The principles of antenatal care

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The principles of antenatal care

  1. 1. The Principles Of Antenatal Care J. Romain
  2. 2. Definition <ul><li>‘ a planned program of observation, education, and medical management of pregnant women directed toward making pregnancy and delivery a safe and satisfying experience.’ (American college of O&G) </li></ul>
  3. 3. Principles <ul><li>To predict problems on the basis of the medical, social and obstetric history and physical examination. </li></ul><ul><li>To prevent or reduce the severity of problems by prophylactic measures </li></ul><ul><li>To detect and treat conditions which have harmful effects on the mother or foetus. </li></ul><ul><li>To provide education, information and reassurance for mother and partner. </li></ul>
  4. 4. Current Approach <ul><li>Prepregnancy counselling </li></ul><ul><li>Booking visit </li></ul><ul><li>Routine antenatal visits </li></ul><ul><li>Antenatal education classes </li></ul><ul><li>Inpatient care if required </li></ul>
  5. 5. Prepregnancy Counselling <ul><li>General principles </li></ul><ul><li>Avoid smoking, ETOH and drugs. Exercise is okay </li></ul><ul><li>Folic acid supplements 6 wks prior to conception and until 14 wks. </li></ul>
  6. 6. Prepregnancy Counselling 2 <ul><li>Conditions requiring referral to Obstetrician </li></ul><ul><li>Maternal- Diabetes and other endocrine disorders </li></ul><ul><li>HTN </li></ul><ul><li>Infections; herpes, HIV </li></ul><ul><li>Genetic disease- age, FH </li></ul><ul><li>Drug exposure </li></ul><ul><li>abnormal nutrition-obese/skinny </li></ul><ul><li>chronic medical problems </li></ul><ul><li>previous adverse obstetric history (preg loss, preterm del, IUGR, congenital defect </li></ul>
  7. 7. General Pregnancy Advice <ul><li>Diet- sensible and may need iron </li></ul><ul><li>Exercise- can continue but not vigorous! </li></ul><ul><li>Coitus- no evidence its harmful </li></ul><ul><li>Employment- tailored to individual </li></ul><ul><li>Clothing- supportive and comfy </li></ul><ul><li>Advice on benefits of breastfeeding </li></ul><ul><li>Antenatal Classes </li></ul>
  8. 8. Booking Visit- history <ul><li>Ideally at 10-12 wks </li></ul><ul><li>Includes </li></ul><ul><li>Identification details +/- shared GP care </li></ul><ul><li>SH- occ, ?married, social situation, DH </li></ul><ul><li>Menstrual/contraception- LMP, periods of infertility, exclude ectopic </li></ul><ul><li>Obs Hx- all prev pregnancies and any complications </li></ul>
  9. 9. Booking Visit- history <ul><li>Maternal Conditions </li></ul><ul><li>Diabetes - Renal disease </li></ul><ul><li>Epilepsy - Endocrine </li></ul><ul><li>Thromboembolic - STD’s </li></ul><ul><li>Anaemia - Rubella </li></ul><ul><li>Cardiorespiratory - psychiatric hx </li></ul><ul><li>HTN - smear results </li></ul>
  10. 10. Genetic Risk <ul><li>Maternal age > 35yrs </li></ul><ul><li>Afro-Caribbean- sickle cell </li></ul><ul><li>Mediterranean or Asian- thalassaemia </li></ul><ul><li>Previous child with abnormality </li></ul><ul><li>Inherited diseases- haemophilia </li></ul>
  11. 11. Booking Scan- Examination <ul><li>Weight, height </li></ul><ul><li>BP </li></ul><ul><li>Urine dip- protein and glucose </li></ul><ul><li>Full CVS and resp exam </li></ul><ul><li>Breast check- inverted nipples </li></ul><ul><li>Abdomen-pelvic mass after 12 wks </li></ul><ul><li> -fundus at umbilicus 20-24 wks </li></ul><ul><li> -xiphisternum at 36-38 wks </li></ul><ul><li>(although with an USS abdo exam not as useful) </li></ul>
  12. 12. Booking- bloods <ul><li>FBC </li></ul><ul><li>Blood group and antibody screen </li></ul><ul><li>Hep B, syphilis, rubella, HIV serology </li></ul><ul><li>Triple test at some centres </li></ul><ul><li>For at risk; sickle test, Hb electrophoresis </li></ul>
  13. 13. Place of Delivery <ul><li>Only low risk women suit home delivery (1% of all deliveries) </li></ul><ul><li>- healthy aged 19-34yrs </li></ul><ul><li>- para 1 or 2 </li></ul><ul><li>- no major contraindications such as; prev complicated obs/med hx, major gynae hx, <5ft, High BMI, abnormality in current preg or postmaturity, no telephone at home. </li></ul>
  14. 14. Screening Tests <ul><li>10-12 weeks booking scan </li></ul><ul><li>Confirm IU preg, foetal HR </li></ul><ul><li>11-13 wks nuchal translucency </li></ul><ul><li>Together with age, estimates likelihood of Downs (normally 1/500) </li></ul><ul><li>14-20 wks serum screening for Downs (triple test not used at PRH; CVS or amniocentesis instead) </li></ul>
  15. 15. Screening Tests <ul><li>18-20 wks, anomaly scan </li></ul><ul><li>Accurate assessment of gestation </li></ul><ul><li>Multiple pregnancy detection </li></ul><ul><li>Placental site </li></ul><ul><li>Detection of congenital abnormalities </li></ul><ul><li>Can see all 4 chambers of heart </li></ul>
  16. 16. Subsequent Visits <ul><li>Timing variable but traditionally </li></ul><ul><li>Every 4 wks until 28wks </li></ul><ul><li>2 wks until 36wks </li></ul><ul><li>Weekly thereafter </li></ul><ul><li>BP and urine checked at each visit </li></ul><ul><li>Abdo- presentation assessed from 32wks </li></ul><ul><li> after 36wks breech needs managing </li></ul><ul><li> fetal head engages at 36-38wks in primip </li></ul>
  17. 17. Subsequent Visits <ul><li>Bloods </li></ul><ul><li>Rhesus neg women have titres measured at 30 and 36wks. Anti-D given at 28 and 34 wks? </li></ul><ul><li>If anaemic can have combined iron/folate preps </li></ul>
  18. 18. Assessment of fetal Growth <ul><li>50% IUGR remain undetected </li></ul><ul><li>Means of monitoring; </li></ul><ul><li>Clinical assessment </li></ul><ul><li>Fetal movements </li></ul><ul><li>Ultrasound Assessment, used in series </li></ul><ul><li>Biophysical profile </li></ul><ul><li>Limb and body movements, breathing, tone, amniotic fluid vol, HR variability </li></ul><ul><li>Fetoplacental Blood Flow </li></ul><ul><li>Cordocentesis, for blood transfusions too </li></ul>
  19. 19. End of Antenatal Care <ul><li>If woman has EDD and passes it she is sometimes surprised. </li></ul><ul><li>Need to explain that it is the probable expected date and not actual </li></ul><ul><li>Still normal if within 2 weeks either side </li></ul><ul><li>If longer, consider use of prostaglandins if cervix favourable. </li></ul><ul><li>Ensure follow up if needed by obstetrician </li></ul>
  20. 20. <ul><li> THE END! </li></ul>

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