AntenatalAntenatal CareCare

Dr. Dr. NUSRAT NOORNUSRAT NOORObstetrics/Gynecology Obstetrics/Gynecology

BackgroundBackground

– detect potential complications of pregnancy and deliverydetect potential complications of pregnancy and delivery– promote good nutrition, hygiene and restpromote good nutrition, hygiene and rest– provide family planning informationprovide family planning information– management of STIsmanagement of STIs– tetanus immunization tetanus immunization – HIV counseling and ART prophylaxisHIV counseling and ART prophylaxis– malaria prophylaxismalaria prophylaxis

Antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and well-being and that of their infants, for example:

Aims Of Antenatal Aims Of Antenatal CareCare

To prevent, detect and manage those To prevent, detect and manage those factors that adversely affect the health factors that adversely affect the health of the babyof the baby

To provide advice, reassurance, To provide advice, reassurance, education and support for the woman education and support for the woman and her familyand her family

To deal with the ‘minor ailments’ of To deal with the ‘minor ailments’ of pregnancy pregnancy

To provide general health screeningTo provide general health screening

Classification OfClassification OfAntenatal CareAntenatal Care

Shared CareShared Care

1.1. Hospital Maternity Team Hospital Maternity Team

2.2. General Practitioner (GP)General Practitioner (GP)

3.3. Community MidwivesCommunity Midwives

Community-Community-BaseBaseCareCare

Hospital-Hospital-BasedBasedCareCare

Advice, Reassurance & Advice, Reassurance & EducationEducation

Reassurance & explanation on pregnancy Reassurance & explanation on pregnancy symptoms:symptoms:

1.1. NauseaNausea

2.2. HeartburnHeartburn

3.3. ConstipationConstipation

4.4. Shortness Of BreathShortness Of Breath

5.5. DizzinessDizziness

6.6. Swelling Swelling

7.7. Back-acheBack-ache

8.8. Abdominal DiscomfortAbdominal Discomfort

9.9. HeadachesHeadaches

Information regarding:Information regarding:

1.1. SmokingSmoking

2.2. Alcohol ConsumptionAlcohol Consumption

3.3. Drugs (Both Drugs (Both LEGALLEGAL and and ILLEGALILLEGAL))

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22ndnd trimester: trimester:- (BPD, HC, AC, FL ± 10 days).- (BPD, HC, AC, FL ± 10 days).

33rdrd trimester: trimester: - Much less accurate.- Much less accurate.

BPDBPD ACAC

FLFL

Confirmation of the Confirmation of the pregnancypregnancy

1.1. The symptom of the pregnancy The symptom of the pregnancy ― Breast tendernessBreast tenderness― NauseaNausea― AmenorrheaAmenorrhea― Urinary FrequencyUrinary Frequency

2.2. Positive urinaryPositive urinary or or serum pregnancy serum pregnancy testtest are usually sufficient are usually sufficient confirmation of a pregnancy.confirmation of a pregnancy.

3.3. Dating PregnancyDating Pregnancy, , confirms the confirms the pregnancy and accurately dates it.pregnancy and accurately dates it.

Dating PregnancyDating PregnancyA.A. Menstrual EDDMenstrual EDD

B.B. Dating by ultrasoundDating by ultrasound Benefits of a dating scan:Benefits of a dating scan:

1.1. Accurate dating women with irregular menstrual Accurate dating women with irregular menstrual cycles or poor recollection of LMP.cycles or poor recollection of LMP.

2.2. Reduced incidence in induction of labor for Reduced incidence in induction of labor for ‘prolonged pregnancy’‘prolonged pregnancy’

3.3. Maximizing the potential for serum screening to Maximizing the potential for serum screening to detect fetal abnormalitiesdetect fetal abnormalities

4.4. Early detection of multiple pregnancies Early detection of multiple pregnancies

5.5. Detection of otherwise asymptomatic failed Detection of otherwise asymptomatic failed intrauterine pregnancyintrauterine pregnancy

Booking HistoryBooking History

1.1. Past Medial HistoryPast Medial History

2.2. Past Obstetric HistoryPast Obstetric History

3.3. Previous Gynaecological Previous Gynaecological HistoryHistory

4.4. Family HistoryFamily History

5.5. Social HistorySocial History

Booking ExaminationBooking Examination

Full Physical Examination:Full Physical Examination: CardiovascularCardiovascular

Respiratory SystemsRespiratory Systems

AbdominalAbdominal

Pelvic ExaminationPelvic Examination Breast ExaminationBreast Examination

Examination for most Examination for most

healthy women healthy women ::

1.1. Accurate measurement of Accurate measurement of blood blood pressurepressure

2.2. Abdominal examination to record the Abdominal examination to record the size of the uterussize of the uterus

3.3. Recognition of any Recognition of any abdominal scarsabdominal scars indicative of previous surgeryindicative of previous surgery

4.4. Measurement of Measurement of height and weightheight and weight for for calculation of the BMI.calculation of the BMI.

Women with a low BMI are at greater risk Women with a low BMI are at greater risk

of fetal growth restriction and obese women of fetal growth restriction and obese women

are at greater risk of fetal growth restriction are at greater risk of fetal growth restriction

and obese women are at significantly greater and obese women are at significantly greater

risk of most obstetric complications, including risk of most obstetric complications, including

gestitational diabetes, pre-eclampsia, need for gestitational diabetes, pre-eclampsia, need for

emergency caesarean section and anaesthetic emergency caesarean section and anaesthetic

difficulties.difficulties.

5.5. Urine examaniationUrine examaniation: asymptomatic bacteriuria : asymptomatic bacteriuria is more likely to ascend and cause is more likely to ascend and cause pyelonephritis in pregnancy. pyelonephritis in pregnancy.

This causes significant maternal morbidity, This causes significant maternal morbidity, but also predisposes to pregnancy loss and but also predisposes to pregnancy loss and preterm labour. preterm labour.

All women at booking should have a All women at booking should have a midstream urine sent for culture or be tested midstream urine sent for culture or be tested with a dipstick which recognizes nitrates, the with a dipstick which recognizes nitrates, the presence of which sensitivity predicts the presence of which sensitivity predicts the presence of significant bacteria.presence of significant bacteria.

Booking InvestigationBooking Investigation1.1. Full Blood CountFull Blood Count

2.2. Blood Group & Red Cell AntibodiesBlood Group & Red Cell Antibodies

― Women found to be rhesus negative will be Women found to be rhesus negative will be offered prophylactic anti-D administration at offered prophylactic anti-D administration at 28 and 34 weeks’ gestation to prevent rhesus 28 and 34 weeks’ gestation to prevent rhesus iso-immunization and future HDN.iso-immunization and future HDN.

― Other possible iso-immunization events, such Other possible iso-immunization events, such as threatened miscarriage after 12 weeks’ as threatened miscarriage after 12 weeks’ gestation, antepartum haemorrhage and gestation, antepartum haemorrhage and delivery of the baby, may require additional delivery of the baby, may require additional anti-D prophylaxis in rhesus-negative women.anti-D prophylaxis in rhesus-negative women.

3.3. Rubella Rubella ― Women who are found to be rubella non-immune Women who are found to be rubella non-immune

should be strongly advised to avoid infectious should be strongly advised to avoid infectious contacts and should undergo rubella immunization contacts and should undergo rubella immunization after the current pregnancy to protect themselves after the current pregnancy to protect themselves for the future.for the future.

4.4. Hepatitis BHepatitis B― Vertical transmission to the fetus may occur, Vertical transmission to the fetus may occur,

mostly during labour, and horizontal transmission mostly during labour, and horizontal transmission to staff or the newborn infant can follow contact to staff or the newborn infant can follow contact with body fluids.with body fluids.

― A baby born to a hepatitis B carrier should be A baby born to a hepatitis B carrier should be actively and passively immunized at delivery.actively and passively immunized at delivery.

5.5. Human Immunodeficiency VirusHuman Immunodeficiency Virus― In known HIV-positive mothers, the use of In known HIV-positive mothers, the use of

antiretroviral agents, elective Caesarean antiretroviral agents, elective Caesarean section and avoidance of breastfeeding section and avoidance of breastfeeding reduces vertical transmission rates from reduces vertical transmission rates from approximately 30% to less than 5%. approximately 30% to less than 5%.

― The Department of Health guidelines now The Department of Health guidelines now recommend that all pregnant women recommend that all pregnant women should be offered an HIV test at booking.should be offered an HIV test at booking.

6.6. SyphilisSyphilis

Haemoglobin StudiesHaemoglobin Studies

― Tests for thalassaemia and sickle cell Tests for thalassaemia and sickle cell disease are usually reserved for disease are usually reserved for women who have an ethnic women who have an ethnic background and those from the background and those from the Middle East.Middle East.

Gestational DiabetesGestational Diabetes

1.1. Random Blood SugarRandom Blood Sugar

2.2. Fasting Blood SugarFasting Blood Sugar

3.3. Formal Oral Glucose ToleranceFormal Oral Glucose Tolerance

BackgroundBackground

WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care.

WHO guidelines are specific on the content of antenatal care visits, which should include:

- blood pressure measurement- urine testing for bacteriuria & proteinuria- blood testing to detect syphilis & severe anemia- weight/height measurement (optional)

International Goals & TargetsInternational Goals & Targets

Special emphasis must be placed on prenatal and postnatal care and care for newborns, particularly for those living in

areas without access to services

Antenatal Care (ROSA)Antenatal Care (ROSA)

Antenatal Care

54

16

28

43

49

60

81

95

0 20 40 60 80 100

South Asia

Afghanistan

Nepal

Pakistan

Bangladesh

India

Maldives

Sri Lanka

% women aged 15-49 years attended at least once during pregnancy by skilled health personnel

Pattern Of Follow Up VisitsPattern Of Follow Up Visits

4 weekly appointments from 20 weeks until 4 weekly appointments from 20 weeks until 32 weeks 32 weeks

Followed by fortnightly visits 32 weeks to 36 Followed by fortnightly visits 32 weeks to 36 weeks and weekly visits.weeks and weekly visits.

The minimum number of ‘visits’ The minimum number of ‘visits’ recommended by the Royal College of recommended by the Royal College of Obstetricians and Gynaecologists is 5, Obstetricians and Gynaecologists is 5, occurring at 12, 20, 28-32, 36 and 40-41 occurring at 12, 20, 28-32, 36 and 40-41 weeks.weeks.

Content Of Follow Up VisitsContent Of Follow Up Visits

General questions regarding maternal well-General questions regarding maternal well-being.being.

Enquiry regarding fetal movements (24 Enquiry regarding fetal movements (24 weeks). weeks).

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

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

Examination for oedema: Examination for oedema:

Oedema Oedema is common in pregnancy and is mostly is common in pregnancy and is mostly an insensitive marker of pre-eclempsia. Oedema an insensitive marker of pre-eclempsia. Oedema of the hands and face is somewhat more of the hands and face is somewhat more important as a warning feature of pre-eclampsia.important as a warning feature of pre-eclampsia.

Abdominal palpation for fundal height: Abdominal palpation for fundal height:

If repeated symphysis–fundal height If repeated symphysis–fundal height measurement are made throughout a measurement are made throughout a pregnancy, the detection of fetal growth pregnancy, the detection of fetal growth problems and abnormalities of liquor volume problems and abnormalities of liquor volume increased.increased.

Auscultation of the fetal heart:Auscultation of the fetal heart:

There is no evidence that this practice is of any There is no evidence that this practice is of any benefit in a woman confident in the movements benefit in a woman confident in the movements of her baby; however, it provides considerable of her baby; however, it provides considerable reassurance and will occasionally detect an reassurance and will occasionally detect an otherwise unrecognized intrauterine fetal death.otherwise unrecognized intrauterine fetal death.

A full blood count and red cell antibody screen is A full blood count and red cell antibody screen is repeated at repeated at 28 and 3628 and 36 weeksweeks..

Depending on the screening policy of the Depending on the screening policy of the particular unit, women at particular unit, women at 28 weeks28 weeks may be may be tested for gestational diabetes.tested for gestational diabetes.

From From 36 weeks36 weeks, the lie of the fetus , the lie of the fetus (longitudinal, transverse or oblique), its (longitudinal, transverse or oblique), its presentation (cephalic or breech) and presentation (cephalic or breech) and the degree of engagement of the the degree of engagement of the presenting part should be assessed and presenting part should be assessed and recorded.recorded.

It is often at this appointment that a It is often at this appointment that a decision is made regarding the mode of decision is made regarding the mode of delivery (i.e. vaginal delivery or planned delivery (i.e. vaginal delivery or planned Caeserean section).Caeserean section).

At At 41 weeks’ gestation41 weeks’ gestation, a discussion , a discussion regarding the merits of induction of labour for regarding the merits of induction of labour for prolonged pregnancy should occur. prolonged pregnancy should occur.

An association between prolonged pregnancy An association between prolonged pregnancy and increased perinatal morbidity and and increased perinatal morbidity and mortality means that women are usually mortality means that women are usually advised that delivery of the baby should advised that delivery of the baby should occur by 42 completed weeks’ gestation.occur by 42 completed weeks’ gestation.

This will usually mean organizing a date for This will usually mean organizing a date for induction of labour at approximately 12 days induction of labour at approximately 12 days past the EDD.past the EDD.

Antenatal complications Antenatal complications

dealt with in dealt with in

customized antenatal customized antenatal clinicsclinics

EndocrineEndocrine (diabetes, thyroid, prolactin and other (diabetes, thyroid, prolactin and other endocrinopathies)endocrinopathies)

Miscellaneous medical disorders (e.g. secondary Miscellaneous medical disorders (e.g. secondary hypertension, autoimmune disease)hypertension, autoimmune disease)

Haematology (thrombophilias, bleeding disorder)Haematology (thrombophilias, bleeding disorder)

Substance MisuseSubstance Misuse

Preterm labourPreterm labour

Multiple gestationMultiple gestation

Teenage pregnancyTeenage pregnancy

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Everyday Pregnancy Everyday Pregnancy Issues!Issues!

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Supplements:Supplements:“Should I be taking anything?”“Should I be taking anything?”

When to start and stop!When to start and stop! Trace elements:Trace elements:

Folate, calcium, Folate, calcium, Iron (+ vit.C), Iron (+ vit.C), multivitamins.multivitamins.

Dietary supplements:Dietary supplements:

Protein drinks.Protein drinks.

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ListeriaListeria

Avoid chilled, ready -to-eat foods:Avoid chilled, ready -to-eat foods: Soft cheeses.Soft cheeses. Takeaway chicken sandwiches.Takeaway chicken sandwiches. Cold meats.Cold meats. Pre-prepared or stored salads.Pre-prepared or stored salads. Raw seafood.Raw seafood. Smoked salmon & smoked oysters Smoked salmon & smoked oysters

(can OK).(can OK).

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EXERCISEEXERCISE

Reduced weight gain.Reduced weight gain.

More rapid weight loss More rapid weight loss after pregnancy.after pregnancy.

Improved mood.Improved mood.

Improved sleep patterns.Improved sleep patterns.

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Some studies have shown:Some studies have shown:

Faster labour.Faster labour. Less need for induction.Less need for induction. Less likely to need epidural.Less likely to need epidural. Fewer operative births.Fewer operative births.

Exercise does NOT increase risk Exercise does NOT increase risk of miscarriage.of miscarriage.

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Exercise commonsense:Exercise commonsense:

Take frequent breaks.Take frequent breaks. Avoid exercise in extremely hot weather.Avoid exercise in extremely hot weather. Avoid unstable ground (joints more lax).Avoid unstable ground (joints more lax). Avoid contact sports.Avoid contact sports. Avoid lifting weights over head.Avoid lifting weights over head. And weights that strain lower back And weights that strain lower back

muscles.muscles.

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Air TravelAir Travel

Travel must be completed by 36th Travel must be completed by 36th week.week.

Medical clearance needed for twins Medical clearance needed for twins & complicated pregnancy.& complicated pregnancy.

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Preventing DVTPreventing DVT

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

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Stretch marksStretch marks

Related to type of collagen Related to type of collagen ieie genetic. genetic.

May have link with pelvic floor & May have link with pelvic floor & perineal “stretchiness”perineal “stretchiness”

Goanna oil, emu oil, olive oil,vitamin E Goanna oil, emu oil, olive oil,vitamin E and other expensive topicals…..and other expensive topicals…..

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Fetal movementsFetal movements- what is normal?- what is normal?

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Vaginal DischargeVaginal Discharge

Normally increases with gestation.Normally increases with gestation.

Exclude rupture of membranes.Exclude rupture of membranes.

Canesten pessaries OK for thrush.Canesten pessaries OK for thrush.

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““Uncomfortables”Uncomfortables”

Can’t sleep!Can’t sleep!

Swollen feet!Swollen feet!

Backache!Backache!

““sick of being pregnant”!sick of being pregnant”!

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Shoes won’t fit,Shoes won’t fit,rings too tight...rings too tight...

85% of pregnancies have 85% of pregnancies have oedema.oedema.

Rest and elevate!Rest and elevate!

Carpal tunnel.Carpal tunnel.

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My back hurts……...My back hurts……...

Posture:Posture: Don’t slouch!, do not bend from waist.Don’t slouch!, do not bend from waist. Choose chair with back support.Choose chair with back support. Bra with support.Bra with support.

Hot pack & panadol.Hot pack & panadol. Elastic brace supports.Elastic brace supports. Physiotherapy review.Physiotherapy review.

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Is my baby too big?!Is my baby too big?!

Fundal height = gestation +/- 2 cm.Fundal height = gestation +/- 2 cm.

Engagement of fetal head.Engagement of fetal head.

Liquor vs EFW.Liquor vs EFW.

Assessing fetal size at term.Assessing fetal size at term.

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I AM SICK OF BEING I AM SICK OF BEING PREGNANT!!!!!PREGNANT!!!!!

Check CTG & AFI when 7 days post EDCheck CTG & AFI when 7 days post EDDD..

Post dates IOL= 10 days after EDPost dates IOL= 10 days after EDD.D.

““Natural IOL” - does it work?Natural IOL” - does it work? Curry, chilli, castor oil, etc..Curry, chilli, castor oil, etc.. Warm bath!Warm bath! Cervical sweep!Cervical sweep!

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Thank youThank you