This document provides guidance on prenatal care for pregnant women. It discusses terminology related to pregnancy, common symptoms and conditions, recommended prenatal visits and assessments. The goals of prenatal care are to establish an estimated due date, diagnose and treat any issues, and promote a healthy pregnancy through nutrition, lifestyle recommendations and monitoring for potential complications. Regular visits include checking vital signs, fetal positioning, and screening tests. The document emphasizes establishing a diagnosis and care plan tailored to each woman's individual risk factors and needs.

1. GENERAL APPROACH
TO THE PREGNANT
WOMAN

3. Pregnancy
Pregnancy (gestation) is the maternal
condition of having a developing fetus in the
body.
The human conceptus from fertilization
through the eighth week of pregnancy is
termed an embryo; from the eighth week
until delivery, it is a fetus.

4. Terminology
Antepartum - before delivery
Postpartum - after delivery
Prenatal - occurring before the birth
Gravida - number of pregnancies
Para - number of pregnancies carried to full term
Primigravida - woman who is pregnant for the first time
Primipara - woman who has given birth to her first child
Multiparous - woman who has given birth multiple times
Gestation - period of time for intrauterine fetal development

5. The diseases specific
to pregnancy
Hyperemesis gravidarum
Gestational diabetes
Preeclampsia (PIH)
Postpartum depression

6. Common diseases that significantly affect
pregnancy include ;
CVS diseases
Diabetes mellitus
Essential hypertension
Endocrine disorders
Autoimmune diseases

7. Most pregnant women will have at least one of
the following symptoms :
Backache
Breathlessness
Fatique
Palpitations
Ankle swelling
Indigestion
Nausea and vomiting
Constipation
Urinary frequency

8.  A woman may perceive early signs of
pregnancy within a few days of the first
missed menstrual period. Usually the
earliest signs are
 Mastodynia (breast tenderness),
 fatique, and
 some abnormal reaction to food.
Early signs of pregnancy

10. ASSESSMENT

11. TURKISH MINISTRY OF
HEALTH RECOMMENDS
1. VISIT : 0-14 WEEK
2. VISIT : 18-24 WEEK
3. VISIT : 30-32 WEEK
4. VISIT : 36-38 WEEK

12. The first prenatal visit
The first prenatal visit ideally should
occur between 6 and 8 weeks of
gestation. The purpose of the first
visit is to identify all risk factors
involving the mother and fetus.
Once identified, high-risk
pregnancies require individualized
specialized care.

13. Certain specific prenatal care tasks
for the physician include the following
Establish the diagnosis and
estimated due date.
Diagnose and treat prenatal
disease
Promote a healthy pregnancy

14. Establish the diagnosis and
estimated due date
The date of the last menstrual period should
be determined. If not known exactly, the date
should be estimated. Information about the
normal menstrual cycle should be obtained.
Nägele’s rule :
EDD = “ estimated due date “ or “ estimated
date of confinement “
EDD = LMP ( Date of the first day of the last
menstrual period ) + 1 year and seven days –
three months

15. The length of human gestation is 280
days, or 40 weeks, as counted from the
first day of the LMP to the EDD.
“ A term pregnancy “ may extend from
37 t0 42 weeks gestation.
If the patient is unsure of her LMP, an
ultrasound examination can date the
pregnancy with a first trimester
accuracy of plus or minus 4 days

16. An examiner may have difficulty
determining the presence of pregnancy
in the first 6 to 8 weeks of gestation..
Although the uterus is usually palpably
enlarged and soft ( Hegar’s sign ) within
6 weeks from the last menstrual period,
the exact size often is not easy to
determine. This is particularly true in
obese women and in women who have
had several children.

17. Chadwick’s sign ( vaginal and
cervical cyanosis ), -a purplish
discoloration of the uterine
cervix resulting from the
increased blood supply-, is often
present by 6 weeks from the
LMP.

18. There are many components of prenatal
care. Initially, confirmation of the
diagnosis of pregnancy and the
estimated gestational age must be
established.
Next is a full history and physical
examination with laboratory evaluation.

19. The physician questions the
patient
regarding her,
past obstetrical experiences,
past medical illnesses,
surgical procedures,
exposures to infection, and
risk of genetic diseases.

20. past obstetrical experiences
The following information is necessary:
Length of gestation,
Birth weight
Fetal outcome
Length of labor
Fetal presentation
Type of delivery ( vaginal, forceps or vacuum, cesarean
section ),
Complications
“ A history of preterm labor is the most important risk factor for its development
in subsequent pregnancies. “

21. past medical illnesses
Some of the most important medical
illnesses that cause problems in
pregnancy include heart disease,
particularly valvular diseases, worsen with
the stress of pregnancy; and diabetes
mellitus, since altered glucose levels may
result in congenital malformations or in a
difficult birth because of a large baby.

22. Troublesome habits during pregnancy are
use of cigarettes, which results in an increased
incidence of intrauterine growth retardation,
preterm labor, and abruptio placenta;
alcohol use, which may result in the fetal alcohol
syndrome, and
illicit drug use, with its potential for numoreous
congenital defects and HIV infection.

23. Sexually transmitted diseases and other
infectious diseases that put the fetus at
risk for infection are :
Herpes simplex type II,
Syphilis,
Gonorrhea,
Chlamydia,
HIV,
Hepatitis B,
Tuberculosis
Toxoplasmosis

24. A history of any genetic diseases
among the patient, the father, or both
extended families should be sought,
particularly of the diseases that are
diagnosable during pregnancy.

25. The risk of Down syndrome
increases with maternal age, and
patients of “ advanced maternal
age “ (>35 years) are advised of
serum and amniotic fluid tests
available for its prenatal diagnosis.

26. The initial physical examination
should include;
measurement of blood pressure and weight,
breast exam and,
pelvic exam for uterine sizing and abnormalities.
The external genitalia, vagina, and cervix should
be inspected carefully for abnormalities that may
lead to difficulties in pregnancy, labor, or
delivery.

27. The physician performs a complete physical
examination early in the pregnancy, paying
special attention to the thyroid, in which
abnormalities can create fetal hyperthyroidism
or hypothyroidism result in decreased
intellectual function ;
the breasts, in which abnormal masses may
grow quickly under the influence of gestational
hormones; and the heart, in which abnormal
sounds may indicate a heart disease that
causes difficulty during pregnancy.
complete physical examination

28. Laboratory data obtained routinely
during pregnancy include ;
1. A complete blood count ( CBC ), to
determine the presence of anemia and to
obtain a baseline platelet count
2. Blood type and Rh, to identify Rh-
negative patients
3. Urine culture, to identify patients with
asymptomatic bacteriuria, with its
attendant risks of pyelonephritis and
preterm labor

29. 4. Rubella screen, to determine the patient’s
rubella status ( if no antibody is present, the
patient is advised to avoid sick children
during the pregnancy and to obtain the
rubella immunization during the post partum
period
5. Papanicolau smear, to identify patients with
dysplasia, who need treatment during
pregnancy
6. Gonorrhea cervical culture, and hepatitis B
surface antigen, to identify patients whose
infants are at risk for prenatal or perinatal
transmission.

30. A Papanicolau smear should be obtained for
every patient at her first prenatal visit unless a
negative exam has been obtained within the
last 6 months.
A hematocrit and a urine culture should be
obtained for all patients as well.
Anemia is defined as a hemoglobin of less
than 11.0 gm / dL in the first and third
trimester and less than 10.5 gm / dL in the
second trimester, or, equivalently, a hematocrit
of 33 and 32 per cent, respectively.
The most common cause of anemia in pregnancy
is iron deficiency.

31. Midtrimester screening
tests

32. a. The couple should be counseled regarding
maternal serum α-fetoprotein
( AFP ) testing for birth defects to be
completed between the fifteenth and
twentieth weeks of gestation ( best between
the sixteenth and eightteenth ).
Although there are numoreous causes for an
abnormal AFP value, its primary purpose is to
screen for neural tube defects.
Abnormal results are further evaluated by
ultrasonography and amniocentesis.

33. b. At 24 to 28 weeks, a one-hour glucola
( blood glucose measurement one hour after a
50 mg oral glucose load ) is obtained to
screen for gestational diabetes in all pregnant
patients.
Those with a particular risk ( e.g., previous
gestational diabetes or fetal macrosomia )
may warrant earlier testing.
Values greater than or equal 140 mg / dl are
evaluated with a three-hour oral glucose
tolerance test.

34. c. Repeat hemoglobin and hematocrit are
obtained at 26 to 30 weeks to determine the
need for iron supplementation.
d. Repeat serologic testing for syphilis is
recommended at 36 weeks for high risk
groups.
e. At 28 to 30 weeks, an antibody screen is
obtained in Rh-negative women.
f. Repeat third-trimester screening for
gonorrhea and chlamydia is recommended in
high-risk population.

35. Promote a healthy pregnancy
The physician emphasizes to the
patient her responsibilities in providing
as healthy an environment for the fetus
as possible and often asks the patient
to read further on the subject.

36. Good nutrition during pregnancy
Women should be encouraged to eat a
balanced, nutritious diet, including whole –
grain cereals and breads , vegetables and
fruit, protein-rich foods , and dairy products.
A healthy diet is achievable from many
cultural perspectives , and the starting point
has to be with foods that are familiar and
enjoyed by the patient.

37. Vitamin and mineral supplementation is not
indicated by women who eat well-balanced
diets, except for iron and folic acid ( Folic acid,
400 micrograms daily should be begun at the
first prenatal visit and continued through the
first three months of pregnancy)
It is not necessary to begin iron
supplementation at the first prenatal visit.
For most women it should be started in the
second trimester and continued throughout
pregnancy at a dose of 30 mg of elemental
iron per day.

38. Calcium supplementation is
recommended only in women who
cannot eat diary products.
The recommended daily allowance of
calcium for the pregnant woman is the
same as that for the nonpregnant
woman, 1200 mg / day.

39. Subsequent visits
The standart schedule for prenatal office visits:
0-32 weeks, once every 4 weeks;
32-36 weeks,once every 2 weeks;
36 weeks to delivery, once each week.

40. Preparation for labor
As term approaches, the patient should be
instructed about the following danger signals:
Rupture of membranes
Vaginal bleeding
Evidence of preeclampsia (marked swelling of
hands and face, blurring of vision, headache,
epigastric pain, convulsions)
Chills or fever
Severe abdominal or back pain

41. What are Leopold maneuvers?
These are performed at each third
trimester visit to assess the
presentation,
position,
engagement of the fetus by using 4
different maneuvers.

42. Leopold maneuver #1
Palpate the fundus of the uterus to determine
which fetal parts are in this portion of the uterus.
It is used for outlining uterine contour and locating head

43. Leopold maneuver #2
Palpate either side of the abdomen to find the fetal back.
It is used for locating the spine

44. Leopold maneuver #3
Palpate just above the pubic symphysis for the presenting part.
It is used for determining the engagement

45. Leopold maneuver #4
Palpate either side of the lower abdomen just above
the pelvic inlet to determine if the head is flexed or extended
It is used to determine the descent