The Principles Of The Principles Of Antenatal CareAntenatal Care

J. RomainJ. Romain

DefinitionDefinition

• ‘ a planned program of observation, education, and medical management of pregnant women directed toward making pregnancy and delivery a safe and satisfying experience.’ (American college of O&G)

PrinciplesPrinciples

• To predict problems on the basis of the medical, social and obstetric history and physical examination.

• To prevent or reduce the severity of problems by prophylactic measures

• To detect and treat conditions which have harmful effects on the mother or foetus.

• To provide education, information and reassurance for mother and partner.

Current ApproachCurrent Approach

• Prepregnancy counselling

• Booking visit

• Routine antenatal visits

• Antenatal education classes

• Inpatient care if required

Prepregnancy CounsellingPrepregnancy Counselling

• General principles

Avoid smoking, ETOH and drugs. Exercise is okay

Folic acid supplements 6 wks prior to conception and until 14 wks.

Prepregnancy Counselling 2Prepregnancy Counselling 2

• Conditions requiring referral to ObstetricianMaternal- Diabetes and other endocrine disorders

HTN Infections; herpes, HIVGenetic disease- age, FHDrug exposureabnormal nutrition-obese/skinnychronic medical problemsprevious adverse obstetric history

(preg loss, preterm del, IUGR, congenital defect

General Pregnancy AdviceGeneral Pregnancy Advice

• Diet- sensible and may need iron

• Exercise- can continue but not vigorous!

• Coitus- no evidence its harmful

• Employment- tailored to individual

• Clothing- supportive and comfy

• Advice on benefits of breastfeeding

• Antenatal Classes

Booking Visit- historyBooking Visit- history

• Ideally at 10-12 wks

IncludesIdentification details +/- shared GP careSH- occ, ?married, social situation, DHMenstrual/contraception- LMP, periods of

infertility, exclude ectopic Obs Hx- all prev pregnancies and any

complications

Booking Visit- historyBooking Visit- history

Maternal Conditions

- Diabetes - Renal disease

- Epilepsy - Endocrine

- Thromboembolic - STD’s

- Anaemia - Rubella

- Cardiorespiratory - psychiatric hx

- HTN - smear results

Genetic RiskGenetic Risk

• Maternal age > 35yrs

• Afro-Caribbean- sickle cell

• Mediterranean or Asian- thalassaemia

• Previous child with abnormality

• Inherited diseases- haemophilia

Booking Scan- ExaminationBooking Scan- Examination

• Weight, height• BP• Urine dip- protein and glucose• Full CVS and resp exam• Breast check- inverted nipples• Abdomen-pelvic mass after 12 wks

-fundus at umbilicus 20-24 wks -xiphisternum at 36-38 wks

(although with an USS abdo exam not as useful)

Booking- bloodsBooking- bloods

• FBC

• Blood group and antibody screen

• Hep B, syphilis, rubella, HIV serology

• Triple test at some centres

• For at risk; sickle test, Hb electrophoresis

Place of DeliveryPlace of Delivery

• Only low risk women suit home delivery (1% of all deliveries)

- healthy aged 19-34yrs

- para 1 or 2

- no major contraindications such as; prev complicated obs/med hx, major gynae hx, <5ft, High BMI, abnormality in current preg or postmaturity, no telephone at home.

Screening TestsScreening Tests

10-12 weeks booking scan

Confirm IU preg, foetal HR11-13 wks nuchal translucency

Together with age, estimates likelihood of Downs (normally 1/500)

14-20 wks serum screening for Downs (triple test not used at PRH; CVS or amniocentesis instead)

Screening TestsScreening Tests

18-20 wks, anomaly scan

Accurate assessment of gestation

Multiple pregnancy detection

Placental site

Detection of congenital abnormalities

Can see all 4 chambers of heart

Subsequent VisitsSubsequent Visits

• Timing variable but traditionally - Every 4 wks until 28wks- 2 wks until 36wks- Weekly thereafter• BP and urine checked at each visit• Abdo- presentation assessed from 32wks

after 36wks breech needs managing

fetal head engages at 36-38wks in primip

Subsequent VisitsSubsequent Visits

• Bloods

- Rhesus neg women have titres measured at 30 and 36wks. Anti-D given at 28 and 34 wks?

- If anaemic can have combined iron/folate preps

Assessment of fetal GrowthAssessment of fetal Growth

50% IUGR remain undetectedMeans of monitoring; Clinical assessment Fetal movements Ultrasound Assessment, used in series Biophysical profileLimb and body movements, breathing, tone,

amniotic fluid vol, HR variability Fetoplacental Blood Flow Cordocentesis, for blood transfusions too

End of Antenatal CareEnd of Antenatal Care

• If woman has EDD and passes it she is sometimes surprised.

• Need to explain that it is the probable expected date and not actual

• Still normal if within 2 weeks either side

• If longer, consider use of prostaglandins if cervix favourable.

• Ensure follow up if needed by obstetrician

THE END!