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Antenatal Care
Antenatal Care
Introduction
The provision of special care for women during pregnancy through the
public health services was a relatively late development in modern obstetrics. In recognition of the potential of care during the antenatal period to improve a range of health outcomes for women and children, the World Summit for Children in 1990 adopted antenatal care as a specific goal, namely Access by all pregnant women to prenatal care,trained attendants during childbirth and referral facilities for high-risk pregnancies and obstetric emergencies. The International Conference on Population and Development in 1994, the Fourth World Conference on Women in 1995, their five-year follow-up evaluations of progress, and the United Nations General Assembly Special Session on Children in 2002 all share similar views.
Source: WHO 2003, Antenatal Care in Developing Countries - Promises, Achievements and Missed Opportunities.
DIAGNOSIS OF PREGNANCY
Symptoms
Nausea
Irritation of the breasts Increased frequency of micturation
Amenorrhea
DIAGNOSIS OF PREGNANCY
Signs
examination and after 12 weeks on abdominal examination Cervical softening and cystic, soft general feeling of uterus by 8 weeks on bimanual examination
Montgomerys tubercles
DIAGNOSIS OF PREGNANCY
Pregnancy tests
monoclonal antibody embedded in the absorbent paper HCG alpha subunit is similar to that of TSH, FSH and LH HCG beta subunit is immunologically specific hence the term HCG.
DIAGNOSIS OF PREGNANCY
HCG is secreted by the synciotrophoblast of fertilised
ovum and definitive placenta Interpretation of results: Positive results if double band of blue or central spot of pink Negative results if single band of blue or absence of pink spot
Pregnancy test
BOOKING VISIT
After pregnancy has been diagnosed
gestation Womans medical state assessed to place current pregnancy into appropriate part of a risk spectrum Baseline data obtained from history, examination and relevant investigations
HISTORY
Date
time
name age
parity
blood group PC
HPC
HISTORY
Menstrual history
agents Calculate EDD using Naegeles rule (add 7 days and 9 months to the first day of the LNMP) Calculate the POG
HISTORY
Obstetric history
afterwards Previous pregnancies dates, number, duration, medical complications of pregnancy, type of delivery, complications of labour, features of the baby
HISTORY
Medical history
that will require continuation of treatment during pregnancy. Eg. Diabetes, epilepsy Drug history Medications taken during pregnancy
HISTORY
Family history
reflected in current pregnancy. Eg. Diabetes, twinning Social history Social class Race of woman Smoking and alcohol consumption Occupation of woman and her partner
EXAMINATION
Brief general examination Height correlates loosely with pelvic size Weight Clinical presence of anemia (mucuous membranes) Dental inspection Thyroid gland Auscultation of heart and lungs BP, pulse rate State of hydration breasts Spine for kyphosis and scoliosis, which might affect pelvic development Legs for edema and varicose veins
EXAMINATION
Speculum examination note condition of cervix
and presence of any vaginal discharge Bimanual examination o Assess adequacy of the pelvis o Search for ovarian tumors or uterine fibroids o To determine whether uterine size corresponds with gestational age
INVESTIGATIONS
Full blood count
and hepatitis screening, antibodies against Dantigen in rhesus negative women and glucose screen
INVESTIGATIONS
Urinalysis proteinuria, glycosuria, ketonuria
RISK ASSESSMENT
Maternal age teenage or advanced maternal age Parity primigravida or grandmultiparity Uncertain gestation Previous obstetric problems medical disorders of pregnancy Preterm deliveries IUGR Fetal anomalies Caesarean section Perinatal loss
Minor complaints
Abdominal pain Vaginal bleeding
BP
Urinalysis Weight gain
(folic acid, iron supplements, calcitrate) Fetal monitoring with daily fetal kick charts and the non-stress test Repeat FBC and antibody screen at 28 weeks Rhesus negative mothers receive routine antenatal anti-D prophylaxis at 28 and 34 weeks gestation
liquor volume in 3rd trimester Assess engagement of head in late 3rd trimester Plan the mode and time of delivery
EXAMINATION
Abdominal examination
Inspection
Scars of previous operations laparoscopy scars below
umbilicus and pfannenstiels incision above pubis Striae gravidarum Linea nigra Distension Umbilicus Hair distribution Fetal movement
PFANNENSTIELS INCISION
EXAMINATION
Palpation Ask if pain any where Soft palpation to feel for any unusual masses, tenderness or
fundus of uterus. Measure height of the fundus from symphysis pubis from 20 weeks the SFH can be obtained.
against one side while the finger tips of the other hand are used to feel for irregularly shaped parts or a smooth persistent regular surface
EXAMINATION
place thumb and first two fingers of the right hand
over lower abdomen just above symphysis ( Pawliks grip) to determine what pole of the fetus is presenting and whether it is engaged or not. Place other hand at fundus of uterus to stabilize it. face feet of patient and place four fingers of each hand over lower abdomen just above symphysis pubis and apply deep pressure downwards to feel features of the presenting part.
EXAMINATION
Percussion
with polyhydramnios)
EXAMINATION
Auscultation
listened for at every visit using the Pinards stethoscope (110-160bpm is normal) which is particularly uncommon today since the advent of the doppler ultrasound.
Conclusion
Antenatal visits offer entry points for a range of
other programmes such as nutrition, malaria, HIV/AIDS and TB as well as for obstetric care. Greater efforts are needed to improve the content and quality of services offered. In addition, increased attention is needed to ensure that particular groups of women, specifically those living in rural areas, the poor and the less educated, obtain better access to antenatal services.