Antenatal Care

Dr Clare Tower Clinical Lecturer St Marys Hospital

Antenatal Care
Aim Guide to antenatal clinics Hand held notes Antenatal examination Assess risk Downs screening

Antenatal clinics
Large amount of antenatal care now provided by midwives
Mixture of midwifery & medical clinics
Medical history identify high risk women Drug history Screening Ultrasound examinations Health promotion Clinical examination

NICE antenatal care

http://guidance.nice.org.uk/CG62/QuickRe fGuide/pdf/English ..\images\CG062QuickRefGuide.pdf

Summary of schedule
Primips: 10 visits + anomaly scan (20 weeks) Multips: 7 visits + anomaly scan
10 16 20
USS

25

28

31

34

36

38

40

41

Booking

Red = extra visits for primips

Handheld notes
Page 1 Medical and Social History Previous pregnancies Antenatal screening Ultrasound Record of Antenatal visits

http://www.preg.info/pages/index.htm

Antenatal examination
Ask permission Blood pressure
Korotkoff V Falls mid pregnancy Increases to term

Urinalysis
Protein Glucose

Antenatal examination
Inspect
Distension Linea nigra

Palpate
Symphysio-fundal height Fundus to top to symphysis 20 weeks = umbilicus 1cm per week

Antenatal examination
Palpate
Fetal lie =Longitudinal axis of baby to that of the mother Presenting part = what is coming 1st Position- laterality of occiput or sacrum Engagement amount of head you can feel in fifths

Auscultate fetal heart

Ask about fetal movements

Fetal lie

Longitudinal

transverse

Presenting part

Cephalic

Footling Breech

Extended breech

Position

Occipito-anterior
OA

Occipito-posterior OP

Head engagement
Amount of head in fifths you can feel in the abdomen

Fully engaged = more head in pelvis than in abdomen = 2 fifths palpable

Screening Downs
Increased risks of trisomy 21, 13 and 18 with maternal age
Age Risk T21 Key nos

20
30 35 40

1:1527
1:895 1:356 1:97

1:1500

1:350 1:100

42

1:55

Screening - Downs
Problem: only way of providing a diagnosis is amniocentesis or chorionic villus biopsy/ sampling (CVB/CVS) Risk of miscarriage:
Amnio 1% CVS higher ? 2%

Screening tests
Many options Measurements of hormone levels USS assessment of nuchal translucency
11-13+6

Screening which test?

Test Integrated test Serum Integrated test Combined test Quadruple test Measurements NT, PAPPA 10 weeks, AFP, E3 HCG 14-20 wks As above no NT NT, PAPPA, HCG 10 wks False +ve for 85% detection 1.2% 2.7% 6.1%

AFP, E3, HCG, Inhibin A 14- 6.2% 20 wks AFP, E3, HCG 14-20 wks AFP, HCG 14-20 wks 12-13 weeks 9.3% 13.1% 20%

Triple test Double test Nuchal Translucency

Screening
By April 2007 75% detection rate for 3% false positives no where near!! Still only generates a risk eg 1:1000 Generated risks heavily weighted to maternal age Arbitarily defined high risk of 1:200-1:250
Based on miscarriage risk from invasive testing

Summary
Antenatal care important- improves outcomes Most Drs meet pregnant women Clinical signs to find!!