Obstetrics

Dr. Hana Lec: -2-

15-Oct-06

Antenatal care

Antenatal care includes

1- preconception care & advice

2-the initial visit & subsequent visit
3-health education for pregnant women
4-alarming symptoms &signs

Definition

ANC is a preventive obstetric health care program aimed at optimizing maternal -

fetal outcome through regular monitoring of pregnancy.

Aim of ANC

1-To prevent , detect & manage those factors that adversely affect the health of the
mother & baby
2- To provide advice , reassurance , education & support for the mother & family
3- To deal with the minor aliments `of pregnancy
4- To provide general health screening

Preconception care and advice

During the preconception exam the following procedures should be completed

1- History
a- demgraphic data
b- medical & surgical history
c-work related exposure to chemicals & irradiation
women with past obstetrical , medical or genetic disorders should be referred to a
specialist for advice.

2- Physical exam.
* measure BP, * determine Rh

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3- Counseling

*maintain proper nutrition

*quit unhealthy habits
*change a dangerous work situation
objectives of ANC

1- Best possible health status for mother & fetus

2-early detection & timely referral of high risk pregnancy
3-education of the mother about

*physiology of pregnancy
*nutrition
*alarming sign & symptoms
*infant care
*breast feeding
*child spacing
*reduction of maternal & perinatal mortality & morbidity

Classification ofantenatal Care

• shared care
• community - based care
• hospital based care

High risk pregnancy

is a pregnancy with conditions that may jeopardize maternal or fetal welfare

1- Personal history
* age less than 18 y old , more than 35 y old
*smoking
* infertility
2- Obstetrical history

* Parity > 5
* Previous IUFD or neonatal death
*previous small for gestational age
* Previous large foe gestational age
* Pervious congenital anomalies

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* recurrent 1st trimester abortion
* previous spontaneous second trimester abortion or preterm labour
* previous C S
*previous retained placenta or PPH
* Previous Rh isoimmunization or hydrops fetalis
*previous instrumental delivery
* hypertension
*heart disease
3- past history
* TB
*epilepsy
* uterine anomalies
* previous myomectomy
* successful repair for fistula,

Schedule of ANC visits

For low risk conditions

up to 28 w gestation every 4 weeks
28 w --- 36 w every 2 weeks
thereafter every week
In low risk pregnancy with no complications a minimum of 5 visits including the
booking visit is acceptable .
The quality of care is more important than the frequency of visits

The initial visit

1-booking procedures (registration )

2-physical examination .
The 1st ANC visit should be as early as possible during the 1st trimester ,so risk
assessment can be determined.
In the booking visit the following must be done
1- confirmation of pregnancy
2-dating of the pregnancy
*menstrual cycle
* dating by US

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Benefits of a dating scan

• Accurate dating in women with irregular MC

• Reduced incidence of induction of labour for prolonged pregnancy
• Maximizing the potential for serum screening to detect fetal abnormalities
• Early detection of multiple pregnancies
• Detection of otherwise asymptomatic failed intrauterine pregnancies

History in booking visit

1- Personal history
name,age, address, occupation (both partners ) , duration of marriage,consanguinity
,smoking

2-Complaints in details

3- Menstrual history

4- Past obstetrical history

5-Present obstetrical history

symptoms of pregnancy,PET,or other diseases, warning signs & fetal movements.

6-Family history
DM,hypertension , multiple pregnancy,& congenital anomalies

7- Medical history
diseases, drugs ,blood transfusion ,XR exposure,Rh incompatibility

8- Surgical history
D&C, vaginal repair, CS, cerclage, non -gynaecological surgery

9-Family planning history

10- Immunization history

11- Breast feeding history

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Examination

1-general examination

*physical signs
vital signs ,Wt ,height,abnormal gait, paler ,jaundice

2-chest examination

3- Heart examination

4- Breast examination

5-lower limb edema

6-skeletal or neurological abnormalities.

7- abdominal examination

1- inspection
2- palpation
3- Fetal heart sound

8-Vaginal examination

Investigation

*CXR no longer performed as routine

*MUE for bacteria, protein , glucose
*blood
CBC, ABO &Rh
screening for diabetes, Wasserman reaction for syphilis,
serological test for rubella, hepatitis B virus ,HIV
Screening for Down syndrome

Down syndrome screening

1- NT at 11-14 w
2- serum screening at 14-20 weeks
ultrasound
CRL performed at 10-13 W
BPD at & beyond 14 weeks
full anomalies scan can be done between 18-20 weeks

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Lab. investigations
• Screening for DM at 28 weeks
• Urine exam
• Hb exam at 30 weeks & 36 weeks
• Offer anti- D immunoglobulin at 28 & 34 weeks
• Assessment of fetal wellbeing in a low risk pregnancy
*fetal size ( FL, SFH )
* fetal kick count ( 10 movement /12 y )
* fetal movements
*FHS

AT 37 weeks
Assessment of pelvic capacity if there is suspicious of pelvic inadequacy ( stature
<145, pelvic fracture or previous CS for CPD
At 41 weeks
• For women who have not given birth by 41 weeks
• Membrane sweep should be offered
• Induction of labour
• BP, protein in urine exam
• SFH should be measured

Health education
1-Working during pregnancy

2- nutritional supplement
* folic acid
* iron (30 mg /day )
* vit A ( < 700 microgram) may be teratogenic.
*calories (2500 Kcal/day)
protein (60gm/day)
*Ca (1.2 gm/day)

3- exercise in pregnancy
Beginning or continuing a moderate course of exercise during pregnancy is not
associated with adverse outcome

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Clothing
* clothing should be loose light
*avoid high heels ,belts or corsets
*avoid tight leg wear
dental care
* have teeth examined twice during pregnancy
*brush teeth after meals
* tooth extraction is allowed even for pregnant women with rheumatic heart disease
if prophylactic antibiotics are given

Subsequent visits
1- recorded new complaints
2-ask about alarming signs
3-ask about fetal movements
4-provide continuous health education
5- encourage institutional delivery

Examination
General exam.
Abdominal exam.
Fl , fetal lie , presentation, & FHS

Breast care
• Wash daily to reduce cracking
• Massage
• Nipples
*if there is dry secretion treat with a mixture of glycerin & alcohol
* If retracted treat by pulling out gently &regularly
* wear a brassiere to support heavy breasts.

Weight gain ( 11- 16 kg)

normal weight women should gain 11.5 – 15 kg
underweight 12.5 – 18 kg

Obese women no more than 7 kg

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4- Sexual intercourse in pregnancy
Is not associated with adverse outcome

5- alcohol &smoking in pregnancy

Excess alcohol has an adverse effect on the fetus.. Therefore it is suggested that
women limit alcohol consumption to no more than standard unit per day.
Each of the following constitutes one unit of alcohol
*a single measure of spirits
*one small glass of wine
*a half pint of ordinary strength beer
Pregnant women should be informed about the specific risks of smoking during
pregnancy (low birth weight , preterm labour)
Advice should be given by physician, group session & behavioural therapy.

Air travel during pregnancy

pregnant women should be informed that long – haul air travel is associated with an
increased risk of venous thrombosis , wearing correctly fitted compression stocking is
effective at reducing the risk.

Immunization

Live attenuated vaccines are contraindicated

Any pregnant women who comes in contact with rubella should be tested for rubella
antibodies
tetanus toxoid (TT) should be administered to prevent tetanus if the women has not
already immunized

TT1 at 1st contact ,or as soon as possible during pregnancy

TT2 at least four weeks after TT1
TT3 at least 6 months after TT2 or during subsequent pregnancy
TT4 at least 6 months afterTT3 or during subsequent pregnancy
TT5 minimum 1 year after TT4 or during subsequent pregnancy.

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Management of common symptoms of pregnancy

Nausea & vomiting

most cases of nausea & vomiting in pregnancy will resolve spontaneously within 16-
20 w of gestation, N&V are not associated with poor pregnancy outcome.
The following intervention appear to be effective in reducing symptoms
nonpharmacological
*ginger
*p6 acupressure
pharmacological
antihistamines ( cyclizine & meclizine)
pyridoxine ( vitamin B6 )
Ptylism (excessive salivation )
avoid giving anticholinergic drugs

Heartburn

Antacid may be offered to women whose heartburn remains troublesome despite

lifestyle & diet modification.
Constipation
Women who present with constipation in pregnancy should be offered information
regarding diet modification, such as bran or wheat fibre supplementation
Haemorrhoids
Start diet modification ,if clinical symptoms remain troublesome, standard
haemorrhoid creams should be considered.
Varicose veins
These are common symptoms during pregnancy that will not harm & that
compression stocking can improve the symptoms but will not prevent varicose veins
from emerging.
Vaginal discharge
Is common physiological change that occurs during pregnancy . If this associated with
itch, soreness, offensive smell or pain on passing urine there may be an effective
cause & investigation should be considered.
For candidiasis 1 week topical imidazole is an effective treatment
oral treatment should be avoided.
Backache
Women should be informed that exercising in water , massage therapy &group or
individual back car classes might help to ease backache during pregnancy.
leg cramps
Painful spasms of the calf muscles are experienced by 50% of pregnant women
magnesium (citrate or lactate) is the only effective supplement.
calcium is not effective ,massaging & stretching the muscle during the attack can
help.

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Alarming symptoms & signs
Pregnant women should be advised to seek immediate medical care if they experience
any of the following
• *vaginal bleeding
• *sever edema
• *Escape of fluid from the vagina
• * abnormal gain or loss of weight
• * decrease or cessation of fetal movement
• *sever headache
• *epigastric pain
• *blurred vision
• * fever
• * abdominal pain

Prepared By:
Rand Aras Najeeb

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