vena cava. Inspection of the mucosal surfaces (mouth, conjunctive) for pallor and the general state of dentition The thyroid glands The heart should be examined to exclude organic murmurs The breast are examined to exclude the presence of any lumps noting also the condition of the nipples The limbs are examined for varicose veins
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PELVIC EXAMINATION

This is not routinely done

ABDOMINAL EXAMINATION IN PREGNANCY

Inspection, palpation, percussion ( in case of polyhydramios) and auscultation

Inspection Describe the enlarge abdomen Describe signs of pregnancy such as linear nigra, striae gravidarum and presence of fetal movements. Any superficial distended veins or scars; Pfannenstiel scars (i.e. transverse low abdominal scars and usually used for caesarean section), Laparoscopy, Appendicectomy, Cholecystectomy scars

Fundal height measurements Measurement of the fundal height from the top of the symphysis pubis to the fundus of the uterus (highest part of the uterus) measure in centimeters. The mean fundal symphyseal (FS) height measure approximately 20cm at 20 wks gestation (upto the umbilicus) and increase approximately 36cm by 36 wks gestation. Thereafter, the distance tends to plateau until term. 2cm either way of the gestation is acceptable upto 35wks, which becomes + 3cm at 36wks and + 4cm at 40wks due to such factors as increase in size of the baby, reduction of amniotic fluid volume, and engagement of the head.
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The accuracy is considerably less if the measurement is made after 36 weeks gestation.

Pregnancy factors such as large baby, polyhydramios, and twins and uterine factors such as fibroids and pelvic tumours lead to FS height greater than dates.
Oligohydramnios, leakage of amniotic fluid, intrauterine growth restriction (IUGR), presenting part deep in the pelvis, and abnormal lies may give rise to uterus smaller than dates,
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Palpation for fetal parts Fetal parts are not usually palpable before 24 weeks gestation. The purpose of palpation is to describe the relationship of the fetus to the maternal trunk and pelvis. Presentation Presentation is the part of the fetus nearest to the pelvic inlet or in the lower uterine segment. Engagement This refers to the passage of maximal diameter of the presentation beyond the pelvic inlet.
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Position This describes the relationship of the denominator of the presenting part as fixed points of the maternal pelvis. These points are sacral promontory (posterior) symphysis pubis (anterior), sacroiliac joint (posterior lateral and may be right or left), and iliopectineal eminence (anterolateral and may be right or left), Auscultation The fetal heart may be heard by Doppler ultrasound (Sonicaid) from above 12 weeks gestation and with a pinard stethoscope from about 24 weeks.
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BOOKING INVESTIGATIONS
Full blood count This screens for anaemia and thrombocytopenia (low platelet count), both of which may require further investigation. Blood grouped and red cell antibodies Found to be rhesus negative will be offered prophylactic anti-D administration at 28 and 34 weeks gestation to prevent rhesus iso-immunizing and future HDN.
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Hepatitis B & C A baby born to a hepatitis B carrier should be actively and passively immunized at delivery,

Human immunodeficiency virus Elective caesarean section and avoidance of breastfeeding reduces vertical transmission rates from approximately 30% to less than 5%.
Haemoglobin studies Reserved for women who have an ethnic background.

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Gestational diabetes A random blood sugar, a fasting blood sugar or a formal oral glucose tolerance test may be employed and many different screening schedules exist, as do the criteria for diagnosis of GDM. Visit to establish the wishes of the couple.

Screening for fetal abnormalities The tests themselves are carried out between 11 and 22 weeks gestation and include.

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Nuchal translucency scanning (11-13 weeks ) or serum screening (15-19 weeks) for Downs syndrome Maternal serum alpha-fetoprotein (15-19 weeks) for neural tube defects, e.g. spina bifida, anencephaly, The detailed or anomaly ultrasound scan ( 19-22 weeks ) for structural congenital abnormalities,

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FOLLOW UP VISITS
Pattern of follow-up visits Four weekly appointments from 20 weeks until 32 weeks, followed by fortnightly visits from32 weeks until 32 weeks, followed by fortnightly visits from 32-36 weeks and weekly visits thereafter, was a common pattern of antenatal care previously adopted for women in their first pregnancy.

Women with a normal past obstetric history are often reviewed less frequently. The minimum number of visits is five, occurring at 12,20, 28-32, 36 and 40-41 weeks.
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THE CONTENT OF FOLLOW-UP VISITS

At every visit General questions regarding maternal well-being.

Enquiry regarding fetal movements ( from 24 weeks )

Measurement of blood pressure (a screen pregnancy- related hypertensive disorders).

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Urinalysis, particularly for protein, blood and glucose: this is used to help detect infection, pre- eclampsia and gestational diabetes.

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Examination for oedema

Abdominal palpation for fundal height Auscultation of the fetal heart

The following are carried out in addition to the above A full blood count and red cell antibody screen is repeated at 28 and 36 weeks

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Depending on the screening policy of the particular unit, woman at 28 weeks may be tested for gestation diabetes. From 36 weeks, the lie of the fetus (longitudinal, transverse or oblique), its presentation (cephalic or breech) and the degree of engagement of the presenting part should be assessed and recorded. At 41 weeks gestation, a discussion regarding the merits of induction of labour for prolonged pregnancy should occur.
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