Antenatal care

ANTENATAL CARE: (ANC)

Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best outcome for both the mother and the child. It is a mixture of both art and science. It involves a no. of routine visits on regular bases throughout pregnancy.
Team work between midwives, general practitioners, and obstetricians will continue to be necessary in effective antenatal care.
Early monitoring and on-going care during pregnancy is associated with more favourable birth outcomes.
Aims of antenatal care:
- Assessment and management of maternal risk and symptoms.
- Assessment and management of fetal risk
- Prenatal diagnosis and management of fetal abnormalities
Diagnosis and management of perinatal complications
Decision regarding timing and mode of delivery
Parental education regarding pregnancy and child birth
Parental education regarding child rearing
So a program should be based on individual requirements of both mother and fetus.
Providers of antenatal care:
There are usually three schemes of care:
community care , supervised predominantly by the midwife.
shared care between the woman`s general practitioner, midwife and obstetrician.
hospital only care in cases where there is increased risk to either the mother, the fetus, or both.
Schedule of visits during pregnancy:
The pregnant woman is seen by her general practitioner as soon as possible following the fist missed period and after an initial assessment is referred to the hospital for her first (booking) visit between 8-14 weeks.
Previously, the antenatal visits were: monthly until 32 weeks` gestation; then fortnightly until 36 weeks, and weekly until delivery, resulting in up to 14 visits during pregnancy.
Currently the trend is towards reducing the no. of visits.


The visits:
Preconception clinic visit
8-14 week visit
20-24 week visit
36-38 week visit
41-42 week visit
Preconceptional visit:
The patient’s general health and wellbeing can be fully assessed, rubella, hepatitis and HIV status can be established and appropriate action taken where indicated.
General advice regarding nutrition and lifestyle can be given at this time. Advice can be given regarding the avoidance of teratogens (as vit. A, cigarette smoking and alcohol)
Daily Folate supplementation (0.4 mg folic acid reduces the risk of neural tube defect by 72% in patient with previous affected pregnancy.
For a woman with diabetes mellitus, abnormal blood glucose control during this period is associated with an increased incidence of fetal abnormalities. A pre-pregnancy counseling might give advice to women with any of the following conditions:
Women who had unsuccessful pregnancy
Women with some diseases who are anxious to know whether pregnancy would exacerbate this, or whether the child might be harmed
Women with a family history of disease
Genetic problems may require special investigations, including chromosomal studies.

High risk pregnancy:

-maternal health conditions
-maternal problems develop during pregnancy.
-disorders of pregnancy.
-fetal complications.


BOOKING VISIT (8-14 WEEKS)
The main purpose of the booking visit is to obtain a comprehensive history, establish the gestational age and identify maternal and fetal risk factors.
Baseline investigations are performed.
physical examination

Laboratory tests:

Routine baseline investigations:
blood tests: Hb, full blood count, if Hb below 8.5 g/dl, send for blood film and transferrin, ferritin, RBC folate and B12 assays, Hb electrophoresis (thalassaemia and sickle cell anaemia) or women at particular risk (Mediterranean, afro-Caribbean & Asian).
Blood group, Rh factor and antibody screen
microbiological: rubella, hepatitis B, syphilis (VDRL),HIV
other tests: (not routine tests)
infections such as varicella zoster, cytomegalovirus, toxoplasmosis which may affect the fetus adversely are not routinely screened (depending on history).
Serum -fetoprotein at 16-18 weeks
Blood glucose screen.
urine tests:
glucose, ketones, proteins, bacterial activity
vaginal speculum examination:
done only if indicated: if vaginal discharge, do high vaginal swab(HVS).
if cervical smear not done, or was abnormal.
Ultrasound:
Confirm gestation by measuring crown rump length. Dx. multiple pregnancy, chorionicity.
Fetal abnormalities as anencephaly (structural abnormality), fetal nuchal translucency in fetal chromosomal abnormality.


MID TRIMESTER VISIT (20-24 WEEKS):
Examination, general examination, gestation, fetal growth
Blood tests:
Hb , antibodies, repeat blood sugar in screening for D.M
Urine test
Ultrasound: gestation, placenta, amniotic fluid, fetal abnormalities, multiple gestation.
In high risk patients we do Doppler ultrasound of the uterine arteries to identify risk of pre-eclampsia and intrauterine growth restriction
We may need invasive methods as amniocentesis, cordocentesis.

ANTENATAL VISIT IN SECOND HALF OF PREGNANCY
Assess maternal health
Fetal growth and wellbeing
Dealing with any complications as hypertension, antepartum haemorrhage.
Women education
Plans for birth
Postpregnancy contraception
Breast feeding
Labor pain

36-38 WEEKS VISIT

It is to anticipate any problems regarding delivery, fetal or maternal as
hypertension, D.M, fetal distress, antepartum haemorrhage and
fetal malpresentation or malposition because these may also indicate a high likelihood of operative delivery.
Adequacy of the pelvis
Fetal well being
Time and place of delivery
Contraception

POST DATE VISIT (41-42 weeks):
Accurate dating
Time of delivery, the need for induction of labor which is usually performed by the 42nd week.
There are two main methods of induction of labor;
Amniotomy or surgical induction.
Medical methods using prostaglandin or oxytocin.


In each visit:
HISTORY
Age, diet, occupation, smoking, an accurate menstrual history, gestational age calculated according to Naegele`s rule (280 days from LMP, crown rump length, biparietal diameter, femur length, and fetal abdominal circumference).
History of contraception, menstrual irregularity
Obstetrical history, parity and gravida, no. of abortions, preterm labor, perinatal death, fetal malformation, antepartum haemorrhage, mode of delivery, third stage complications as postpartum haemorrhage, puerperium.
Gynaecological history as pelvic mass, infertility, previous pelvic surgery, pastmedical history, as hypertension, D.M, heart disease, past surgical history.
Physical examination:
Height, weight (complications occur with wt. of ˂ 45kg and wt.˃ 100kg)
General examination and vital signs, pallor, oedema, breast examination.
Respiratory and cardiovascular examination
Abdominal examination, fundal height, lie, presentation, engagement, fetal heart auscultation.
-Vaginal examination late in pregnancy often provides valuable information:
Confirmation of the presenting part.
Station of the presenting part.
Clinical estimation of pelvic capacity and its general configuration.
Consistency, effacement and dilatation of the cervix.
Investigations: Urine and Blood
Screening:
It allows us to place women into low or high risk groups
Biochemical screening tests:
These include serum oestriol, alpha fetoprotein, hCG, inhibin. The only way to diagnose a chromosomal anomaly is to perform an invasive test, e.g. amniocentesis, chorion villus sampling, or cordocentesis.
Ultrasound as screening and diagnosing, for accurate dating, the diagnosis of multiple gestation and chorionicity, in the diagnosis of structural and chromosomal abnormalities and for the identification of pregnancies at high risk of pre-eclampsia, intrauterine growth restriction and placenta praevia.
U/S scanning will also be performed when there are clinical indications, such as antepartum haemorrhage, suspected PPROM, low symphysis-fundal height, reduced fetal movements or suspected malpresentation.
Doppler ultrasound may be needed.


Diet:
There is no need for a large increase in calorie value of the diet; 2400 calories is recommended, protein should be increased, carbohydrates can be reduced slightly to compensate for the increased calorie value of the protein.
The amount of calcium required daily by an adult is 0.5g; during pregnancy the amount is increased to 1.5g.
If calcium intake is judged to be deficient, a half- litre of milk, providing 500-600mg, should be taken daily.
Vitamins and iron supplementation:
The daily absorption of iron from an ordinary diet is about 1.2mg, while the requirement during pregnancy average 3.5mg. An iron supplementation is therefore often given. The preparation commonly used is ferrous sulphate 200mg three times daily, 300mg of ferrous gluconate, or 100mg of ferrous fumarate.
During pregnancy megaloblastic anaemia from deficiency of folic acid may occur,
A daily dose of 0.5mg of folic acid is required. Higher therapeutic doses (5mg/day) are usually reserved for prophylaxis against neural tube defect.
Routine multivitamin supplementation is not recommended unless the maternal diet is questionable or if she is at nutritional risk e.g. multiple gestation, complete vegetarians, and epileptics.
Exercise:
Exercise is beneficial during pregnancy because it helps to maintain a feeling of wellbeing. Although violent exercise should be avoided during pregnancy, the woman should be encouraged to continue all ordinary activities.
Preparation for lactation:
The best preparation for lactation is to ensure that the expectant mother is aware of the normal course of events following delivery and is mentally prepared for breast- feeding.
Attention is given during antenatal examination to the nipples. A poorly developed, retracted or inverted nipple cannot be drawn into the infant’s mouth, and may be traumatized because the baby cannot fix onto the nipple properly. If the nipples are retracted some advocate the mother to wear glass or plastic nipple shells during the day, and at night during the latter part of pregnancy.
There should be no attempt to harden the nipples with spirit only ordinary washing is necessary. Dry skin on the nipples may be treated with an occasional application of lanolin. The breasts should be supported by a well fitting brassiere, which does not press upon the nipples.

MAJOR SYMPTOMS REQUIRING URGENT INVESTIGATION:

-vaginal bleeding
-abdominal pain, uterine contractions
-premature rupture of membranes
-headache, unwell
-Cessation of fetal movement
-collapse, including convulsions
-acute leg pain and swelling


SPECIAL PROBLEMS:
-Problems among teenagers, they are single unsupported, greater risk to have pre-eclampsia
-Drug abuse, other social problems
-Problems in ethnic minority groups, some diseases are specific to certain ethnic groups such as sickle cell disease in Afro-Caribbean population, thalassaemia in Mediterranean population, glycogen storage disorders in the Jewish population.