Transcript Antenatal care

Traditional Antenatal Care
Amr Nadim, MD
Professor of Obstetrics & Gynecology
Ain Shams Maternity & Women’s Hospital
The Pillars of Safe Motherhood
BASIC HEALTH SERVICES
EQUITY
EMOTIONAL AND PSYCHOLOGICAL
SUPPORT
Essential Obstetric Care
Postpartum Care
Clean/safe Delivery
Antenatal Care
Postabortion
Family Planning
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
Signs
- Vulva: Soft and violet (Jacque-Mier’s sign).
- 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 nonpregnant cervix feels like the cartilage of the nose.
- Uterine signs:
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The uterus is enlarged and soft.
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At 8 weeks size of an orange.
At 12 weeks the 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 uterus is felt elastic above the
compressible isthmus, while the cervix is felt firm below as if it is
separate from the uterus which mimics an enlarged adnexa. It is
positive in pregnant women beween 6-8 weeks.
Hegar’s sign
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
Pregnancy Tests
• Urine Pregnancy Test
– Agglutination Inhibition
– ELISA ( sensitive to a
50 mIU/ ml level)
• Blood Pregnancy Test
– RIA
– ELISA
False positive urinary pregnancy test
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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
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Goodell’s sign (softening of the
cervix)
Chadwick’s sign (bluish vaginal
tissue)
Hegar’s sign (softening of the cervix)
Ballottement
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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
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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.
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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).
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Quickening
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first time at which the mother percepts fetal movements.
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It is not a sure sign but is useful for accurate dating of the
pregnancy.
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It is felt earlier in multipara (16-18 weeks) than in primigravida
(18-20 weeks) due to previous experience.
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Enlargement of the abdomen:
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This occurs after the 12th week when the uterus becomes
abdominal.
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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.
DD
• Early Pregnancy
– Causes of amenorrhea
– Causes of symmetrical
enlargement of the
uterus
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myomas,
hematometra,
adenomyosis,
extrauterine mass.
• Late Pregnancy
– Pelviabdominal
swelling
– Pseudocyesis
The Initial “Booking” Prenatal Visit
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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
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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.
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Causes of oversized
• Causes of undersized
uterus (larger than period uterus (smaller than
of amenorrhea):
period of amenorrhea):
Wrong dates.
Polyhydramnios.
Hydatidiform mole.
Macrosomic fetus.
Concealed accidental
hemorrhage.
Twins.
Tumors as fibroids and
ovarian cysts.
Fetal malformations as
hydrocephalus.
– 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
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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
Laboratory Analysis and Testing
• 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
• Other Testing
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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
1-Hour Routine Screening
(ACOG,1994)
50 G Glucose screening test (GST)
between 24 and 28 weeks (non-fasting)
If results <130-140
No further screening needed.
• If 130-140mg% <GST< 190mg%, proceed to 3 hr
GTT (25% of the screened Population) or repeat the
1 hour test in one week.
• If GST > 190 mg%: This is diagnostic of GDM
Determination of GDM
(ACOG, 1994)
100 Grams OGTT (3hrs)
75 Grams OGTT (2hrs)
Fasting
1 hour
2 hour
3 hour
Ranges of Accepted
Values
95-105
180-190
155-165
140-145
- If 2 or more values met or exceeded = GDM
- Consuming at least 150 grams/day for the 3 days
preceding the test with 8 hours overnight fasting
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
Leopold’s Maneuvers
• 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
• 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
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Individualized according to pre-pregnancy weight
Weight assessed at every visit
Weight loss is never normal
Excessive weight gain requires evaluation
Option I
Traditional Food Pyramid
• 55% carbohydrate,
• 25% protein,
• 20% fat
Option II
Balanced Diet
35-40%
Carbohydrates
35-40% Fat
20--25%
Protein
Option III
Low Glycemic Carbohydrates
• More Protein
• Low Carbs
• Appropriate Fats
Diet…
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• Calories:
– The requirements increase from 2200 to 2500 Kcal (Kilocalories) calories.
• The additional energy required is more than 300 Kcal but is reduced by
reduced physical activity
• Proteins:
– Increased protein demands are needed for fetal, uterine, placental and
breast growth and increased blood volume.
– During the last 6 months of pregnancy 1 kg of protein is deposited
amounting to 5-6 g per day.
– The majority is required as in animal form as meat, milk, eggs. Milk is the
ideal source. Lactose intolerance can be prevented by eating youghort
and cheese.
• Fats and Carbohydrates:
– Fried food, cream, sweets chocolates and sugar should be consumed
sensibly to avoid excess weight gain.
– Empty calories are better avoided
– Jams, cakes, pastries, biscuits and large quantities of bread and potato
should also be restricted.
Vitamins and Minerals
Iron is the only nutrient for which requirements are not met by diet
alone. Routine multivitamin is not recommended as any general diet
supplies the required vitamins but women who do not consume an
adequate diet need a supplement containing iron, zinc, copper,
calcium, vitamin B6, folate, vitamin C vitamin D.
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Iron:
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Daily requirement is 30-60 mg. As
Normal diet contains about 15 mg,
One gram of iron is needed.
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300 for the fetus and placenta,
500 for the increased blood volume and
200 for the uterus.
7 mg per day are needed
30 mg of a simple iron salt as ferrous sulphate, gluconate, fumarate
once daily provides sufficient iron.
60-100 mg are needed if the woman is large, has twins takes iron
irregularly.
Anemic women need 200 mg in divided doses.
Calcium and magnesium in multivitamins reduces iron absorption so
iron is best given alone iron is not needed in the first 4 months if there
is no anemia.
Given at bedtime is better.
Vitamins and Minerals
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Sodium: Salting food to taste gives sufficient salt.
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There is no evidence that excess salt predisposes to
pregnancy induced hypertension but some restriction is
required if the woman is hypertensive.
Iodine: Deficiency may lead to congenital goitre and
maternal goitre.
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Calcium: calcium supplementation is unlikely to be
of benefit. Two glasses of milk are sufficient
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Vitamin A: daily requirement in pregnancy is 5000
I.U.
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Vitamin B6 deficiency may cause vomiting
Folic acid: about 1mg (1000 mcg) provides very
effective prophylaxis against megaloblastic anemia.
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Vitamin A in excess amount is teratogenic
Folic acid supplementation before and early in pregnancy
significantly reduces the risk of neural tube defects.
Vitamin B12: Its deficiency only occurs in strict
vegetarians.
Vitamin C: Deficiency leads to postpartum
hemorrhage and scurvy (100 mg/d).
Vitamin K: Deficiency leads to postpartum
hemorrhage and it may cause hemorrhage in the
fetus
Routine weighing at A/N visits - evidence
• weighing at every antenatal visit routine
practice for many years
• No conclusive evidence for weighing at each
visit. Maternal weight not clinically useful
screening tool for detection of IUGR,
macrosomia or pre-eclampsia.
• Weighing at booking or other times may be
indicated eg anaesthetic risk assessment (done
BIV at RWH) or maternal weight concerns
Body Mass Index (BMI)
• A commonly used measure to
differentiate underweight, normal weight,
overweight and obesity.
• Obtained by dividing the weight of the
subject (in kilos) by the square of his
(her) height in meters.
• A BMI of approximately 25 kg/m2
corresponds to about 10 percent over
ideal body weight.
Body Mass Index Definitions
Classification
BMI
Underweight
<18.5
Healthy Weight
18.5 to 24.9
Overweight
25.0 to 29.9
Class I obesity
30.0 to 34.9
Class II obesity
35 to 39.9
Class III obesity
> 40.0
Body Mass Index and
Recommended Weight Gain
Pre-pregnant weight status
A. Twin Pregnancy
Recommended
range of weight gain
15- 20 Kg.
B.Underweight (BMI<18.5)
12- 17 kg.
C.Normal Weight (BMI 18.5 to
24.9)
11- 15 Kg.
D.Overweight (BMI 25.0 to
29.9)
6- 11 Kg.
E. Obese (BMI > 30.0)
6 Kg.
Smoking:
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Birth weights are lower , IUGR, increased
perinatal deaths and preterm labor are present
in smoking mothers.
This is due to effect of carbon monoxide, the
vasoconstricting effect of nicotine on the fetal
vessels in the placenta, which decreases
placental perfusion, reduced appetite and
decreased maternal blood volume expansion.
Passive smoking is also very harmful to
women. It leads to ptyalism, nervousness and
increased hyperemesis gravidarum.
Alcohol Consumption
• Fetal alcohol syndrome (FAS) is a
birth defect syndrome caused by the
mother's intake of alcohol during
pregnancy .
• In order to receive a diagnosis of
FAS from a physician, three criteria
must be present:
– Characteristic facial features include
- a flattened midface, thin upper lip,
indistinct/absent philtrum and short
eye slits
– Growth retardation - lower birth
weight, disproportional weight not
due to nutrition, height and/or weight
below the 5th percentile.
– Central Nervous System
neurodevelopmental abnormalities
such as - impaired fine motor skills,
learning disabilities, behavior
disorders or a mental handicap (the
latter of which is found in
approximately 50% of those with
FAS)
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Sleep:
Adequate rest of about 8 hours at night and 1 or 2 hours in the afternoon is
recommended.
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Exercise:
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It is not necessary to limit exercise as long as she does not get excessively fatigued
or there is a risk to injury herself.
Women accustomed to exercise before pregnancy should be allowed to continue but
avoid starting new exercise programs
walking is the best to recommend.
Regular exercise improves metabolic efficiency.
Exercise does not increase risk of spontaneous abortion, shortens active labor and
leads to fewer cesarean sections.
Exercise is avoided in women with twin pregnancies, pregnancy induced
hypertension, growth restricted fetuses and severe heart and lung diseases.
Work:
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Birth weights of women who worked during the third trimester are 150-400 gm less
than those who do not work.
It is greatest if the woman is underweight, with low weight gain and whose work
requires standing. Standing was also associated with increase in preterm births.
Heavy work defined as sufficient to cause sweating was not deleterious.
Any occupation that causes severe physical strain is avoided. No work that causes
undue fatigue should be allowed and adequate periods of rest during the working day
should be allowed.
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Traveling: This has no harmful effect.
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Coitus:
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Coitus should only be avoided in threatened abortion, PROM,
threatened preterm delivery or if there is a placenta previa
Sexual intercourse does not do harm before the last 4 weeks of
pregnancy.
Clothing:
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Air travel is also safe but in long trips of more than 6 hours the
woman should walk about every 2 hours to prevent deep venous
thrombosis.
The greatest risk is to travel away from proper medical facilities or to
areas with infectuous diseases
Seat belts are advised but the lap belt should be placed under the
abdomen and across the thighs and the shoulder belt between the
breasts.
should be practical and non-restricting.
High heels are avoided to prevent loss of balance and prevent
increased lordosis and backache.
Care of teeth:
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Pregnancy is not a contraindication for any dental treatment.
The concept that pregnancy aggravates dental caries is not true.
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Bowels:
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Bowel habits become irregular due to relaxation of the bowel
smooth muscles and compression of the lower bowel by the
pregnant uterus.
Passage of hard stools can cause bleeding and fissures in the
edematous rectal mucosa.
Hemorrhoids are more common.
Prevention of constipation is by drinking sufficient amount of fluid,
daily exercise, foods containing roughage as fruit and salad.
Harsh laxatives and enemas are avoided.
Bathing:
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Well fitting supporting brassieres are required as breasts become
painful and pendulous.
Crusts or dried secretion over the nipples are washed by warm
wateror boric acid.
The nipples are drawn for a short time daily by the thumb and
fingers and painted with a lubricant during the last 6 weeks.
There are no restrictions but the mother should be careful not to
slip in the tub and showers are safer.
Douching:
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Use of hand bulb syringes are contraindicated.
The douche bag should not be raised more than 60 cm above the
hips and the nozzle not more than 7 cm in the vagina.
Immunization:
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Live attenuated virus vaccines as measles,
rubella, mumps, poliomyelitis are contraindicated.
Inactivated virus vaccines as influenza, and rabies
are safe to be given.
Inactivated bacterial vaccines as cholera,
meningococcus, and typhoid are safe to be given.
Toxoids as tetanus and diphtheria toxoid are safe
to be given.
Immune globulins as for hepatitis, tetanus and
rabies can be given.
Tetanus Vaccination Campaign
Dose
Given
Protection
Immunity
1st Dose
After the 3rd month
0%
0%
2nd Dose
At least 4 weeks after the first
shot and 2 weeks before
delivery
80%
3 years
3rd Dose
-6months after the 2nd dose
-Or during the next
pregnancy ( within 5 years)
95%
5 years
4th Dose
-1 year after the 3rd Dose
-Or During the next
pregnancy ( within 5 years)
99%
10 years
5th Dose
- 1 year after the 4th Dose
-Or During the next
pregnancy ( within 5 years)
99%
Lifelong
Warning signs:
The pregnant woman must immediately report
if any one of the following signals occur:
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Vaginal bleeding.
Swelling of the face, fingers and limbs.
Swollen tender calf muscles
Severe headache.
Blurring of vision.
Abdominal pain.
Persistent vomiting.
Chills and fever.
Escape of fluid from the vagina.
Visit Schedule
• The return visits are
– Every 4 weeks until 28 weeks then
– Every 2 weeks until 36 weeks then
– Weekly thereafter. A more flexible schedule is at
times better.
• Perinatal outcome benefits were more
pronounced with antenatal care after 30 weeks.
• The mother is advised to call or come when she
feels undue worry. In each visit the well being of
mother and fetus are assessed.
• The WHO recommends at least 4 antenatal
visits
First appointment
The first appointment needs to be earlier in pregnancy (prior to 12 weeks) than
may have traditionally occurred and, because of the large volume of
information needs in early pregnancy,
two appointments may be required.
At the first (and second) antenatal appointment:
– give information, with an opportunity to discuss issues and ask questions; offer
verbal information supported by written information (on topics such as diet and
lifestyle considerations, pregnancy care services available, maternity benefits and
sufficient information to enable informed decision making about screening tests)
– identify women who may need additional care and plan pattern of care for the
pregnancy
– check blood group and RhD status
– offer screening for anaemia, red-cell alloantibodies, Hepatitis B virus, HIV, rubella
susceptibility and syphilis
– offer screening for asymptomatic bacteriuria (ASB)
– offering screening for Down’s syndrome
– offer early ultrasound scan for gestational age assessment
– offer ultrasound screening for structural anomalies (20 weeks)
– measure BMI, blood pressure (BP) and test urine for proteinuria.
• 16 weeks
– review, discuss and record the results of all screening
tests undertaken; reassess planned
– pattern of care for the pregnancy and identify women
who need additional care
– investigate a haemoglobin level of less than 11g/dl
and consider iron supplementation if indicated
– measure BP and test urine for proteinuria
– give information, with an opportunity to discuss issues
and ask questions; offer verbal information supported
by antenatal classes and written information.
18–20 weeks
– If the woman chooses, an ultrasound scan should be performed
for the detection of structural anomalies.
– For a woman whose placenta is found to extend across the
internal cervical os at this time, another scan at 36 weeks should
be offered and the results of this scan reviewed at the 36-week
appointment.
25 weeks
– At 25 weeks of gestation, another appointment should be
scheduled for nulliparous women. At this appointment:
– measure and plot symphysis–fundal height
– measure BP and test urine for proteinuria
– give information, with an opportunity to discuss issues and ask
questions; offer verbal information supported by antenatal
classes and written information.
• 31 weeks
Nulliparous women should have an appointment
scheduled at 31 weeks to:
– measure BP and test urine for proteinuria
– measure and plot symphysis–fundal height
– give information, with an opportunity to discuss issues
and ask questions; offer verbal information supported
by antenatal classes and written information
– review, discuss and record the results of screening
tests undertaken at 28 weeks; reassess planned
pattern of care for the pregnancy and identify women
who need additional care.
34 weeks
At 34 weeks, all pregnant women should be seen in
order to:
– offer a second dose of anti-D to rhesus-negative
women
– measure BP and test urine for proteinuria
– measure and plot symphysis–fundal height
– give information, with an opportunity to discuss issues
and ask questions; offer verbal information supported
by antenatal classes and written information
– review, discuss and record the results of screening
tests undertaken at 28 weeks; reassess planned
pattern of care for the pregnancy and identify women
who need additional care
36 weeks
At 36 weeks, all pregnant women should be seen
again to:
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measure BP and test urine for proteinuria
measure and plot symphysis–fundal height
check position of baby
for women whose babies are in the breech
presentation, offer external cephalic version (ECV)
– review ultrasound scan report if placenta extended
over the internal cervical os at previous scan
– give information, with an opportunity to discuss issues
and ask questions; offer verbal information supported
by antenatal classes and written information.
38 weeks
Another appointment at 38 weeks will allow for:
– measurement of BP and urine testing for proteinuria
– measurement and plotting of symphysis–fundal height
– information giving, with an opportunity to discuss
issues and ask questions; verbal information supported
by antenatal classes and written information.
40 weeks
For nulliparous women, an appointment at 40
weeks should be scheduled to:
– measure BP and test urine for proteinuria
– measure and plot symphysis–fundal height
– give information, with an opportunity to discuss issues
and ask questions; offer verbal information supported
by antenatal classes and written information.
• 41 weeks
For women who have not given birth by 41 weeks:
– a membrane sweep should be offered
– induction of labour should be offered
– BP should be measured and urine tested for
proteinuria
– symphysis–fundal height should be measured and
plotted
– information should be given, with an opportunity to
discuss issues and ask questions; verbal information
supported by written information.
Evidence-Based Evaluation
– Beneficial forms of care
– Forms of care likely to be beneficial
– Forms of care with trade-off between benefit
and harm
– Forms of care unlikely to be beneficial
– Forms of care that are ineffective or harmful
Beneficial forms of care:
Effectiveness demonstrated by clear evidence from
controlled trials
•
•
•
Pre- and Periconceptional Folic acid
supplementation to prevent recurrent
neural tube defects.
Folic acid supplementation (or high folate
diet) for all women contemplating
pregnancy
Iodine supplementation in populations with
a high incidence of endemic cretinism.
Beneficial forms of care:
•
•
•
•
•
Antihistamines for nausea and vomiting of
pregnancy if simple measures fail.
Local imidazoles for candida infection.
Anti-D postpartum and at 28 weeks for Rh –ve
women.
Antibiotic treatment for asymptomatic
bacteriuria.
Tight as opposed to strict or moderate control
of blood glucose levels in diabetic women.
Beneficial forms of care:
•
•
•
External cephalic version at term to avoid
breech presentation at birth.
Corticosteroids to promote fetal lung
maturation before preterm birth.
Offering induction of labor at 41+ weeks of
gestation
Ineffective or Harmful forms of
care:
•
Dietary restriction to prevent pre-eclampsia
(including salt restriction).
•
Ante-natal breast or nipple care for women
who plan breast feeding.
•
Contraction stress test .
•
Non-stress test.
Ineffective or Harmful forms of
care:
•
DES during pregnancy.
•
External cephalic version before term to
avoid breech presentation at birth.
•
Progestogens to stop preterm labor.
•
Routine enema in labor.
•
Routine pubic shaving in preparation for
delivery.
•
Screening for Toxoplasmosis.
Forms of care unlikely to be
beneficial:
•
•
•
•
•
Advise to restrict sexual activity during
pregnancy.
Imposing dietary restrictions during
pregnancy.
Routine vitamin supplementation in well
nourished populations.
Routine vitamin supplementation in well
nourished populations.
Routine ultrasound use in late pregnancy
Forms of care unlikely to be
beneficial:
•
Screening for pre-eclampsia by:
 Roll-over test, Cold-pressor test, Edema,
Isometric exercise, Measuring uric acid.
•
Diuretics, Diazoxide for pre-eclampsia.
•
Screening for gestational diabetes:
 Routine glucose challenge test, routine
measurement of blood glucose.
Forms of care unlikely to be
beneficial:
•
Calcium supplementation for leg cramps.
•
Bed rest for threatened abortion.
•
Hospitalization or cervical cerclage for
twin pregnancy.
•
Prophylactic tocolysis with preterm
premature rupture of membranes.
Forms of care unlikely to be
beneficial:
•
Regular leucocyte counts for PROM.
•
Betamimetics for preterm labor in women with
heart disease or DM.
•
Hydration to arrest preterm labor.
•
Diazoxide for preterm labor.
Summary
Antenatal care includes goal-directed
interventions
•
•
•
•
Skilled attendant.
Preparation for birth and complications.
Health promotion.
Detection of complications.
Guided by Evidence.