Antenatal Assessment

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Antenatal Assessment??

Antenatal/prenatal care 

Systematic supervision of a woman during pregnancy is called antenatal (prenatal care)

Why is it important? 
Determines the wellbeing of the newborn and chance for survival (mother history)

AREA OF CONCERNS: 
Pre-conception counselling  Assessment of risk factors  Ongoing assessment of fetal well-being  Ongoing assessment of complications  Education  Discussion of birthing care options

Timing of antenatal visits: 
The first visit should not be deferred beyond the second missed period.  Once a month until 28 weeks.  Twice a month until 36 weeks.  Every week during the last 4 weeks of pregnancy.

PROCEDURE AT THE FIRST VISIT 
> Detailed Health History  > Physical Examination  > Breast and Pelvic Examination

Vital statistics: 
Name  Age  Ward/unit  IP no  Address  Religion  Occupation  Education  LMP  EDC  GA  Obstetric score  Blood group 

Gravida: nulligravida primigravida multigravida 

Parity: nullipara primipara multipara grandmultipara

Maternal history 
Present ob. History: 
Diagnosis? Planned/unplanned Minor disorders Immunization Exposure to drugs/radiation

Pregnancy tests

Maternal History and Risk Factors 
Comprehensive maternal history and physical examination is important to point out the risk factors.  Risk factors can be related to mother, during pregnancy, during labor and delivery, or after delivery.  Antenatal assessment starts with determination of risk factors.  Better knowledge about risk factors better preparation to care for the patient.

abortion 
31% of pregnancies end in miscarriage  Only rarely would an abortion cause problems in a subsequent pregnancy  increased risk of miscarriage only in women who have had multiple induced abortions.

Risk Factors 
Preterm Birth: 
What is considered preterm??  The second greatest cause of morbidity and mortality in neonates.  Previous preterm birth increases the subsequent preterm birth:  1 prior = 15% of subsequent preterm birth.  2 prior = 32% of subsequent preterm birth.

Risk Factors 
Incompetent Cervix: 
Caused by cervical trauma, previous surgery, or may be congenital.  Usually leads to membrane rupture and premature delivery.  If severe, a suture around the cervical canal is performed.

Risk Factors 
Maternal Smoking and Alcohol Intake: 
In the US, about 10% of pregnant mothers smoke, drink alcohol or use drugs.  Maternal intake of alcohol leads to fetal growth problems.  Smoking HBCO decreases availability of oxygen to placenta and fetus.

Risk Factors 
Maternal Hypertension 
Complicates 6-8% of pregnancies.  Hypertension during pregnancy (after W24) is termed: Preeclampsia.  Preeclampsia (High BP, proteinuria, edema)  Can lead to placental abruption, and preterm delivery.

Risk Factors 
Diabetes: 
Increase the risk for CV and CNS malformations, and metabolic disturbances.  When appears during pregnancy (Gestational Diabetes Mellitus, GDM).  Treatment: glycemic control.

Risk Factors 
Infections Diseases: 
Infections can be transmitted to fetus.  Early screening and detection of the infection is important.  Complicated by the rupture of the membrane.

Risk Factors 

Problems in Placenta, UC, and Fetal Membrane:
births. 

premature rupture : causes 50% of preterm  UC : Prolapse, short, single artery (3%)  Placental problems

Antenatal assessment 
Height  Weight  Pallor  Jaundice  Vital signs

BREAST EXAMINATION 
flat (nipple does not protrude with stimulation)  retracted (nipple pulls back slightly)  inverted (nipple pulls inward when compressed)

Breast examination

INVERTED NIPPLES Grade 1

Grade 2: the nipple is inverted or retracted under the areola

Grade 3 There is no projection of the nipple, elements of nipple are usually buried under the breast and will not come out.

Abdominal examination 
Inspection 
Size Shape Contour Flank Skin Bladder Fetal movements

palpation

Measuring SFH

After 14 weeks gestation the SFH in centimeters = Number of weeks of gestation + 3 cm.

Antenatal schedule

Investigations 
First visit: Hb, Blood group, Rubella, Hep B and C and HIV screening.  10-12 weeks: Chorionic villous sampling  15-18 weeks: USG, serum AFP/triple test , amniocentesis  28 weeks: Hb ,TC/DC, ferritin, GTT, and low vaginal swab to exclude Group B strep.  36 weeks: Hb

Antenatal chart should record the following: 
Weight gain (12-15 kg in total)  BP (a diastolic pressure>90, or increase of >20 from first visit is significant)  Urinalysis (watch for protein, glucose, and UTIs)  Fetal movements  Uterine size in accordance with dates and ultrasound  Fetal lie, presentation, and engagement, especially after 36 weeks

Antenatal Assessment
ULTRASOUND 
Uses high frequency sound waves.  Hand-held transducer is placed directly over the mother¶s abdomen, and reflected waves are recorded on screen image.  Can give valuable information about pregnancy and fetus

Clinical Uses of Ultrasound 
Identify pregnancy.  Determine fetal age.  Observe amniotic fluid abnormalities.  Detect fetal anomalies.  Identify placental abnormalities.  Determine fetal position.  Examine fetal HR, and RR

Embryo at 6 weeks

Antenatal Assessment
AMNIOCENTESIS 
Is the procedure of obtaining a sample of amniotic fluid.  Usually performed after W15 (w15-20).  A needle is inserted through the skin and uterine wall to the amniotic sac.  Insertion is guided by Ultrasound.  Sample from amniotic fluid is obtained for analysis.  Very safe procedure (complication rate <1%).

Antenatal Assessment
FETAL HEART RATE (FHR) MONITORING  Heart starts to beat between W16-W20, but beats can be detected as early as W8.  Normal 120-160 bpm.  Becomes very common test.

Antenatal advices 
        

Diet exercise Rest and sleep Bowel Bathing Clothing Dental care Coitus Care of breast Immunisation

FHR Monitoring

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