1. Antenatal Care Dr. NUSRAT NOOR Obstetrics/Gynecology

2. Background – detect potential complications of pregnancy and delivery – promote good nutrition, hygiene and rest – provide family planning information – management of STIs – tetanus immunization – HIV counseling and ART prophylaxis – malaria prophylaxis Antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and well-being and that of their infants, for example:

3. Aims Of Antenatal Care To prevent, detect and manage those factors that adversely affect the health of the baby To prevent, detect and manage those factors that adversely affect the health of the baby To provide advice, reassurance, education and support for the woman and her family To provide advice, reassurance, education and support for the woman and her family To deal with the ‘minor ailments’ of pregnancy To deal with the ‘minor ailments’ of pregnancy To provide general health screening To provide general health screening

4. Classification Of Antenatal Care Shared Care Shared Care 1. Hospital Maternity Team 2. General Practitioner (GP) 3. Community Midwives

5. Community-Base Care

6. Hospital-Based Care

7. Advice, Reassurance & Education  Reassurance & explanation on pregnancy symptoms: 1. Nausea 2. Heartburn 3. Constipation 4. Shortness Of Breath 5. Dizziness 6. Swelling 7. Back-ache 8. Abdominal Discomfort 9. Headaches

8.  Information regarding: 1. Smoking 2. Alcohol Consumption 3. Drugs (Both LEGAL and ILLEGAL)

10. 10 2 nd trimester: - (BPD, HC, AC, FL ± 10 days). 2 nd trimester: - (BPD, HC, AC, FL ± 10 days). 3 rd trimester: - Much less accurate. 3 rd trimester: - Much less accurate. BPD AC FL

11. Confirmation of the pregnancy 1. The symptom of the pregnancy ― Breast tenderness ― Nausea ― Amenorrhea ― Urinary Frequency 2. Positive urinary or serum pregnancy test are usually sufficient confirmation of a pregnancy. 3. Dating Pregnancy, confirms the pregnancy and accurately dates it.

12. Dating Pregnancy A. Menstrual EDD B. Dating by ultrasound  Benefits of a dating scan: 1. Accurate dating women with irregular menstrual cycles or poor recollection of LMP. 2. Reduced incidence in induction of labor for ‘prolonged pregnancy’ 3. Maximizing the potential for serum screening to detect fetal abnormalities 4. Early detection of multiple pregnancies 5. Detection of otherwise asymptomatic failed intrauterine pregnancy

13. Booking History 1. Past Medial History 2. Past Obstetric History 3. Previous Gynaecological History 4. Family History 5. Social History

14. Booking Examination  Full Physical Examination:  Cardiovascular  Respiratory Systems  Abdominal  Pelvic Examination  Breast Examination

15.  Examination for most healthy women : 1. Accurate measurement of blood pressure 2. Abdominal examination to record the size of the uterus 3. Recognition of any abdominal scars indicative of previous surgery

16. 4. Measurement of height and weight for calculation of the BMI. Women with a low BMI are at greater risk of fetal growth restriction and obese women are at greater risk of fetal growth restriction and obese women are at significantly greater risk of most obstetric complications, including gestitational diabetes, pre-eclampsia, need for emergency caesarean section and anaesthetic difficulties.

17. 5. Urine examaniation: asymptomatic bacteriuria is more likely to ascend and cause pyelonephritis in pregnancy. This causes significant maternal morbidity, but also predisposes to pregnancy loss and preterm labour. All women at booking should have a midstream urine sent for culture or be tested with a dipstick which recognizes nitrates, the presence of which sensitivity predicts the presence of significant bacteria.

18. Booking Investigation 1. Full Blood Count 2. Blood Group & Red Cell Antibodies ― Women found to be rhesus negative will be offered prophylactic anti-D administration at 28 and 34 weeks’ gestation to prevent rhesus iso- immunization and future HDN. ― Other possible iso-immunization events, such as threatened miscarriage after 12 weeks’ gestation, antepartum haemorrhage and delivery of the baby, may require additional anti-D prophylaxis in rhesus-negative women.

19. 3. Rubella ― Women who are found to be rubella non- immune should be strongly advised to avoid infectious contacts and should undergo rubella immunization after the current pregnancy to protect themselves for the future. 4. Hepatitis B ― Vertical transmission to the fetus may occur, mostly during labour, and horizontal transmission to staff or the newborn infant can follow contact with body fluids. ― A baby born to a hepatitis B carrier should be actively and passively immunized at delivery.

20. 5. Human Immunodeficiency Virus ― In known HIV-positive mothers, the use of antiretroviral agents, elective Caesarean section and avoidance of breastfeeding reduces vertical transmission rates from approximately 30% to less than 5%. ― The Department of Health guidelines now recommend that all pregnant women should be offered an HIV test at booking. 6. Syphilis

21. Haemoglobin Studies ― Tests for thalassaemia and sickle cell disease are usually reserved for women who have an ethnic background and those from the Middle East.

22. Gestational Diabetes 1. Random Blood Sugar 2. Fasting Blood Sugar 3. Formal Oral Glucose Tolerance

23. Background WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content of antenatal care visits, which should include: - blood pressure measurement - urine testing for bacteriuria & proteinuria - blood testing to detect syphilis & severe anemia - weight/height measurement (optional)

24. International Goals & Targets Special emphasis must be placed on prenatal and postnatal care and care for newborns, particularly for those living in areas without access to services

25. Antenatal Care (ROSA)

26. Pattern Of Follow Up Visits Pattern Of Follow Up Visits  4 weekly appointments from 20 weeks until 32 weeks  Followed by fortnightly visits 32 weeks to 36 weeks and weekly visits.  The minimum number of ‘visits’ recommended by the Royal College of Obstetricians and Gynaecologists is 5, occurring at 12, 20, 28-32, 36 and 40-41 weeks.

27. Content Of Follow Up Visits Content Of Follow Up Visits General questions regarding maternal well- being. General questions regarding maternal well- being. Enquiry regarding fetal movements (24 weeks). Enquiry regarding fetal movements (24 weeks). Measurement of blood pressure (a screen for pregnancy-related hypertensive disorders). Measurement of blood pressure (a screen for pregnancy-related hypertensive disorders). Urinalysis, particularly for protein, blood and glucose: this is used to help detect infection, pre-eclampsia and gestational diabetes. Urinalysis, particularly for protein, blood and glucose: this is used to help detect infection, pre-eclampsia and gestational diabetes.

28. Examination for oedema: Examination for oedema: Oedema is common in pregnancy and is mostly an insensitive marker of pre- eclempsia. Oedema of the hands and face is somewhat more important as a warning feature of pre-eclampsia. Abdominal palpation for fundal height: Abdominal palpation for fundal height: If repeated symphysis–fundal height measurement are made throughout a pregnancy, the detection of fetal growth problems and abnormalities of liquor volume increased.

29. Auscultation of the fetal heart: Auscultation of the fetal heart: There is no evidence that this practice is of any benefit in a woman confident in the movements of her baby; however, it provides considerable reassurance and will occasionally detect an otherwise unrecognized intrauterine fetal death. A full blood count and red cell antibody screen is repeated at 28 and 36 weeks. A full blood count and red cell antibody screen is repeated at 28 and 36 weeks. Depending on the screening policy of the particular unit, women at 28 weeks may be tested for gestational diabetes. Depending on the screening policy of the particular unit, women at 28 weeks may be tested for gestational diabetes.

30. From 36 weeks, the lie of the fetus (longitudinal, transverse or oblique), its presentation (cephalic or breech) and the degree of engagement of the presenting part should be assessed and recorded. From 36 weeks, the lie of the fetus (longitudinal, transverse or oblique), its presentation (cephalic or breech) and the degree of engagement of the presenting part should be assessed and recorded. It is often at this appointment that a decision is made regarding the mode of delivery (i.e. vaginal delivery or planned Caeserean section).

31. At 41 weeks’ gestation, a discussion regarding the merits of induction of labour for prolonged pregnancy should occur. At 41 weeks’ gestation, a discussion regarding the merits of induction of labour for prolonged pregnancy should occur. An association between prolonged pregnancy and increased perinatal morbidity and mortality means that women are usually advised that delivery of the baby should occur by 42 completed weeks’ gestation. This will usually mean organizing a date for induction of labour at approximately 12 days past the EDD.

32. Antenatal complications Antenatal complications dealt with in customized antenatal clinics

33.  Endocrine (diabetes, thyroid, prolactin and other endocrinopathies)  Miscellaneous medical disorders (e.g. secondary hypertension, autoimmune disease)  Haematology (thrombophilias, bleeding disorder)  Substance Misuse  Preterm labour  Multiple gestation  Teenage pregnancy

34. 34 Everyday Pregnancy Issues! Everyday Pregnancy Issues!

35. 35 Supplements: “Should I be taking anything?” When to start and stop! When to start and stop! Trace elements: Trace elements: Folate, calcium, Folate, calcium, Iron (+ vit.C), multivitamins. Iron (+ vit.C), multivitamins. Dietary supplements: Dietary supplements: Protein drinks. Protein drinks.

36. 36 Listeria Avoid chilled, ready -to-eat foods: Avoid chilled, ready -to-eat foods: Soft cheeses. Soft cheeses. Takeaway chicken sandwiches. Takeaway chicken sandwiches. Cold meats. Cold meats. Pre-prepared or stored salads. Pre-prepared or stored salads. Raw seafood. Raw seafood. Smoked salmon & smoked oysters (can OK). Smoked salmon & smoked oysters (can OK).

37. 37 EXERCISE Reduced weight gain. Reduced weight gain. More rapid weight loss after pregnancy. More rapid weight loss after pregnancy. Improved mood. Improved mood. Improved sleep patterns. Improved sleep patterns.

38. 38 Some studies have shown: Faster labour. Faster labour. Less need for induction. Less need for induction. Less likely to need epidural. Less likely to need epidural. Fewer operative births. Fewer operative births. Exercise does NOT increase risk of miscarriage. Exercise does NOT increase risk of miscarriage.

39. 39 Exercise commonsense: Take frequent breaks. Take frequent breaks. Avoid exercise in extremely hot weather. Avoid exercise in extremely hot weather. Avoid unstable ground (joints more lax). Avoid unstable ground (joints more lax). Avoid contact sports. Avoid contact sports. Avoid lifting weights over head. Avoid lifting weights over head. And weights that strain lower back muscles. And weights that strain lower back muscles.

40. 40 Air Travel Travel must be completed by 36th week. Travel must be completed by 36th week. Medical clearance needed for twins & complicated pregnancy. Medical clearance needed for twins & complicated pregnancy.

41. 41 Preventing DVT Support stockings. Support stockings. Hydration. Hydration. Ankle rolls, walks around plane. Ankle rolls, walks around plane. Baby aspirin. Baby aspirin.

42. 42 Stretch marks Related to type of collagen ie genetic. Related to type of collagen ie genetic. May have link with pelvic floor & perineal “stretchiness” May have link with pelvic floor & perineal “stretchiness” Goanna oil, emu oil, olive oil,vitamin E and other expensive topicals….. Goanna oil, emu oil, olive oil,vitamin E and other expensive topicals…..

43. 43 Fetal movements - what is normal?

44. 44 Vaginal Discharge Normally increases with gestation. Normally increases with gestation. Exclude rupture of membranes. Exclude rupture of membranes. Canesten pessaries OK for thrush. Canesten pessaries OK for thrush.

45. 45 “Uncomfortables” Can’t sleep! Can’t sleep! Swollen feet! Swollen feet! Backache! Backache! “sick of being pregnant”! “sick of being pregnant”!

46. 46 Shoes won’t fit, rings too tight... 85% of pregnancies have oedema. 85% of pregnancies have oedema. Rest and elevate! Rest and elevate! Carpal tunnel. Carpal tunnel.

47. 47 My back hurts……... Posture: Posture: Don’t slouch!, do not bend from waist. Don’t slouch!, do not bend from waist. Choose chair with back support. Choose chair with back support. Bra with support. Bra with support. Hot pack & panadol. Hot pack & panadol. Elastic brace supports. Elastic brace supports. Physiotherapy review. Physiotherapy review.

48. 48 Is my baby too big?! Fundal height = gestation +/- 2 cm. Fundal height = gestation +/- 2 cm. Engagement of fetal head. Engagement of fetal head. Liquor vs EFW. Liquor vs EFW. Assessing fetal size at term. Assessing fetal size at term.

49. 49 I AM SICK OF BEING PREGNANT!!!!! Check CTG & AFI when 7 days post EDD. Check CTG & AFI when 7 days post EDD. Post dates IOL= 10 days after EDD. Post dates IOL= 10 days after EDD. “Natural IOL” - does it work? “Natural IOL” - does it work? Curry, chilli, castor oil, etc.. Curry, chilli, castor oil, etc.. Warm bath! Warm bath! Cervical sweep! Cervical sweep!

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52. 52 Thank you Thank you