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Antenatal care. Pre conception counselling. Smoking Alcohol Drugs Diet Exercise Folic acid. Pre conception counseling. Family history Personal history Past obstetric history Folic acid Rubella status. First visit. LMP EDD POH MH PMH Drugs Allergies. First visit. Smoking

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pre conception counselling
Pre conception counselling
  • Smoking
  • Alcohol
  • Drugs
  • Diet
  • Exercise
  • Folic acid
pre conception counseling
Pre conception counseling
  • Family history
  • Personal history
  • Past obstetric history
  • Folic acid
  • Rubella status
first visit
First visit
  • LMP EDD
  • POH
  • MH
  • PMH
  • Drugs
  • Allergies
first visit1
First visit
  • Smoking
  • Alcohol
  • FH
  • Advise
  • Exemption card
  • Referral
low risk pregnancies
Low risk pregnancies
  • 12-14/52 hosp visit
    • Routine blood tests
      • Blood group + rhesus factor
      • Fbc + haemoglobinopathies if indicated
      • Randon blood sugar
      • Treponemal antibody
      • Hep b
      • Hiv
      • pappa
low risk pregnancies1
Low risk pregnancies
  • Hosp visit 12-14/52
  • History
  • Nuchal transluceny scan
low risk pregnancy
Low risk pregnancy
  • 15 weeks
    • Serum AFP and downs screening
    • If booking scan not done before 14 weeks
low risk pregnancy1
Low risk pregnancy
  • 23 weeks – anomally scan
  • 26 weeks – midwife/gp
  • 28 weeks – fbc + antibodies
  • 30 weeks – midwife/gp
  • 34/36/38/40 weeks – midwife/gp
  • 41 weeks - hosp
exercise
Exercise
  • Non – contact sport only after 16/52
  • Intensity decreased by 25%
  • HR under 140/min
  • Core temp < 38
  • Strenuous exercise limited to 15-20 mins
antenatal visits
Antenatal visits
  • Weight gain 12-15kg in total
  • BP dias. >90 or increase > 20 from first visit is significant
  • Urinalysis watch for protein glucose uti
  • Fetal movements
  • Uterine size
  • Fetal lie presentation
common discomforts
Common discomforts
  • Pelvic pains – ligamental stretch
  • Urinary frequency - ? Uti
  • Ankle swelling – ivc compression
  • Varicosities – support stockings
  • Heartburn – posture antacids
  • Constipation – fluids, fibre, fybogel
common discomforts1
Common discomforts
  • Low back pain – posture and relaxin
  • Dental decay – see dentist
  • Skin changes – chloasma
  • Itch – iron def, cholestasis antihistamines
  • Stretach marks - moisturisers
first trimester
First trimester
  • Ectopic preg
    • Sharp pain
    • Irregular vaginal bleeding
    • Abdo tenderness
    • Dizziness or fainting
ectopic pregnancy
Ectopic pregnancy
  • Diagnosis
    • Pos preg test
    • Serial hcg levels they increase more slowly
    • Progesterone level lower than normal
    • Ultra sound scan vaginally/abdominally
ectopic pregnancy risk factors
Ectopic pregnancy risk factors
  • PID
  • Previous tubal preg or tubal surgery
  • Endometriosis
  • IUD
  • Multiple induced abortions
  • Drugs that stimulate ovulation
ectopic pregnancy treatment
Ectopic pregnancy treatment
  • Tube not ruptured
    • Methotrexate
    • Salpinostomy flushng the tube out
    • Laparoscopic removal
ectopic pregnancy treatment1
Ectopic pregnancy treatment
  • Tube ruptured
    • Laparoscopic removal of embryo and tube
miscarriage
Miscarriage
  • Symptoms
    • Pv bleeding
    • Colicky pain
    • Refer to EPAU
hyperemesis
hyperemesis
  • 1 in 300 preg
  • Weeks 8-20
  • Cause unknown – high oestrogen & hcg
  • More commom multiple preg obesity first babies
treatment
Treatment
  • Exclude other causes
  • Drink small amounts frequently
  • Diet high in cho and proteins
  • Admit for iv fluids if severe, dehydrated or electrolyte imbalance
  • Drugs -
anaemia
Anaemia
  • Symptoms
    • Fatigue weakness
    • Pallor
    • Dizziness or fainting
    • SOB
    • palpitations
anaemia1
Anaemia
  • Treatment
    • Diet
    • Pregaday
    • Does not alter outcome in most cases
infection in pregnancy
Infection in pregnancy
  • Chicken pox – only 2% of infections age > 20yrs
    • 3% risk of fetal damage in first 20/52
    • If mum’s rash develops 1/52 before delivery or to 4/52 after baby can get sever infection needs protection
    • No risk between 20/52 and term
    • If no history of cp check varicella antibodies
    • If non immune needs VZ Ig no later than 10 days from exposure
infections in pregmnancy
Infections in pregmnancy
  • Rubella – 2-10/52 90% chance of featal damage
  • Toxoplasma gondii 89% adults not immune
  • If fetus infected 10% chance of fetal damage
  • Avoid kittens particularly litter trays
  • Eat well cooked meat
  • Wash vegetables
  • Listeria – soft cheeses, pate. Cookchill foods
pre eclampsia
Pre eclampsia
  • Raised BP
  • Proteinura
  • XS swelling
pre eclampsia1
Pre eclampsia
  • 3-4% pregnancies
  • !% very severe
  • 50,000 deaths world wide
pre eclampsia2
Pre eclampsia
  • Risk factors
    • Young mothers teenagers
    • Older mothers > 35 yrs
    • Family history
    • First pregnancy
    • New father
    • Diabetes
    • hypertension
pre eclampsia3
Pre eclampsia
  • Serious adverse effects
    • Fits
    • Stroke
    • Pulmonary oedema
    • Kidney failure
    • Liver damage
    • D I C
pre eclampsia4
Pre eclampsia
  • Warning signs
    • Raised bp
    • Proteinuria
    • Xs swelling
    • Headcahe
    • Flashing lights
    • Vomiting
    • Upper abdo pain
pre eclampsia5
Pre eclampsia
  • Treatment
    • Lower bp
    • Magnesium sulphate
    • Deliver baby
    • Aspirin
    • Metabolic syndrome
gestational diabetes
Gestational diabetes
  • Plenty of insulin, but insulin malfunctioning
  • Macrosomia > 4500g
  • Problems with labour and delivery
  • Newborn has low blood sugar
  • Increased risk stillbirth
  • Proper management prevents increased risk ofcomplications
risk factors
Risk factors
  • Incidence 1%-3% pregnancies
  • Family history
  • Obesity
  • Maternal age > 30 yrs
  • Previous large baby
  • Prior icidence of gestational diabetes
  • Ethnic group – south asians, mexican american
treatment1
Treatment
  • Control blood sugar
  • Exercise
  • Diet
  • Blood glucose monitoring
  • A few will need insulin
intra uterine growth retardation
Intra uterine growth retardation
  • Birth weigth < 2500g
  • Causes
    • Smoking
    • Poor nutrition
    • Placental factors
    • Maternal ill health
risk factors1
Risk factors
  • Smoking
  • Drug and alcohol use
  • Severe malnutrition
  • Maternal high bp, or pre eclampsia
  • Infections – cmv, rubella, toxoplasma
  • Chronic maternal disease – diabetes, rheumatological
diagnosis
Diagnosis
  • Fundal height – 18-34/52 height = distance in cm
  • Ultra sound – ratio of head circumference to abdo
treatment2
Treatment
  • Stop smoking
  • Good nutrition
  • Bed rest on left side
  • Fetal movement chart
  • Serial ultrasound scans
  • Volume of amniotic fluid
hydatidiform mole
Hydatidiform mole
  • Incidence 1 in 2000 preg
  • Increased risk with age
  • Abnormalities in sperm chromosome
  • Abnormalities of egg
hydatidiform mole1
Hydatidiform mole
  • Signs
    • Uterus larger than date
    • Vaginal bleeding
  • Diagnosis
    • Ultrasound
    • Hcg higher than normal
hydatidiform mole2
Hydatidiform mole
  • Treatment
    • Suction curettage
    • Monitor hcg for several months due to risk of choriocarcinoma
    • Postpone preg for a year
slide42
APH
  • Placenta abruptio
    • 1% of all deliveries
    • Vaginal bleeding in 3rd trimestre
    • Constant back or abdo pain
    • Contractions tenderness or rigidity of uterus
risk factors2
Risk factors
  • Smoking
  • Pergnancy induced hypertension
  • Alcohol or drug use
  • Increased maternal age >40 yrs
  • Premature rupture of membranes
  • Injury to mother
diagnosis1
Diagnosis
  • No clear test
  • May or may not show on ultrasound
  • Exclusion of other causes of bleeding – placenta praevia
treatment3
Treatment
  • Evaluate maternal well being
  • Monitor
  • Evaluate fetal well being
  • If severe bleeding or fetal distress cesarean
placenta previa
Placenta previa
  • 4-8% placentas low lying
  • Only 10% remain low
  • Marginal – placenta near edge of os
  • Partial – placenta covers cervical opening
  • Total – placent completely covers os
  • All need cesarean
placenta previa1
Placenta previa
  • Signs
    • Painless bright red vaginal bleeding
  • Risk factors
    • Smoking
    • First preg after lscs
    • Previous placenta previa
    • Advanced maternal age
placenta previa2
Placenta previa
  • Diagnosis
    • Ultrasound
  • Treatment
    • lscs
post term pregnancy
Post term pregnancy
  • > 42/52
  • Risks
    • Reduced amniotic fluid increased risk of cord compression
    • Meconium in liquor inhlaed by baby causing pneumonia
    • Too large baby > 4500g
management
Management
  • Monitor baby
    • Too large baby
    • Decreased amniotic fluid
    • Deliver if cervix ripe try oxytocinon
    • If cervix not ripe try prostaglandin gel
    • Otherwise lscs
pre term labour
Pre term labour
  • Labour before end of 36th week preg
  • Low birth weight < 2500g
  • 8-12% of all pregnancies
signs and symptoms
Signs and symptoms
  • Regular uterine contractions for more than 1 hr
  • Backache
  • Intestinal cramping with or without diarrhoea
  • Spotting or blood tinged discharge
  • Thin cervix, dilation beyond 1 cm, contractions
risk factors3
Risk factors
  • Smoking alcohol drugs
  • Previous pre term delivery
  • 3 or more 1st trimestre miscarriages
  • Cervical incompetence
  • Placenta previa
  • Serious maternal infection
  • Low maternal weight < 45 kg
postnatal care
Postnatal care
  • Maternal
  • Lochia xs bleeding = pph admit
  • Breasts – engorgement lasts 2-3 days mild temp fell fluey
  • Nipple pain- camomile creams daktarin if candidal
  • Mastitis – empty breast flucloxacillin
postnatal care1
Postnatal care
  • Blood pressure
  • Fundal height
  • Perineum
  • Symptoms of depression
  • Contraceptive advice
postnatal care2
Postnatal care
  • Fetal
    • Method of delivery
    • Length of gestation
    • Weight
    • Feeding
    • concerns
postnatal care3
Postnatal care
  • Fetal examination
    • Fontanelles
    • Eyes- cataract
    • Sclera – jaundice
    • Hs
    • Lungs
    • Abdo - masses
postnatal care4
Postnatal care
  • Fetal exam
    • Genitalia
    • Hips
    • Femoral pulses
    • Spine
    • Birth marks
6 week exam
6 week exam
  • Maternal
    • Feeding
    • Depression
    • Lochia
    • Contracption
    • Bp
    • Abdo exam
    • Smear if due
6 week exam1
6 week exam
  • Fetal
    • According to chs schedule