Antenatal care dr rabi


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antenatal care

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Antenatal care dr rabi

  1. 1. Antenatal Care Dr. Rabi Narayan Satapathy Assistant Professor Dept. of Obst. & Gyn. S.C.B. Medical College,Cuttack. Mail; Mob; 9861281510/8270088880
  2. 2. Evolution of ANC
  3. 3. “ Hints to Mothers for the Management of Health during the Period of Pregnancy and in the Lying-in Room with an Exposure of Common Errors in Connection with these Subjects” Thomas Bull (1937)
  4. 4. ● 1901  Paper by Ballantyne entitled “A plea for a pro-maternity hospital” Led to establishment of the first antenatal bed at the Edinburgh Royal Maternity Hospital. ● 1915  First antenatal clinic at Edinburgh. ● 1950  2000 antenatal clinics in England & Wales
  5. 5. ● ANC as we know it today emerged in the 1960s. ● Sought to prevent or cure most of the hazards of pregnancy. ● Promised to make pregnancy and subsequent delivery as smooth as possible ● Development of new technologies aided this aim
  6. 6.  Early incorporation into India’s MCH services  ANC now became more streamlined  Benefits felt immediately in succeeding years  MMR  from 2000/100,000 live births in 1938 1000/100,000 live births in 1959
  7. 7.  Promote,protect & maintain the physical, mental and social well-being of both mother & child.  To detect high-risk cases  To foresee complications  To remove the anxiety & dread associated with delivery
  8. 8.  To educate mother regarding child care, nutrition, personal hygiene, environmental sanitation etc.  To sensitise the mother to the need for family planning.  To reduce MMR & IMR To maintain the “normal” status of a normal physiological event.
  9. 9. Components of ANC
  10. 10.  A set of professional check-ups  Tetanus & other immunizations  Iron & folic acid prophylaxis  Regular blood-pressure check-ups  Risk-approach  Advice regarding delivery methods, nutrition, personal hygiene etc.  Maintenance of records  Home visits.
  11. 11. Successes OF ANC Routine antenatal care is an example of preventive health care at its best Drastic reduction of MMR in the last five decades Considerable improvement in PNMR High cost-effectiveness
  12. 12. Successes of ANC…contd. 78%women covered by tetanus prophylaxis Introduction of screening & early detection of foetal abnormalities using biochemistry & ultrasound. ( detection of anomalies by USG AT 19 wks. Had 85% sensitivity & 99.9% sensitivity)
  13. 13. AT THE CROSS-ROADS  The MMR,though dipping in the past decades has not reached an ideal figure. It still stands at an alarming 407/100,000 live births. MMR in some countries : UK – 13 USA -17 Bangladesh – 380 Sri Lanka - 92
  14. 14. At the Cross - roads 40% maternal deaths due to haemorrhage, sepsis 12% maternal deaths due to eclampsia  20% due to indirect causes (notably anaemia) 29% 19% 16% 10% 9% 8% 9% Hemorrhage Anemia Sepsis Obstructed labour Abortion Toxemia Others
  15. 15. At the Cross-Roads  ANC reaches out to 20-70% of pregnant women,depending on area surveyed, (urban,semi-urban or rural)  About 80% of these have only one visit,3/4ths receive their first visit between 6th to 8th month of pregnancy  About 25% of women who receive ANC have a complication during labour and delivery
  16. 16. At the Cross-Roads  300 women die every day in India during childbirth or due to pregnancy related causes  MMR in developing countries remains 100 times more than in the developed countries
  17. 17. At the Cross- Roads  Majority of maternal deaths take place after delivery, most within 24 hrs. after delivery. Yet, only 17% of deliveries taking place outside of a health institution are followed up by PP check- ups; only 14%within the critical two-day period.
  18. 18. Limitations of current ANC Practices ● Low-Outreach – Inability to bring all pregnant women into its fold. Reasons :a)Not thinking check-ups were necessary (60%) b) Inability to meet costs (15%) c)Family or peer pressure (9%) d)Lack of knowledge about ANC e)Long distances to health centre f) Lack of transportation
  19. 19. LIMITATIONS … contd. ● Competency of health care provider ● Home deliveries unattended by trained health professional ● Disregard for basic hygienic environment ● No change in incidence of preterm labour,despite increased awareness of risk factors and sophisticated diagnostic procedures ● Limited usefulness of high-risk approach
  20. 20. Limitations…contd. ● 70% of adverse perinatal outcomes cannot be predicted by existing assessment methods ● Only 44% of IUGR correctly diagnosed ● 30% of women developing PET presented for the first time in labour ● Despite existing ANC services, emergency admissions far outweigh elective admissions
  21. 21. Limitations…contd. ● Though figures are hard to come by; for every maternal death, there are 10-15 women who survive only to suffer from the sequelae of pregnancy and neglected childbirth ●Onset of unpredictable complications even with full antenatal supervision eg. PROM, vag.bleeding, HTN, cord prolapse, shoulder dystocia etc.
  22. 22. A Way Forward Safe Motherhood Programme in 1992 RCH Programme in 1997.Provision of care for the pregnant woman became a major thrust .JSY in 2005
  23. 23. A Way Forward…contd. ■ In its Annual Report 2001-2002,the GOI Planning Commission notes that both the lack of universal screening for risk factors and the lack of appropriate referral are the major reasons that maternal and child mortality and morbidity have not declined in the past two decades.
  24. 24. Future Policy Goals of the National Population Policy 2000 ■ Reducing MMR to <100/100,000 live births ■ Achieving 80% deliveries within health institutions ■ Delivery of all births by trained personnel ■ Adressing the unmet needs for basic reproductive and child health services, supplies and infrastructure
  25. 25. A Way Forward ● Continuity of ANC by health care provider. The set of competencies necessary for adequate ANC is more important than the cadre of the health care provider ● Screening and detection of existing diseases (eg. HTN, TB, HIV, DIABETES )will have a direct impact on pregnancy and perinatal outcome
  26. 26. . Antenatal Visits  *once / month till 7 mths *twice / month in the 8th mth *weekly thereafter Revised visit schedule  *1st visit as soon as pre detected/20th wk *2nd visit at 32 wks *3rd visit at 36 wks
  27. 27. Aims 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.
  28. 28. 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.
  29. 29. 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
  30. 30. Booking Visit  History  Age  Parity  Menstrual history  Medical history  Surgical history  Socio-background  Obstetric history
  31. 31. 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
  32. 32. 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???
  33. 33. 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
  34. 34. Specific Information  How the baby develops during pregnancy  Nutrition and diet, including Iron supplement.  The pregnancy care pattern  Planning the place of birth  breastfeeding
  35. 35. 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:
  36. 36. USS to determine anomalies  10-12 weeks  20 weeks
  37. 37. Down’s syndrome screening  Combined test, 11-14 weeks of gestation  Serum screening (Triple or quadruple test) 15-20 weeks.
  38. 38. Main purpose of visits  History and examination, clarification of uncertain gestation, identification of risk factors for the pregnancy.  Booking blood tests
  39. 39. 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.
  40. 40. 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 ??????
  41. 41. 24 weeks  Measure BP and test urine for?????  Measure the plot symphysis-fundal height for nulliparous
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. . Prenatal Advice: ● Diet and Nutrition ● Personal hygiene ● Drugs ● Radiation risk ● Warning signs ● Child care
  51. 51. . Specific Health Protection :  Anaemia  Other nutritional deficiencies  Toxaemias of pregnancy  Tetanus immunization
  52. 52. A Way Forward ■ Modification of the “Risk- Approach”. Current literature strongly suggests that the focus of obstetric care should be shifted from predicting complications to identification of risk factors and detection of signs and symptoms of current problems
  53. 53. A Way Forward ■ Birth-preparedness or a Birth-action plan * Who attends,who accompanies * Transportation,decision-makers,finance * Complication preparedness * Potential blood donors The action plan to be made after discussion with the woman and her family members
  54. 54. A Way Forward…contd. ■ Easy access to Emergency Obstetric Care ■ To provide useful information to the pregnant woman and her family ■ Universal USG screening ■ ? Universal HIV screening ■ ? Genetic screening
  55. 55. Conclusion • The current day ANC, though serving an extremely useful purpose, has not met the expectations of the nation. • Since it is nearly impossible to predict which woman will develop a complication, it is important to work with all women to recognize complications and to establish a plan of action in case they arise. •This will ensure that they arrive earlier at points in the health care system where they can receive appropriate care. Only then can we reach much nearer to the goals we have set for ourselves.