4th Stage Obstetrics ‫ هدية‬.

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Antenatal Care
Definition of Antenatal care
- comprehensive health supervision of a pregnant woman before delivery.
- Or it is planned examination, observation and guidance given to the
pregnant woman from conception till the time of labor.

The aims of antenatal care are:

- To optimize pregnancy outcomes for women and babies.
- To prevent, detect and manage those factors that adversely affect the
health of mother and baby.
- To provide advice, reassurance, education and support for the woman and
her family.
- To deal with the ‘minor ailments’ of pregnancy.
- To provide general health screening.

Schedule for Antenatal Visits:

The first visit or initial visit should be made as early is pregnancy as
possible.

Return Visits:
1- Once every month till 28 w.
2- Once every 2 weeks till the 36 w
3- Once every week, till labor.

- Complete History taking

- Examination
- Investigation

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Health Teaching during the First Trimester

1- Physiological changes during 12- Smoking :
pregnancy 13- Medications
2- Weight gain 14- Infection
3- Fresh air and sunshine 15- Irradiation
4- Rest and sleep 16- Occupational and
5- Diet environmental hazards
6- Daily activities 17- Travel
7- Exercises and relaxation 18- Follow up
8- Hygiene 19- Minor discomforts
9- Teeth 20- Signs of Potential
10- Bladder and bowel Complications
11- Sexual counseling

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

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- 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.

Gestational age assessment

 New Pregnant women should be offered an early ultrasound scan between
10 weeks 0 days and 13 weeks 6 days to determine gestational age and to
detect multiple pregnancies.
 New Crown–rump length measurement should be used to determine
gestational age. If the crown–rump length is above 84 mm, the gestational
age should be estimated using head circumference.

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Causes of oversized uterus Causes of undersized uterus

(larger than period of (smaller than period of
amenorrhea): amenorrhea):
1- Wrong dates. 1- Wrong dates
2- Polyhydramnios 2- Oligohydramnios
3- Hydatidiform mole. 3- Fetal death
4- Macrosomic fetus. 4- IUGR or Small fetus
5- Concealed accidental 5- Pregnancy during period of
hemorrhage. amenorrhea as lactation or
6- Twins. injectable contraception
7- Tumors as fibroids and ovarian 6- Malpresentations as transverse
cysts. lie
8- Fetal malformations as
hydrocephalus.
Asymptomatic Bacteriuria
Women should be offered routine screening for asymptomatic
bacteriuria by midstream urine culture early in pregnancy. Identification and
treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis.
Screening for fetal anomalies
New The 'combined test' (nuchal translucency, beta-human chorionic
gonadotrophin, pregnancy-associated plasma protein-A) should be offered to
screen for Down's syndrome between 11 weeks 0 days and 13 weeks 6 days.
Screening for gestational diabetes
- New risk factors for gestational diabetes :
1- body mass index above 30 kg/m2
2- previous macrosomic baby weighing 4.5 kg or above
3- previous gestational diabetes (refer to 'Diabetes in pregnancy
4- family history of diabetes (first-degree relative with diabetes)
5- family origin with a high prevalence of diabetes:

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Screening for haematological conditions

- New Screening for sickle cell diseases and thalassaemias should be
offered to all women as early as possible in pregnancy (ideally by 10
weeks).
Anaemia
- Screening shouldtake place early in pregnancy (at the booking
appointment).
- at 28 weeks when other blood screening tests are being performed.
- At 36 weeks.
- Normal range:
• 11 g/100 ml at first contact and 10.5 g/100 ml at 28 weeks) should be
investigated and iron supplementation considered .
Blood grouping and red-cell alloantibodies
- Women should be offered testing for blood group and rhesus D status in
early pregnancy.
- To give anti-D at 28 weeks and post delivery if the baby (+)
Hepatitis B virus
Serological screening for hepatitis B virus should be offered to
pregnant women so that effective postnatal interventions can be offered to
infected women to decrease the risk of mother-to-child transmission.
Hepatitis C virus
Pregnant women should not be offered routine screening for hepatitis
C virus because there is insufficient evidence to support its clinical and cost
effectiveness.
Rubella
Rubella susceptibility screening should be offered early in antenatal
care to identify women at risk of contracting rubella infection and to enable
vaccination in the postnatal period for the protection of future pregnancies.

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Initial recommended tests

1- FBS.
2- FBC , MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low)
3- Blood group/Ab screen
4- HIV (level 1 evidence)
5- Hep B
6- Syphilis (ideally prior 16 weeks)
7- Rubella Abs
8- Urine testing- either 2 step or MSU+dipstick
9- PAP if due
10- dating US
Warning signs:
The pregnant woman must immediately report if any one of the
following signals occur:
1- Vaginal bleeding.
2- Swelling of the face, fingers and limbs.
3- Swollen tender calf muscles
4- Severe headache.
5- Blurring of vision.
6- Abdominal pain.
7- Persistent vomiting.
8- Chills and fever.
9- Escape of fluid from the vagina.