Antenatal care for undergraduate

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ANTENATAL CARE

• DR MANAL BEHERY
• Zagazig University , Egypt

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Definition

• Antenatal care refers to the care that is given
  to an expected mother from time of conception is
  confirmed until the beginning of labor
• It is a preventative cost effective service

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GOALS

• 1-Ensure mother health.
• 2- Ensure delivery of a healthy infant.
• 3-Anticipate problem
• 4- Diagnose problem early.

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Objectives

• 1-Early detection and if possible, prevention of
  complications of pregnancy.
• 2-Educate women on danger and emergency signs
  symptoms.
• 3-Prepare the woman and her family for childbirth
• 4- Give education counseling on
  family planning

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Schedual of antenatal care
Medical check up every four weeks up to 28 weeks
gestation Every 2 weeks until 36 weeks of
gestation Every week until delivery An
average 7-11 antenatal visits/pregnancy More
frequent visits may be required if complications
arise.
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On first antenatal visit

• 1-First Confirm pregnancy by pregnancy test or
  US.
• 2-History
• 3-Physical examination
• 4-investigation

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History

• Personal history
• Menstrual history
• Obstetrical history
• Family history
• Medical and surgical history
• History of present pregnancy

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Menstrual history

• Ask about
• 1-Last menstrual period (LMP).
• 2-Regularity and frequency of menstrual cycle.
• 3-Contraception method used .
• 4-Calculate expected date of delivery (EDD) as
• 1st day of LMP -3 months 7 days, and change the
  year.

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Obstetric History

• Gravidity? Parity? abortion, and living children.
  
• Weight of infant at birth length of gestation.
• Type of delivery, location of birth, and type of
  anesthesia.
• Maternal or infant complications.

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Medical and surgical history

• 1-Chronic conditions as diabetes mellitus,
  hypertension, and renal disease ,cardiac disease.
• 2-Prior operation as cesarean section, genital
  repair, and cervical cerclag.
• 3-Allergies, and medications.
• 4-Accidents involving injury of the bony pelvis

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History of present pregnancy

• History suggesting e.g. Diabetes,
  hypertension and ante partum hemorrhage.
• Ask about episodes of fever or chills
• Ask about pain or burning sensation on urination.
• Abnormal vaginal discharge, itching at the vulva
  or if partner has a urinary problem.

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IMMEDIATE ASSESSMENT for emergency signs.

• Vaginal bleeding
• Severe abdominal or pelvic pain
• Severe headache with visual disturbance
• Persistent vomiting
• Unconscious/Convulsion
• Severe difficulty in breathing
• High grade Fever
• Looks very ill

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Assessment and physical examination
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Weight measurement

• Maternal height and weight measurements to
  determine body mass index(BMI).
• Maternal weight should be
• measured at each
• antenatal visit

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Check for pallor or anemia.

• 1-Look for palmar pallor.
• 2-Look for conjunctival pallor
• 3-Count respiratory rate in one minute.

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Blood pressure measurement

• Measure BP in sitting position.
• If diastolic BP is 90 mm Hg or higher repeat
  measurement after 6 hour rest.
• If diastolic BP is still 90 mm Hg or higher ask
  the woman if she has
• Severe headache
• Blurred vision
• Epigastric pain
• Check urine for protein.

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Investigations

• Get baseline on the first or following the first
  visit.
• Hemoglobin, blood type
• Urine analysis
• VDRL or RPR to screen for syphilis
• Hepatitis B surface antigen To detect carrier
  status or active disease

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At each visit
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At each visit

• 1-Questions about fetal movement
• 2-Ask for danger signs during this pregnancy
• 3-Ask patient if she has any other concerns

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Symphysis Fundal hieght

• LMP plus 280 days
• Add 7 days, subtract 3 months
• MacDonald's Rule (cm weeks)

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At third trimester

• Do
• Leopolds exam

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• Provide advice on

1. Diet and weight gain
2. Medication
3. Avoid Radiation exposure
4. Self-care during pregnancy
5. Minor complaints.
6. Family planning Breastfeeding
7. Birth place preparation and anticipation of
   complication Emergency situations.

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Diet in pregnancy

•  
• Total caloric intake increase to 300 kcal /day
  due to 15 increase in BMR .
• Diet show contain 20Protein(better from animal
  source), 30 fat ,and 50 carbohydrates .
• Sufficient fluids should be available.

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Supplementation

• 1-Folic acid 0.4 mg tab daily
• 2- iron (ferrous sulphate or gluconate )300
  mg/daily
• 3- Ca 1200mg /daily
• 4-
• -Those with a normal balanced diet
• probably dont need extra vitamins

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Weight gain in pregnancy

• There is a slight loss of pounds during early
  pregnancy if the patient experiences much nausea
  and vomiting.
• Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of
  the first trimester.
• Gain of 1 lb(0.5)/ per wk is expected during the
  second and third trimesters.
• Monitoring of weight gain should be done in
  conjunction with close monitoring of BP.

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Medications During Pregnancy

• Antibiotics - some OK, some not
• Local anesthetics - OK
• Local with epinephrine - not OK
• Aspirin - not OK
• Immunizations - some are OK, some are not
• Antimalarial - some OK, some are not
• Narcotics - OK except for addiction issue

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• Case Study

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Case Study

• A 35-year-old G2 P10 woman is seen for her first
  prenatal visit.
• Based on her LMP, she is at 15 weeks gestation.
• She has no complaints, and no significant medical
  history.
• She denies dysuria or urinary urgency.
• Her surgical history is remarkable
• Her last delivery was a vaginal delivery and was
  uncomplicated

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On examination

• Her blood pressure (BP) is 100/65 mm Hg
• heart rate (HR)90 (bpm),
• respiratory rate (RR) 12,temperature 98F
  (36.6C),
• weight 70KG.
• general physical examination is normal

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Abdominal examination

• Her abdomen is non tender
• Fundal height is at the level ofthe umbilicus.
• Fetal heart tones are 140 bpm.
• Her extremities are without edema.

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Prenatal laboratories

• CBC Hgb 10.0 g/dL ,Plt 150,000 WBC 8,000
• Rubella nonimmune
• Hepatitis B surface antigen positive
• Blood type O, Rh negative
• UCS 10,000 cfu/mL of group Bstreptococcus
• Gonorrhea assay negative Chlamydia assay
  negative

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Questions

• ? What items should be listed on the problems
  list?
• ? What is your next step for the problems listed?
• ? What other testing should be recommended to the
  patient?

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Problem List

• Advanced maternal age 35 Y or greater at EDD
• fundal height at umbilicus corresponds to 20
  weeks)
• Mild microcytic anemia (Hgb lt 10.5)
• Hepatitis B surface antigen (HBsAg) positive
• Rh-negative blood type
• Urine culture with GBS 10,000 cfu/mL,
• Rubella nonimmune

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Next Steps

• 1. AMAgenetic counseling
• 2. Size/datesfetal ultrasound to assess GA,
  multiple gestation
• 3. Anemiatherapeutic trial of iron
• 4. HBsAg positivecheck liver function tests, and
  hepatitis B serology toassess for active
  hepatitis versus chronic carrier status

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Next step

• 5. Rh negative Rhogam at 28 weeks and at delivery
  if the baby proves to be Rh positive
• 6. Urine culture with GBStreat with ampicillin
  and re-culture urine, peni-cillin IV prophylaxis
  in labor
• 7. Rubella statusvaccinate postpartum

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Other tests recommended to patient

• consider early diabetic screen

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• Thank you