Traditional Antenatal Care Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Maternity & Women’s Hospital
SAFE MOTHERHOOD Postabortion Clean/safe Delivery Postpartum Care Antenatal Care Family Planning Essential Obstetric Care BASIC HEALTH SERVICES EQUITY EMOTIONAL AND PSYCHOLOGICAL SUPPORT The Pillars of Safe Motherhood
Objectives of ANC • Promote and maintain the physical, mental and social health of mother and baby by providing education on nutrition, personal hygiene and birthing process • Detect and manage complications during pregnancy, whether medical, surgical or obstetrical • Develop birth preparedness and complication readiness plan • Help prepare mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially
What is Effective ANC? • Care from a skilled attendant and continuity of care • Preparation for birth and potential complications • Promoting health and preventing disease • Tetanus toxoid, nutritional supplementation, tobacco and alcohol use, etc • Detection of existing diseases and treatment • HIV, syphilis, tuberculosis, other co-existing medical diseases (e.g., hypertension, diabetes) • Early detection and management of complications
What you should do… • Diagnose Pregnancy through an understanding of the presumptive, probable, and positive signs of pregnancy. • Given the date of the last menstrual period: calculate the EDC and the gestational age at any time. • Describe the interventions appropriate to the expected physiologic and psychologic changes of pregnancy. • Describe the care of the pregnant patient at the initial prenatal visit and follow up visits
Given the patient’s OB/GYN history, determine the gravidity and parity • Teach patients how to manage common pregnancy discomforts • Analyze risk factors of the pregnant patient • Consider developmental level and cultural background when planning pregnancy care and delivery.
Diagnosis of Pregnancy • Clinical Diagnosis • Symptoms of early Pregnancy • Signs • Investigations • Presumptive • Probable • Positive
Presumptive Signs of Pregnancy Symptoms • Cessation of menstruation / Amenorrhea • Nausea and vomiting – Changes in appetite • Fatigue • Urinary frequency • Breast enlargement and tenderness • Mood Changes • Quickening
- Vulva: Soft and violet (Jacque-Mier’ssign). - Vagina: Soft, warm, and dark blue or purplish red (Chadwick’s sign) Cervix: soft, and violet (Goodell’s sign). By 6-8 weeks the cervix softens and has the consistency of lips of the mouth while the non-pregnant cervix feels like the cartilage of the nose. - Uterine signs: The uterusisenlarged and soft. At 8 weeks size of an orange. At 12 weeksthe uterus is globular and about 8 cm in diameter (grape fruit size) with the fundus at the upper border of symphysis pubis Palmer’s sign: Intermittent uterine contractions felt during bimanual examination. Hegar’s sign: The body of the uterusisfeltelasticabove the compressible isthmus, while the cervixisfeltfirmbelow as if itisseparatefrom the uteruswhichmimics an enlargedadnexa. It is positive in pregnantwomenbeween 6-8 weeks. Signs
The Breast • Enlargement of the breasts with dilated veins over it • Pigmentation of the areola and nipples • Appearance of the secondary areola ( slightly elevated as a mound) • Prominent Montgomery tubercles • Colostrum secretion in third month
Urine Pregnancy Test Agglutination Inhibition ELISA ( sensitive to a 50 mIU/ ml level) Blood Pregnancy Test RIA ELISA Pregnancy Tests
False positive urinary pregnancy test • Proteinuria • Pelvic tuberculosis • Drugs stmulating LH release from pituitary as penicillin and phenothiazines • Immunologic diseases as systemic lupus erythematosisbecause Ig M interacts with test reagents • Perimenopausal women with high LH • Excessively alkaline urine • HCG producing tumors as choriocarcinoma • Hematuria as hemoglobin is a protein
Probable Signs of Pregnancy • Goodell’s sign (softening of the cervix) • Chadwick’s sign (bluish vaginal tissue) • Hegar’s sign (softening of the cervix) • Ballottement • Internal ballottement: It is present between 16th and 28th week. • External ballottement: It can be detected after the 24th week Positive Pregnancy Test
Sure signs of Pregnancy • Ultrasound Evidence • The concept of the discriminatory level • A TVS should detect an intra-uterine gestational sac if the beta subunit hCG level is 1500 mIU/L. • A transabdominal • Fetal heart • Identification of Fetal parts
Ultrasonography • The pregnancy sac can be detected at 4-5 weeks. • The gestational ring is detected universally at 6 weeks. • The embryonic echo can be seen at 7 weeks. • The fetal heart can be detected at 8 weeks. • Vaginal ultrasonography can detect a pregnancy sac of 2 mm at about 16 days gestation and fetal heart at 6 weeks. • Also, the fetal heart sounds can be heard after the 10th week by the doppler (Sonicaid).
Quickening • first time at which the mother percepts fetal movements. • It is not a sure sign but is useful for accurate dating of the pregnancy. • It is felt earlier in multipara (16-18 weeks) than in primigravida (18-20 weeks) due to previous experience. • Enlargement of the abdomen: • This occurs after the 12th week when the uterus becomes abdominal. • This is less pronounced in primigravida because in multipara the abdominal wall is more flaccid and the uterus sags forward and is more seen when she is standing.
Early Pregnancy Causes of amenorrhea Causes of symmetrical enlargement of the uterus myomas, hematometra, adenomyosis, extrauterine mass. Late Pregnancy Pelviabdominal swelling Pseudocyesis DD
The Initial “Booking” Prenatal Visit • Medical history • Menstrual history • Physical exam • Investigations • Diagnostic tests • Screening Tests • Assess risk factors and building up a strategy for the antenatal care • Health Education with exhaustive efforts and advices
Important Demographic Data • Age • Occupation • Education • Residence • Ethnicity • Race • Religion • Pets
Medical and Family History Includes client and her partner • Information to obtain • Prior or current health issues • Medications and allergies • Possible inherited diseases in the families • Significant health issues in family members • Use of tobacco, alcohol, street drugs
Menstrual History • What is the concept of ‘Reliable Dates’ ?
Expected Date of Delivery • Duration of pregnancy • 280 days or 40 weeks or 10 lunar months • Naegele’s rule – Add seven days to the first day of the LMP and subtract three months [or add 9 months] • The concept of reliable dates
Other indicators of gestational age • FHT with doppler at 10–12 weeks • Fetal movement felt at about 20 weeks • Fundal height correlation with gestational age • Ultrasound : Dating U/S is a first trimester US… or 2 mid-trimester, 2 weeks apart • Gestational sac • CRL • BPD
Measurement Symphyseal Fundal height • Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth • measurement should start at the variable point (F) and continue to the fixed point (S) • SF measurement should be recorded in a consistent manner (therefore in cms)
Between 20 and 36 weeks of pregnancy, the height of the fundus in centimeters • to the upper border of the symphysis pubis equals • the duration of pregnancy in weeks.
Causes of oversized uterus (larger than period of amenorrhea): Wrong dates. Polyhydramnios. Hydatidiform mole. Macrosomic fetus. Concealed accidental hemorrhage. Twins. Tumors as fibroids and ovarian cysts. Fetal malformations as hydrocephalus. Causes of undersized uterus (smaller than period of amenorrhea): Wrong dates Oligohydramnios Fetal death IUGR or Small fetus Pregnancy during period of amenorrhea as lactation or injectable contraception Malpresentations as transverse lie
Gravidity and Parity • Gravida–number of pregnancies • Para–number of births after 20 weeks • Five-digit system • G–total number of pregnancies • T–full-term pregnancies (37–40 weeks) • Preterm deliveries (20–36 weeks) • A–abortions and miscarriages (before 20weeks) • L–living children
Blood Work Blood type and Rh status Antibody screen (Coombs’ test) CBC Rubella titer HIV Hepatitis B Syphilis Sickle cell Glucose screen Triple screen Cystic fibrosis Varicella Laboratory Analysis and Testing • Other Testing • Ultrasound • Urinalysis • Pap smear • GC culture • Chlamydia culture • Group B streptococci
Routine BP measurement • HT is defined when systolic BP is 140mmHg +/or DBP is 90 mmHg or there is an incremental rise of 30 systolic or 15 diastolic. • Automated devices & ambulatory devices should not be used (Mercury devises seem best)
Fetal Presentation and Descent • Check presenting part beginning around 36 weeks • Descent of presenting part is important as term approaches
Auscultation of fetal heart • Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion) • Should be offered at each visit after about 20 weeks • NST and CST ? • Asking the mother about fetal Kicks. • Counsel her to count to 10 during the last 4 weeks of pregnancy.
Urinalysis by dipstick for proteinuria - evidence • high incidence of false +ve and - ve using dipsticks of 24 hr urine collection • unreliable in detecting highly variable elevations in protein in pre-eclampsia Gribble et al AJOG 1995; 173: 214-7
Initial recommended tests • FBS. • MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low) • Blood group/Ab screen • HIV (level 1 evidence) • Hep B • Syphilis (ideally prior 16 weeks) • Rubella Abs
Urine testing- either 2 step or MSU+dipstick • PAP if due • dating US
Retesting (32-34 Weeks) When? • Negative initial test, risk factors present • Obesity • >33 years of age • Positive 1 hour screen followed by a negative OGTT • 3+/4+ glucosuria
Screening for Asymptomatic Bacteruria • MSU sample • Colony count >105 /ml necessitates treatment according to Culture and sensitivity.
Hepatitis C screening • Should be offered to all at increased risk • history of injecting drugs • partner who injected drugs • tattoo or piercing • been in prison • blood t/f later positive for Hep C • long-term dialysis or organ transplant before 7/92
The patient lies supine and you stand at her side facing her head. You place your hands on the fundus to determine the presence or absence of a fetal pole (vertical versus transverse lie), and the nature of the pole (vertex or breech). The fetal breech is larger, less well defined, and less ballottable than the head Leopold’s Maneuvers
Still facing the maternal head, you then examine the lateral walls of the uterus to determine which side the fetal back and small parts occupy.
In cephalic presentations, a point of the fetal head may be noted as a protuberance that arrests the hand outlining the fetus. • As the hands are moved along the lateral walls of the fetus toward the pelvis, either the occiput or the chin will be encountered.
You now turn toward the patient’s feet and place your hands laterally above the symphysis and bring them toward the midline. • You are trying to determine the nature of the fetal pole (vertex or breech) and the degree of descent of the pole, indicating the station of the presenting part.
Nutrition • Avoidance of potential teratogens • What could be teratogenic in food ? • Folic acid supplementation • Prenatal vitamin and mineral supplements • Weight gain • Individualized according to pre-pregnancy weight • Weight assessed at every visit • Weight loss is never normal • Excessive weight gain requires evaluation
Option ITraditional Food Pyramid • 55% carbohydrate, • 25% protein, • 20% fat