ANTENATAL CARE

MUHAMMAD WASIL KHAN AND RAMSHA MAZHAR

AIMS OF ANTENATAL CARE
 The mother reaches the end of pregnancy as healthy as or even healthier than she was
before pregnancy.
 Any physical or psychological issues arising during pregnancy are detected and treated.
 The mother gives birth to a healthy baby.
 Any complication of pregnancy is either prevented or detected early and managed
appropriately.
 The mother is iformed about any proposed procedures, the reason and the probable
outcome.
 The couple is prepared for birth and child rearing, including receiving information about
diet, childcare and family planning.
PRECONCEPTION ADVICE

A preconception visit helps to review personal and family history and to optimize control of conditions such as:
 Discuss the tests she will be offered.
 If she is over/underweight, she can be given appropriate dietary advice and offered referral to a dietitian.
 If there is a history of congenital/genetic abnormalities, a referral to a genetics clinic can be made.
 The immune status can be explored, blood group and Rhesus factor, Hepatitis B and C, HIV.
 All women should be advised to take folic acid 0.4 mg prior to pregnancy.
 Women with past history of neural tube defects should increase their intake to 4mg.
 Women who smoke should be strongly encouraged and supported to quit.
 Counselling regarding certain drugs, anti-depressants, anti-epileptic, isotretinoin.
PSYCHOLOGICAL PREPARATION FOR MOTHERHOOD

 Most women have concerns regarding pregnancy and childbirth.

 In early weeks they fear that pregnancy may terminate.
 Later in pregnancy many women fear the baby will be malformed/intellectually
disabled or that childbirth will be painful and dangerous.
 Some women are concerned their bodies may not regain their pre-pregnancy body
shape.
DIET IN PREGNANCY
ANTENATAL SCREENING

 Screening regimen for Down syndrome (trisomy 21), trisomy 13 and 18:
 Plasma protein A and β-hCG are assessed at 9-13 weeks.
 Nuchal thickness of fetus assessed at 11-13 weeks.
 Triple test is performed at 15-20 weeks.
 AFP, Beta hCG and Alpha-fetoprotein.
 Non-Invasive Prenatal Testing (NIPT):
 Cell-free fetal DNS (cffDNA) test allows early screening for genetic anomalies by
detecting fetal DNA from placenta in maternal circulation from 1st trimester.
 It can screen for:
 Sex linked conditions
 Achondroplasia
 Aneuploidy
 DIAGNOSTIC PROCEDURES
 Chorionic villus sampling:
 A sample of chorionic tissue (20mg) is
removed from placental edge at 9-11
weeks by introducing a needle
transabdominally under ultrasound
guidance.
 Amniocentesis:
 A needle is introduced through the
abdominal wall into the amniotic sac
guided by ultrasound to avoid the
placenta and a sample of amniotic fluid
is removed.
BLOOD PRESSURE

 A significant rise in blood pressure in early pregnancy provides an early warning that
patient may develop gestational diabetes or more severe, pre-eclampsia hence her
blood pressure should be monitored at each antenatal visit.
 In normal pregnancy BP tends to remain at a constant level until the last quarter
where it may rise <10mmHg.
 Systolic pressure of >140mmHg and diastolic pressure >90mmHg indicate
hypertension.
WEIGHT AND BMI

 BMI (Body Mass Index) should be calculated at

each antenatal visit.
 Low weight gain increases risk of small for
gestational age babies and difficulty initiating
breastfeeding.
 High weight gain increases risk of high birth
weight, maternal HTN, pre-eclampsia and
neonatal metabolic disorders.
 Obese women require additional prenatal care
as they may develop gestational diabetes, pre-
eclampsia and are at an increased risk of
thromboembolism and late fetal death.
THE INITIAL “BOOKING” PRENATAL VISIT

 Medical history
 Menstrual history
 Physical exam
 Investigations
 Diagnostic tests
 Screening Tests
 Assess risk factors and building up a strategy for the antenatal care
 Health Education with exhaustive efforts and advices
IMPORTANT DEMOGRAPHIC DATA

 Age
 Occupation
 Education
 Residence
 Ethnicity
 Race
 Religion
 Pets
 MEDICAL AND FAMILY HISTORY

Includes client and her partner

 Information to obtain
 Prior or current health issues
 Medications and allergies
 Possible inherited diseases in the families
 Significant health issues in family members
 Use of tobacco, alcohol, street drugs
GRAVIDITY AND PARITY

 Gravida–number of pregnancies
 Para–number of births after 20 weeks
 Five-digit system
 G–total number of pregnancies
 T–full-term pregnancies (37–40 weeks)
 Preterm deliveries (20–36 weeks)
 A–abortions and miscarriages (before 20weeks)
 L–living children
GROWTH OF THE FETUS DURING PREGNANCY

MEASUREMENT SYMPHYSEAL FUNDAL HEIGHT

 Evidence supports either palpation or S- F measurement at
every AN visit to monitor fetal growth
 measurement should start at the variable point (F) and continue
to the fixed point (S)
 SF measurement should be recorded in a consistent manner
(therefore in cms)
 Between 20 and 36 weeks of pregnancy, the height of the fundus in centimeters
 to the upper border of the symphysis pubis equals
 the duration of pregnancy in weeks.
 The lie of the fetus refers to the relationship of its long axis to the mother. By the 38th week the fetus
may have a longitudinal lie or an oblique or a transverse lie (Fig. 6.14).
 The presentation of the fetus relates to the fetal part that occupies the lower part of the uterus over the
pelvic brim. If the fetal head presents, it is termed a cephalic presentation; if the buttocks present it is a
breech presentation; if a shoulder presents it is termed a shoulder presentation.
 The presenting part of the fetus is that portion of the fetus which is presenting against the cervix in the
first stage of labour, or against the vagina in the second stage. If the presentation is cephalic, the
presenting part is usually the posterior part of the fetal head, the vertex or occiput, but it may be the
face or the brow.
 The attitude of the fetus is de ned as the relation of various fetal parts to other parts. Normally the fetus
lies with all its joints exed, but in some breech presentations the legs are extended along its body.
 The position of the presenting part of the fetus is of little clinical significance until labour is
established.
NORMAL AND ABNORMAL LIE AND PRESENTATION OF THE FETUS
LEOPOLD’S MANEUVERS

 The patient lies supine and you

stand at her side facing her
head.
 You place your hands on the
fundus to determine the
presence or absence of a fetal
pole (vertical versus transverse
lie), and the nature of the pole
(vertex or breech).
 The fetal breech is larger,
less well defined, and less
ballottable than the head
 Still facing the maternal
head, you then examine
the lateral walls of the
uterus to determine
which side the fetal back
and small parts occupy.
 In cephalic presentations, a
point of the fetal head may
be noted as a protuberance
that arrests the hand
outlining the fetus.
 As the hands are moved
along the lateral walls of the
fetus toward the pelvis,
either the occiput or the chin
will be encountered.
 You now turn toward the
patient’s feet and place your
hands laterally above the
symphysis and bring them
toward the midline.
 You are trying to determine
the nature of the fetal pole
(vertex or breech) and the
degree of descent of the
pole, indicating the station
of the presenting part.
Causes of oversized uterus (larger than Causes of undersized uterus (smaller than
period of amenorrhea): period of amenorrhea):

 Wrong dates.  Wrong dates

 Polyhydramnios.  Oligohydramnios
 Hydatidiform mole.  Fetal death
 Macrosomic fetus.  IUGR or Small fetus
 Concealed accidental hemorrhage.
 Pregnancy during period of
 Twins.
amenorrhea as lactation or injectable
 Tumors as fibroids and ovarian contraception
cysts.
 Malpresentations as transverse lie
 Fetal malformations as
hydrocephalus.
SMOKING:

 Birth weights are lower , IUGR, increased perinatal

deaths and preterm labor are present in smoking
mothers.
 This is due to effect of carbon monoxide, the
vasoconstricting effect of nicotine on the fetal vessels
in the placenta, which decreases placental perfusion,
reduced appetite and decreased maternal blood volume
expansion.
 Passive smoking is also very harmful to women. It
leads to ptyalism, nervousness and increased
hyperemesis gravidarum.
 ALCOHOL CONSUMPTION
 Fetal alcohol syndrome (FAS) is a birth defect syndrome
caused by the mother's intake of alcohol during pregnancy .
 In order to receive a diagnosis of FAS from a physician, three
criteria must be present:
 Characteristic facial features include - a flattened
midface, thin upper lip, indistinct/absent philtrum and
short eye slits
 Growth retardation - lower birth weight, disproportional
weight not due to nutrition, height and/or weight below
the 5th percentile.
 Central Nervous System neurodevelopmental
abnormalities such as - impaired fine motor skills,
learning disabilities, behavior disorders or a mental
handicap (the latter of which is found in approximately
50% of those with FAS)
Sleep:
Adequate rest of about 8 hours at night and 1 or 2 hours in the afternoon is recommended.
Exercise:
 It is not necessary to limit exercise as long as she does not get excessively fatigued or there is a risk to injury herself.
 Women accustomed to exercise before pregnancy should be allowed to continue but avoid starting new exercise
programs
 walking is the best to recommend.
 Regular exercise improves metabolic efficiency.
 Exercise does not increase risk of spontaneous abortion, shortens active labor and leads to fewer cesarean sections.
 Exercise is avoided in women with twin pregnancies, pregnancy induced hypertension, growth restricted fetuses and
severe heart and lung diseases.
 Traveling: This has no harmful effect.
 Air travel is also safe but in long trips of more than 6 hours the woman should walk about every 2 hours to prevent deep
venous thrombosis.
 The greatest risk is to travel away from proper medical facilities or to areas with infectuous diseases
 Seat belts are advised but the lap belt should be placed under the abdomen and across the thighs and the shoulder belt
between the breasts.
Coitus:
 Coitus should only be avoided in threatened abortion, PROM, threatened preterm delivery or if there is a placenta previa
 Sexual intercourse does not do harm before the last 4 weeks of pregnancy.

Work:
 Birth weights of women who worked during the third trimester are 150-400 gm less than those who do not work.
 It is greatest if the woman is underweight, with low weight gain and whose work requires standing. Standing was also
associated with increase in preterm births.
 Heavy work defined as sufficient to cause sweating was not deleterious.
 Any occupation that causes severe physical strain is avoided. No work that causes undue fatigue should be allowed and
adequate periods of rest during the working day should be allowed.
Clothing:
 should be practical and non-restricting.
 High heels are avoided to prevent loss of balance and prevent increased lordosis and backache.
Care of teeth:
 Pregnancy is not a contraindication for any dental treatment.
 The concept that pregnancy aggravates dental caries is not true.
Breasts:
 Well fitting supporting brassieres are required as breasts become painful and pendulous.
 Crusts or dried secretion over the nipples are washed by warm wateror boric acid.
 The nipples are drawn for a short time daily by the thumb and fingers and painted with a lubricant during
the last 6 weeks.
Bowels:
 Bowel habits become irregular due to relaxation of the bowel smooth muscles and compression of the lower
bowel by the pregnant uterus.
 Passage of hard stools can cause bleeding and fissures in the edematous rectal mucosa.
 Hemorrhoids are more common.
 Prevention of constipation is by drinking sufficient amount of fluid, daily exercise, foods containing roughage
as fruit and salad.
 Harsh laxatives and enemas are avoided.
Bathing:
 There are no restrictions but the mother should be careful not to slip in the tub and showers are safer.
Douching:
 Use of hand bulb syringes are contraindicated.
 The douche bag should not be raised more than 60 cm above the hips and the nozzle not more than 7 cm in the
vagina.
IMMUNIZATION:

 Live attenuated virus vaccines as measles, rubella,

mumps, poliomyelitis are contraindicated.
 Inactivated virus vaccines as influenza, and rabies are
safe to be given.
 Inactivated bacterial vaccines as cholera,
meningococcus, and typhoid are safe to be given.
 Toxoids as tetanus and diphtheria toxoid are safe to be
given.
 Immune globulins as for hepatitis, tetanus and rabies
can be given.
WARNING SIGNS:
THE PREGNANT WOMAN MUST IMMEDIATELY REPORT IF ANY ONE OF THE
FOLLOWING SIGNALS OCCUR:

 Vaginal bleeding.
 Swelling of the face, fingers and limbs.
 Swollen tender calf muscles
 Severe headache.
 Blurring of vision.
 Abdominal pain.
 Persistent vomiting.
 Chills and fever.
 Escape of fluid from the vagina.
VISIT SCHEDULE

 The return visits are

 Every 4 weeks until 28 weeks then
 Every 2 weeks until 36 weeks then
 Weekly thereafter. A more flexible schedule is at times better.
 Perinatal outcome benefits were more pronounced with antenatal care after 30
weeks.
 The mother is advised to call or come when she feels undue worry. In each visit
the well being of mother and fetus are assessed.
 The WHO recommends at least 4 antenatal visits
First appointment
The first appointment needs to be earlier in pregnancy (prior to 12 weeks) than may have traditionally occurred and,
because of the large volume of information needs in early pregnancy,
two appointments may be required.
At the first (and second) antenatal appointment:
 give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by written
information (on topics such as diet and lifestyle considerations, pregnancy care services available, maternity benefits and
sufficient information to enable informed decision making about screening tests)
 identify women who may need additional care and plan pattern of care for the pregnancy
 check blood group and RhD status
 offer screening for anaemia, red-cell alloantibodies, Hepatitis B virus, HIV, rubella susceptibility and syphilis
 offer screening for asymptomatic bacteriuria (ASB)
 offering screening for Down’s syndrome
 offer early ultrasound scan for gestational age assessment
 offer ultrasound screening for structural anomalies (20 weeks)
 measure BMI, blood pressure (BP) and test urine for proteinuria.
 16 weeks
 review, discuss and record the results of all screening tests undertaken; reassess planned
 pattern of care for the pregnancy and identify women who need additional care
 investigate a haemoglobin level of less than 11g/dl and consider iron supplementation if
indicated
 measure BP and test urine for proteinuria
 give information, with an opportunity to discuss issues and ask questions; offer verbal
information supported by antenatal classes and written information.
18–20 weeks
 If the woman chooses, an ultrasound scan should be performed for the detection of structural
anomalies.
 For a woman whose placenta is found to extend across the internal cervical os at this time, another
scan at 36 weeks should be offered and the results of this scan reviewed at the 36-week
appointment.
25 weeks
 At 25 weeks of gestation, another appointment should be scheduled for nulliparous women. At this
appointment:
 measure and plot symphysis–fundal height
 measure BP and test urine for proteinuria
 give information, with an opportunity to discuss issues and ask questions; offer verbal information
supported by antenatal classes and written information.
 31 weeks
Nulliparous women should have an appointment scheduled at 31 weeks to:
 measure BP and test urine for proteinuria
 measure and plot symphysis–fundal height
 give information, with an opportunity to discuss issues and ask questions; offer
verbal information supported by antenatal classes and written information
 review, discuss and record the results of screening tests undertaken at 28 weeks;
reassess planned pattern of care for the pregnancy and identify women who need
additional care.
34 weeks
At 34 weeks, all pregnant women should be seen in order to:
 offer a second dose of anti-D to rhesus-negative women
 measure BP and test urine for proteinuria
 measure and plot symphysis–fundal height
 give information, with an opportunity to discuss issues and ask questions; offer
verbal information supported by antenatal classes and written information
 review, discuss and record the results of screening tests undertaken at 28 weeks;
reassess planned pattern of care for the pregnancy and identify women who need
additional care
36 weeks
At 36 weeks, all pregnant women should be seen again to:
 measure BP and test urine for proteinuria
 measure and plot symphysis–fundal height
 check position of baby
 for women whose babies are in the breech presentation, offer external cephalic
version (ECV)
 review ultrasound scan report if placenta extended over the internal cervical os at
previous scan
 give information, with an opportunity to discuss issues and ask questions; offer
verbal information supported by antenatal classes and written information.
38 weeks
Another appointment at 38 weeks will allow for:
 measurement of BP and urine testing for proteinuria
 measurement and plotting of symphysis–fundal height
 information giving, with an opportunity to discuss issues and ask questions; verbal
information supported by antenatal classes and written information.
40 weeks
For nulliparous women, an appointment at 40 weeks should be scheduled to:
 measure BP and test urine for proteinuria
 measure and plot symphysis–fundal height
 give information, with an opportunity to discuss issues and ask questions; offer
verbal information supported by antenatal classes and written information.
 41 weeks
For women who have not given birth by 41 weeks:
 a membrane sweep should be offered
 induction of labour should be offered
 BP should be measured and urine tested for proteinuria
 symphysis–fundal height should be measured and plotted
 information should be given, with an opportunity to discuss issues and ask
questions; verbal information supported by written information.