antenatal care.ppt-by manojit (ms),malda medical college
TRANSCRIPT
Antenatal Care
Definition of Antenatal care
comprehensive health supervision of a pregnant woman before delivery
Or it is planned examination, observation and guidance given to the pregnant woman from conception till the time of labor.
GoalsTo reduce maternal and perinatal
mortality and morbidity rates
To improve the physical and mental health of women and children
Importance of Antenatal Care
To ensure that the pregnant woman and her fetus are in the best possible health.
To detect early and treat properly complications
Offering education for parenthood
To prepare the woman for labor, lactation and care of her infant
Schedule for Antenatal Visits:
The first visit or initial visit should be made as early is pregnancy as possible.
Return Visits:Once every month till 28 w.Once every 2 weeks till the 36 wOnce every week, till labor.
Frequency of antenatal appointments
NulliparousNulliparous with an uncomplicated pregnancy, a schedule of 10 appointments.
ParousParous with an uncomplicated pregnancy, a schedule of 7 appointments.
Assessment
History Examination Investigation
History
Personal historyFamily history Medical and surgical history Menstrual history Obstetrical history History of present pregnancy
Fetal kick count
The pregnant woman reports at least 10 movements in 12 hours.
Absence of fetal movements precedes intrauterine fetal death by 48 hours.
Physical Examinations
Height of over 150 cm indication of an average-sized pelvis
The approximate weight gain during pregnancy is 12 kg.; 2kg in the first 20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term).
Symphysis–fundal height should be measured and recorded at each antenatal appointment from 24 weeks.
Fetal presentation should be assessed by abdominal palpation at 36 weeks.
Fetal heart sound is heard by sonicaid as early as 10thweek of pregnancy.
Fetal heart sound is heard by Pinard' s fetal stethoscope after the 20thweek of pregnancy.
Breech presentation at term
ECV. If is not possible to schedule at 37 weeks
then ?!
Pregnancy after 41 weeks
Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping.
42 weeks ?!
Investigations(in clinic):
Urine should be tested for ketones and protein.
Health Teaching during the First Trimester
Physiological changes during pregnancy
Weight gain Fresh air and sunshine Rest and sleep Diet Daily activities Exercises and relaxation Hygiene Teeth Bladder and bowel Sexual counseling
Smoking : Medications Infection Irradiation Occupational and
environmental hazards Travel Follow up Minor discomforts Signs of Potential
Complications
Common Discomforts of Pregnancy, Etiology, and Relief Measures: Urinary frequencyRELIEF MEASURES:
Decrease fluid intake at night. Maintain fluid intake during day. Void when feel the urge.
Fatigue
RELIEF MEASURES:
Rest frequency.
Go to bed earlier.
Sleep difficulties RELIEF MEASURES:
Rest frequencyDecrease fluid intake at night
Nasal stuffiness and epistaxis
ETIOLGY: Elevated estrogen levels RELIEF MEASURES :
Avoid decongestants.Use humidifiers, and normal saline drops.
Ptyalism (excessive salivation)
ETIOLGY: UnknownRELIEF MEASURES:
Perform frequent mouth care.Chew gum.Decrease fluid intake at night.Maintain fluid intake during day.
Nausea and vomiting
•most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks.•that nausea and vomiting are not usually associated with a poor pregnancy outcome.
•non-pharmacological:non-pharmacological:•ginger•P6 (wrist) acupressure
•pharmacological:pharmacological:•antihistamines.
Nausea and vomiting
RELIEF MEASURES:Avoid food or smells that exacerbate condition.Eat dry crackers or toast before rising in
morning. Eat small, frequent meals.Avoid sudden movements. Get out of bed slowlyBreath fresh air to help relieve nausea.
Heartburn RELIEF MEASURES:
Eat small, more frequent meals.Use antacids.Avoid overeating and spicy foods.
Dependent edema
Avoid standing for long periods. Elevate legs when laying or sitting. Avoid tight stockings.
Varicosities
Rest in sims' position. Elevate legs regularly. Avoid crossing legs. Avoid long periods of standing
Hemorrhoids
RELIEF MEASURES:Maintain regular bowel habits.Use prescribed stool softeners.Apply topical or anesthetic ointments to area.
Constipation
RELIEF MEASURES:Maintain regular bowel habits.Increase fiber in diet.Increase fluids.Find iron preparation that is least constipating
Backache
RELIEF MEASURES:Wear shoes with low heels.Walk with pelvis tilted forward.Use firmer mattress.Perform pelvic rocking or tilting
Leg cramps RELIEF MEASURES:
Extend affected leg and dorsiflex the foot.Elevate lower legs frequently.Apply heat to muscles.
Faintness
RELIEF MEASURES:•Rise slowly from sitting to standing.•Evaluate hemoglobin and hematocrit.•Avoid hot environments
ScreeningScreening
Asymptomatic Bacteriuria
Women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis.
Gestational age assessment
New Pregnant women should be offered an early ultrasound scan between 10 weeks 0 days and 13 weeks 6 days to determine gestational age gestational age and to detect multiple pregnanciesdetect multiple pregnancies.
New Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84 mm, the gestational age should be estimated using head head circumference.circumference.
Screening for fetal anomalies
New The 'combined test' (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down's syndrome between 11 weeks 0 days and 13 weeks 6 days.
For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.
Screening for gestational diabetes
New risk factors for gestational diabetes :
body mass index above 30 kg/m2
previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes (refer to 'Diabetes in pregnancy family history of diabetes (first-degree relative with diabetes) family origin with a high prevalence of diabetes:
South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
black Caribbean Middle Eastern (specifically women whose country of family origin is Saudi Arabia,
United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
Screening for haematological conditions
New Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks).
Anaemia
Screening shouldtake place early in pregnancy (at the booking appointment).
at 28 weeks when other blood screening tests are being performed.
At 36 weeks.
Normal range: 11 g/100 ml 11 g/100 ml at first contact and 10.5 10.5
g/100 g/100 ml at 28 weeks) should be investigated and iron supplementation considered .
Blood grouping and red-cell alloantibodies
Women should be offered testing for blood group and rhesus D status in early pregnancy.
To give anti-D at 28 weeks and post delivery if the baby (+)
Hepatitis B virus
Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal interventions can be offered to infected women to decrease the risk of mother-to-child transmission.
Hepatitis C virus
Pregnant women should notnot be offered routine screening for hepatitis C virus because there is insufficient evidence to support its clinical and cost effectiveness.
Rubella
Rubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies.
Nutritional SupplementsNutritional Supplements
Folic Acid
Start before conception and throughout the first 12 weeks.
reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bifida).
The recommended dose is 400 micrograms per day.
Vitamin D
New women at greatest risk are following advice to take this daily supplement. These include:
women of South Asian, African, Caribbean or Middle Eastern family origin women who have limited exposure to sunlight, such as women who are
predominantly housebound, or usually remain covered when outdoors women who eat a diet particularly low in vitamin D, such as women who
consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal
women with a pre-pregnancy body mass index above 30 kg/m2.
Vitamin A
Vitamin A supplementation (intake above 700 micrograms700 micrograms) might be teratogenic and should therefore be avoided
Iron
Iron supplementation should notnot be offered routinely to all pregnant women. It does not benefit the mother's or the baby's health and may have unpleasant maternal side effects.
Antenatal care
Pre conception counselling Smoking Alcohol Drugs Diet Exercise Folic acid
Pre conception counseling
Family history
Personal history
Past obstetric history
Folic acid
Rubella status
First visit LMP EDD POH MH PMH Drugs Allergies
First visit Smoking Alcohol FH Advise Exemption card Referral
Low risk pregnancies 12-14/52 hosp visit
Routine blood testsBlood group + rhesus factorFbc + haemoglobinopathies if indicatedRandon blood sugarTreponemal antibodyHep bHiv pappa
Low risk pregnancies
Hosp visit 12-14/52
History
Nuchal transluceny scan
Low risk pregnancy 15 weeks
Serum AFP and downs screening
If booking scan not done before 14 weeks
Low risk pregnancy 23 weeks – anomally scan 26 weeks – midwife/gp 28 weeks – fbc + antibodies 30 weeks – midwife/gp 34/36/38/40 weeks – midwife/gp 41 weeks - hosp
Exercise
Non – contact sport only after 16/52
Intensity decreased by 25%
HR under 140/min
Core temp < 38
Strenuous exercise limited to 15-20 mins
Antenatal visits Weight gain 12-15kg in total BP dias. >90 or increase > 20 from first visit is
significant Urinalysis watch for protein glucose uti Fetal movements Uterine size Fetal lie presentation
Common discomforts Pelvic pains – ligamental stretch Urinary frequency - ? Uti Ankle swelling – ivc compression Varicosities – support stockings Heartburn – posture antacids Constipation – fluids, fibre, fybogel
Common discomforts
Low back pain – posture and relaxin
Dental decay – see dentist
Skin changes – chloasma
Itch – iron def, cholestasis antihistamines
Stretach marks - moisturisers
First trimester
Ectopic pregSharp pain
Irregular vaginal bleeding
Abdo tenderness
Dizziness or fainting
Ectopic pregnancy
Diagnosis
Pos preg test
Serial hcg levels they increase more slowly
Progesterone level lower than normal
Ultra sound scan vaginally/abdominally
Ectopic pregnancy risk factors PID Previous tubal preg or tubal surgery Endometriosis IUD Multiple induced abortions Drugs that stimulate ovulation
Ectopic pregnancy treatment
Tube not ruptured
Methotrexate
Salpinostomy flushng the tube out
Laparoscopic removal
Ectopic pregnancy treatment
Tube ruptured
Laparoscopic removal of embryo and tube
Miscarriage
Symptoms
Pv bleeding
Colicky pain
Refer to EPAU
hyperemesis
1 in 300 preg
Weeks 8-20
Cause unknown – high oestrogen & hcg
More commom multiple preg obesity first babies
Treatment Exclude other causes Drink small amounts frequently Diet high in cho and proteins Admit for iv fluids if severe, dehydrated or
electrolyte imbalance Drugs -
Anaemia
SymptomsFatigue weaknessPallorDizziness or faintingSOBpalpitations
Anaemia
Treatment
Diet
Pregaday
Does not alter outcome in most cases
Infection in pregnancy
Chicken pox – only 2% of infections age > 20yrs 3% risk of fetal damage in first 20/52 If mum’s rash develops 1/52 before delivery or to 4/52 after
baby can get sever infection needs protection No risk between 20/52 and term If no history of cp check varicella antibodies If non immune needs VZ Ig no later than 10 days from exposure
Infections in pregmnancy Rubella – 2-10/52 90% chance of featal damage Toxoplasma gondii 89% adults not immune If fetus infected 10% chance of fetal damage Avoid kittens particularly litter trays Eat well cooked meat Wash vegetables Listeria – soft cheeses, pate. Cookchill foods
Pre eclampsia
Raised BP
Proteinura
XS swelling
Pre eclampsia
3-4% pregnancies
!% very severe
50,000 deaths world wide
Pre eclampsia Risk factors
Young mothers teenagersOlder mothers > 35 yrsFamily historyFirst pregnancyNew fatherDiabeteshypertension
Pre eclampsia Serious adverse effects
FitsStrokePulmonary oedemaKidney failureLiver damageD I C
Pre eclampsia Warning signs
Raised bpProteinuriaXs swellingHeadcaheFlashing lightsVomiting Upper abdo pain
Pre eclampsia Treatment
Lower bpMagnesium sulphateDeliver babyAspirinMetabolic syndrome
Gestational diabetes Plenty of insulin, but insulin malfunctioning Macrosomia > 4500g Problems with labour and delivery Newborn has low blood sugar Increased risk stillbirth Proper management prevents increased risk
ofcomplications
Risk factors Incidence 1%-3% pregnancies Family history Obesity Maternal age > 30 yrs Previous large baby Prior icidence of gestational diabetes Ethnic group – south asians, mexican american
Treatment
Control blood sugar
Exercise
Diet
Blood glucose monitoring
A few will need insulin
Intra uterine growth retardation
Birth weigth < 2500g
Causes Smoking
Poor nutrition
Placental factors
Maternal ill health
Risk factors Smoking Drug and alcohol use Severe malnutrition Maternal high bp, or pre eclampsia Infections – cmv, rubella, toxoplasma Chronic maternal disease – diabetes,
rheumatological
Diagnosis
Fundal height – 18-34/52 height = distance in cm
Ultra sound – ratio of head circumference to abdo
Treatment Stop smoking Good nutrition Bed rest on left side Fetal movement chart Serial ultrasound scans Volume of amniotic fluid
Hydatidiform mole
Incidence 1 in 2000 preg
Increased risk with age
Abnormalities in sperm chromosome
Abnormalities of egg
Hydatidiform mole
Signs Uterus larger than date
Vaginal bleeding
Diagnosis Ultrasound
Hcg higher than normal
Hydatidiform mole
Treatment
Suction curettage
Monitor hcg for several months due to risk of choriocarcinoma
Postpone preg for a year
APH
Placenta abruptio1% of all deliveriesVaginal bleeding in 3rd trimestreConstant back or abdo painContractions tenderness or rigidity of uterus
Risk factors Smoking Pergnancy induced hypertension Alcohol or drug use Increased maternal age >40 yrs Premature rupture of membranes Injury to mother
Diagnosis
No clear test
May or may not show on ultrasound
Exclusion of other causes of bleeding – placenta
praevia
Treatment
Evaluate maternal well being
Monitor
Evaluate fetal well being
If severe bleeding or fetal distress cesarean
Placenta previa 4-8% placentas low lying Only 10% remain low Marginal – placenta near edge of os Partial – placenta covers cervical opening Total – placent completely covers os All need cesarean
Placenta previa Signs
Painless bright red vaginal bleeding Risk factors
SmokingFirst preg after lscsPrevious placenta previaAdvanced maternal age
Placenta previa
Diagnosis
Ultrasound
Treatment
lscs
Post term pregnancy > 42/52 Risks
Reduced amniotic fluid increased risk of cord compression
Meconium in liquor inhlaed by baby causing pneumonia
Too large baby > 4500g
Management Monitor baby
Too large babyDecreased amniotic fluidDeliver if cervix ripe try oxytocinon If cervix not ripe try prostaglandin gelOtherwise lscs
Pre term labour
Labour before end of 36th week preg
Low birth weight < 2500g
8-12% of all pregnancies
Signs and symptoms
Regular uterine contractions for more than 1 hr
Backache
Intestinal cramping with or without diarrhoea
Spotting or blood tinged discharge
Thin cervix, dilation beyond 1 cm, contractions
Risk factors Smoking alcohol drugs Previous pre term delivery 3 or more 1st trimestre miscarriages Cervical incompetence Placenta previa Serious maternal infection Low maternal weight < 45 kg
Postnatal care Maternal Lochia xs bleeding = pph admit Breasts – engorgement lasts 2-3 days mild temp
fell fluey Nipple pain- camomile creams daktarin if
candidal Mastitis – empty breast flucloxacillin
Postnatal care
Blood pressure
Fundal height
Perineum
Symptoms of depression
Contraceptive advice
Postnatal care Fetal
Method of deliveryLength of gestationWeightFeedingconcerns
Postnatal care Fetal examination
Fontanelles Eyes- cataractSclera – jaundiceHsLungsAbdo - masses
Postnatal care
Fetal examGenitalia Hips Femoral pulsesSpineBirth marks
6 week exam Maternal
Feeding DepressionLochiaContracptionBpAbdo examSmear if due
6 week exam Fetal
According to chs schedule