1. Antenatal Care

2. Objectives I want you to be able to: Understand the value of Antenatal care. Perform a booking visit. Know the booking investigations. Act on the results of the investigations. Pick up abnormalities during the ANC.

3. Amis of Pre-pregnancy Care To bring the woman to pregnancy in the best possible health. To provide the means of ensuring that preventable factors are attended to before pregnancy starts, e.g., Rubella To discuss relevant issues. To give advice about the effect of: Preexisting disease and its treatment on the pregnancy—Diabetes, Hypertension the effect of pregnancy on preexisting disease and its treatment To consider the likelihood and effects of any recurrence of events from previous pregnancies and deliveries.

4. Aims of Antenatal Care 1.Management of maternal symptomatic problems. 2.Management of fetal symptomatic problems. 3.Screening and prevention of fetal problems. 4.Preparation of the mother for childbirth. 5.Preparation of the couple for childbearing.

5. Booking appointment Ideally by 10 weeks of gestation Identify women who may need additional care and plan the pattern of care. Measure the weight (Wt) and height (Ht) Measure blood pressure (BP) and check urine for proteinuria. Determine risk for gestational Diabetes and Pre-eclampsia

6. Booking Visit  History  Age  Parity  Menstrual history  Medical history  Surgical history  Socio-background  Obstetric history

7. Booking Visit  Examination  Face; complexion, eyes, teeth  Thyroid gland  Chest, lungs, Heart and breasts  Abdomen, changes of pregnancy, any scars Uterine size Fetal heart  Pelvic ???/ vagina

8. Booking Investigation Offer blood tests: Blood group and Rhesus status Screen for anaemia and haemoglobinopathies Hepatitis B Virus Rubella susceptibility Syphilis Toxoplasmosis Mid stream urine Offer early ultrasound, for gestational age, structural anomalies Offer screening for Down syndrome???

9. Supportive Information Give information supported by written information. Give an opportunity to discuss issues and ask questions. Be alert to any factors, social that may affect the health of both mother and fetus/baby. Offer ante-natal classes

10. Specific Information How the baby develops during pregnancy Nutrition and diet, including Iron supplement. The pregnancy care pattern Planning the place of birth breastfeeding

12. Ultrasound Scan (USS)  USS to determine gestational age using: Gestational sac Crown-rump measurement, 10-13 weeks Bipareital diameter (BPD) 14 18 weeks Fetal Biometry: BPD, Head Circumference (HC), Femur length (FL), Abdominal Circumference (AC) 18-24 weeks  USS to determine fetal growth: using fetal biometry variables  USS to determine fetal wellbeing Using:

13. USS to determine anomalies 10-12 weeks 20 weeks

14. Down’s syndrome screening Combined test, 11-14 weeks of gestation Serum screening (Triple or quadruple test) 15-20 weeks.

15. Main purpose of visits History and examination, clarification of uncertain gestation, identification of risk factors for the pregnancy. Booking blood tests

16. Subsequent Visits 14-16 weeks Review history, discuss and record screening tests, Measure BP and test urine, Check Hb level if < 11gm/dl consider Iron supplement. Examine the fundal height and listen to the fetal heart.

20. 18-20 weeks Measure BP and test urine, Examine the fundal height and listen to the fetal heart. Discuss the structural anomaly scan If placenta extends across the internal cervical os, offer another scan at ??????

21. 24 weeks Measure BP and test urine for????? Measure the plot symphysis-fundal height for nulliparous

22. 28 weeks Measure BP and test urine Offer another screening for anaemia and atypical red-cell alloantibodies Investigate a Hb <10gm/dl Offer anti-D prohylaxis to a women who are Rhesus D-negative Offer screening for gestational Diabetes Measure symphysis fundal height

23. 32 weeks of gestation Check the dates from LMP. Review, discuss and record the results undertaken at 28 weeks. Measure BP and test urine Measure S-F height

25. 34-36 weeks Check the dates from LMP. Review, discuss and raised issue. Measure BP and test urine Measure S-F height Offer a second does of anti-D prophylaxis Arrange an USS if low-lying placenta at 20 weeks Give specific information on preparation for labour

26. 36-37 weeks Check the dates from LMP. Review, discuss and record the results undertaken at 28 weeks. Measure BP and test urine Measure S-F height Check the presentation, if breech offer external cephalic version(ECV) Give specific information on preparation for labour Information on breastfeeding

27. 38 weeks Check the dates from LMP. Measure BP and test urine Measure S-F height Check the presentation, if breech offer external cephalic version (ECV) Give specific information on preparation for labour Information on breastfeeding

28. 40 weeks Check the dates from LMP. Measure BP and test urine Measure S-F height Check the presentation, if breech offer external cephalic version(ECV), can be difficult Give specific information on preparation for labour Information on breastfeeding

29. 41 weeks Check the dates from LMP. Measure BP and test urine Measure S-F height Give specific information on preparation for labour Information on breastfeeding Offer membrane sweep Offer induction of laour

30. Clinical assessment of bony pelvis It is not important. However if done should include checking the: Anteroposterior diameter, from the symphysis pubis to the sacral promontory. Curve of the sacrum. Promimance of the ischial spines. The angle of the greater sciatic notch Subpubic angle

31. Further Reading www.nice.org.uk