Ante Natal Care

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Ante Natal Care

• Prof. Fawzia Ahmed Habib
• Professor
• Consultant Obstetrics Gynecology

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Objectives

• To have knowledge of ante partum care
• Be able to give advise on health education
• Some practical obstetrics skill
• Manage minor pregnancy problems

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Introduction Ante natal care is intended to
facilitate preparation for child birth, and to
some extent, subsequent child care.

• Ante natal care embraces
• Maternal health checks
• Evaluation of fetal health development
• Disease screening
• Analysis of risk for the development of
  complications
• Provision of advise and education

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All maternity services should be centered on the
woman her needs. Each woman should be given
sufficient help and information to enable her to
make an informed decision about her care.

• Communication has become a key factor between
  different health professionals and the woman for
  an effective team working to provide continuity
  of care.

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Organization of ante natal care

• Pre conceptional visit
  prenatal advise education
• First visit
  idealy before 12 weeks
• A minimum of monthly check-ups until 28
  weeks
• Fort nightly check-ups
  until 36 weeks
• Weekly visits
  until labor

• Subsequent care would be according to risk
  evaluation at the booking clinic

Full hospital care
Shared care (hospital GP)
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Maternal health

• Improvements in the standard of living for
  most of the pregnant ladies, raises some habits
  which was known in the society e.g. smoking.
• So maternal advise education is important in
  the first ante natal visit.

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Supplements Vitamins

• Folate supplementation 400 microgram up to
• 3 months before conception is recommended
• and to be continued up to 3 months after
• conception on the basis of strong evidence that
• the incidence of Neutral tube defect is
• reduced.
• Vitamin A supplements should be avoided
• Iron Calcium only if indicated.

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Food HygieneAttention to food hygiene is
advised in order to avoid food poisoning and
specific effects of some micro-organisms as the
pregnancy.

• Listeria
  avoid soft cheese, unbasterurized
• 
  milk
• Toxo plasma undercooked
  meat
• Raw eggs
  salmonella

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Physical extortionPhysically demanding work has
been associated with poor outcomes, such as
preterm birth, pre eclampsia low birth weight.

• It is better to stop employment after 33 weeks of
  pregnancy
• Normal, mild exercise is encouraged during
  pregnancy
• Sexual intercourse has not been found to be
  associated with increased risk of preterm
  delivery.

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SmokingThe association between maternal
smoking and low birth weight is well known.If
women cease smoking, fewer complications develop
during pregnancy. There is less chance of
placental abruption, preterm, labor fetal cleft
lip/palate.
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First ante natal visit

• Confirm pregnancy urine or blood
• Document LMP
• Calculate EDD
• Calculate gestational age
• Booking history and risk assessment

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Common risk factors at booking and arising during
pregnancy which needed referral to maternity
services.
Risk Suggested actions
Pre existing medical condition e.g. DM, high Bp Epilepsy, asthma Refer to specialist obstetric clinic
Family history of genetic disorder Down Syndrome multiple congenital anomalies Refer to perinatology clinic
Previous genital tract surgery e.g. myomectomy Refer to specialist obstetric clinic for opinion about delivery
Cervical cone biopsy- late termination previous ,cervical cerclage Refer by 12 weeks to specialist obstetric clinic for cervical cerclage if considered
Anal sphincter surgery Consider elective caesarian section
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Post obstetrics history Post obstetrics history
Five or more previous births Three or more miscarriages Serious complications during pregnancy Preterm labor-Ante Partum haemorrhage hypertension still birth etc. Delivery caesarian section third degree tear Post partum haemorrhage infection large baby shoulder dystocia neonatal admission neonatal death Refer to obstetrics units Refer to obstetrics units
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Present pregnancy urgent referral to maternity services Present pregnancy urgent referral to maternity services
Multiple pregnancy Refer to obstetrics unit
Anemia lt Hb less than 8 gm/dL Refer to obstetrics unit
BPgt 140/90 mmHg Admit to obstetrics unit
Haemorrhage after 24 weeks Admit to obstetrics unit

Transverse lie after 36 weeks Admit to obstetrics unit
Concern about fetal movement Refer to obstetrics unit
Not delivered at 41 weeks Refer to obstetrics unit
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Maternal Examination Maternal Examination
Maternal height (short stature less than 150 cm.
Maternal Weight Each visit
BMI More than 29 weeks is an indication for dietary advise
BP recording each visit Identify hypertension/PET
Auscultation of the heart lungs. First visit
Breast examination 1st visit masses
Abdominal examination scars Symphysis fundal height regularly from 20-40 weeks fetal lie presentation from 36 weeks
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Investigations Investigations
Full blood count at booking then at 28 weeks -36 weeks Would Health Organization Definition lt 11 gl dL Severe anemia lt 7 gl dL
Platelet count Levels lt 100 x 109 L should be referred to obstetrics and hematology unit
Blood group red cell antibodies at booking visit Rhesus status, blood group red blood cell antibodies Rh-negative urgent refer Postive red cell antibodies to Atypical red cell antibodies Obstetric un
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Maternal infection screening Maternal infection screening
Rubella Ig G antibodies positive Rubella I g G antibodies negative Rubella I g M antibodies - positive Indicate immunity Needs post natal vaccination Infection congenital rubella syndrome
Hepatitis B negative Hepatitis Bs Ag - positive No intervention Urgent refer to obstetric unit
Syphilis VDRL positive TPHA - negative Urgent referral to obstetric unit
Toxoplasmosis Ig M positive Ig G positive Ig M - negative urgent referral to obstetric unit Previous infection
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Ultrasound scans

• Dating scan multiple pregnancy Before
  12 weeks
• Congenital abnormally 18-22 weeks
• scan
• Growth scan 32 weeks

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Glucose challenge test Glucose challenge test
All patients 24-28 weeks 50 gm glucose to non fasting mothers then BL sugar after one hour upper limit (7.8 m mole/L)
Oral glucose tolerance test 75 gm 100 g Fasting results (5.3 5.8 mmol/L) Cut-off values at 2 hours 8.6 mmole/L 9.2 mmol/L
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Urinalysis for protein uria each visit whenever Bp is checked Microscopic urine examination urine culture and sensitivity for all pregnant women Protein is an indication for urgent referral to obstetrics unit Rule out A symptomatic Bactiruria
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Evaluation of fetal health

• Fetal movements
• Normal fetal activity during the third trimeter
  is an indication of adequate fetal oxygenation
• Biological variations in fetal activity,
  including fetal rest activity need to be taken
  into account when interpreting concerns about
  fetal activity
• Woman who are concerned about reduction of fetal
  movements should be reported fro further
  investigation

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Fetal growth monitoring clinical palpation of
the abdomen and measurement of symphysis fundal
distance

• Identify fetus is small or large
• - smaller fetus carries risk of hypoxia in
  labor
• - large fetus carries risk of shoulder
  dystocia
• Refer to obstetric unit for further investigation

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• Fetal growth by ultrasound for low risk
  pregnancies
• Scan at 32 weeks
• Biophysical profile Doppler ultrasound
  examination only to be ordered by obstetrician is
  high risk pregnancies
• Fetal cardiotocography - GTG
• If indicated due to concern about fetal
  activity urgent to obstetric units.
• Prenatal Diagnosis Needs urgent referral to
  perinatal clinic
• Indicated for detecting abnormalities in the
  fetus when suspected by ultrasound.
• Indications 1. chromosomal abnormalities
  (trisomies)
• 2. congenital
  abnormalities
• 3. metabolic
  diseases
• 4. rhesus
  incompatibility
• 5. fetal infection

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Minor Symptoms of Pregnancy

• A minor and physiological changes to
• body functions occur during pregnancy
• need to be dealt by general practitioner.

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Gastro interstinal Gastro interstinal
Nausea vomiting hyperemesis gravidarum (severe) gastric reflux oesophagitis Constipation Antihistamines Admit to obstetric unit Antacids --small meal Fibre supplements and osmotic laxatives lactulose-
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Cardio Vascular Cardio Vascular
Headache and occasional Fainting in early pregnancy Explain physiological changes
Short episode palpitation Persistence headache in the third trimester Varicose veins Posture change Could be pre eclampsia Support tights Pregnancy periods of rest
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Respiratory Respiratory
Dyspnoea breathlessness Rest Exlude infection, asthma-heart failure pulmonary emboli
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Musculoskeletal Musculoskeletal
Carpal tunnel syndrome ulner nerve compression Backache Pubic symphysis diastasis Leg cramps Oedema of lower legs Analgesia Advise on posture Advise on posture Analgesia Common avoid over heating of the legs at night common
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Genitourinary Genitourinary
frequency of micturition Mucoid vaginal discharge Watery vaginal leakage Vulval irritation itching Common Common ??liquor Refer to obstetric unit to exclude SROM Candida albicans Miconazol pessaries or cream
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Routine Induction of labor

• By 40 weeks gestation, less than 60 percent of
• woman have delivered --- If not delivered by 40
  weeks do
• ultrasonography for
• amount of amniotic fluid and growth to be done
• if both satisfactory keep
• till 41 weeks.
• Induction of labor by 42 weeks refer to
  obstetric
• unit

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• Wish you uncomplicated
• delivery