ANTENATAL CARE
BY DR.SHARON
MODERATOR DR.YOGESH BANGERA
• A COMPREHENSIVE ANTEPARTUM CARE
PROGRAM THAT INVOLVES A
COORDINATED APPROACH TO MEDICAL
CARE AND PSYCHOSOCIAL SUPPORT
THAT OPTIMALLY BEGINS BEFORE
CONCEPTION AND EXTENDS THROUGHT
THE ANTEPARTUM PERIOD
•
•
•
•
.PRECONCEPTIONAL CARE
.DIAGNOSIS OF PREGNANCY
.PREGNANCY CARE
.FOLLOW UP PRENATAL VISITS
Preconceptional counselling
Preconceptional counselling
• COUPLES READINESS FOR CONTEMPLATING
CHILDBEARING,AND TO MINIMISE ANY
FORSEEABLE ADVERSE FACTORS BY MEANS OF
A CAREFUL DIAGNOSTIC REVIEW OF MEDICAL
BACKGROUND OF
PARTNERS,UNDERSTANDING THEIR SOCIAL
BACKGROUND AND ECONOMIC STATUS,SO AS
TO HELP THE COUPLE TO PLAN THEIR
PREGNANCY AT AN APPROPRIATE TIME,AND
PROVIDE THEM WITH NECESSARY EDUCATION
AND THERAPY TO OPTIMISE PREGNANCY
OUTCOME
• AGE
• OPTIMAL AGE FOR CHILDBEARING IS
BETWEEN 20 TO 35YEARS
• .IDENTIFICATION OF RISK FACTORS
•
DETAILED EVALUATION OF
MEDICAL,FAMILY,OBSTETRIC,PERSONAL
HISTORY TAKEN
• BASE LEVEL HEALTH STAUS INCLUDING BLOOD
PRESSURE IS RECORDED
• .RUBELLA AND HEPATITIS IMMUNISATION IN A
NON-IMMUNISED WOMAN IS OFFERED
• FOLIC ACID SUPPLEMENTATION STARTING
3MTHS PRIOR TO CONCEPTIONUPTO 12WKS
OF PREGNANCY
• MATERNAL HEALTH IS OPTIMISED
PRECONCEPTIONALLY
•
OVERWEIGHT,UNDERWEIGHT,ANAEMIA
ARE TREATED APPROPRIATELY
• .FEAR OF INCOMING PREGNANCY IS
REMOVED
• PATIENT WITH MEDICAL COMPLICATIONS
SHOULD BE EDUCATED ABOUT THE EFFECT
OFDISEASE ON PREGNANCY AND ALSO EFFECT
OF PREGNANCY ON DISEASE
• DRUGS USED BEFORE PREGNANCY ARE
VERIFIED AND CHANGED IF REQUIRED SO AS
TO AVOID ANY ADVERSE EFFECTS ON FETUS
• WOMAN SHOULD BE URGED TO STOP
SMOKING,TAKING ALCOHOL AND ABUSIVE
DRUGS
• INHERITABLE GENETIC DISEASES ARE
SCREENED BEFORE CONCEPTION AND THE
RISK OF PASSING CONDITION TO OFFSPRING IS
DISCUSSED
• COUPLES WITHHISTORY OF RECURRENT FETAL
LOSS OR WITH FAMILY HISTORY OF
CONGENITAL ABNORMALITIES ARE
INVESTIGATED AND COUNSELLED
• LIMITATIONS
•
SMALL PERCENTAGE OF WOMEN TAKE
ADVANTAGE OF PRECONCEPTIONAL CARE
LACK OF PUBLIC AWARNESS
• MOST PREGNANCIES ARE UNPLANNED
AIMS
• .TO SCREEN ‘HIGH RISK’ CASES
• .PREVENT AND TREAT AT THE EARLIEST ANY
COMPLICATIONS
• .ENSURE CONTINUED MEDICAL SURVEILLANCE
AND PROPHYLAXIS
• .EDUCATE THE MOTHER PHYSIOLOGY OF
PREGNANCY AND LABOUR,SO THAT FEAR IS
REMOVED AND PSYCOLOGY IS IMPROVED
• .TO DISCUSS WITH COUPLE PLACE TIME,MODE OF
DELIVERY
• .MOTIVATE COUPLE NEED OF FAMILY PLANNING
AND ADVICE TO COUPLE SEEKING MEDICAL
TERMINATION OF PREGNANCY
• OBJECTIVE
• . TO ENSURE A NORMAL PREGNANCY WITH
DELIVERY OF A HEALTHY BABY FROM A HEALTHY
MOTHER
DIAGNOSIS OF PREGNANCY
•
•
•
•
•
•
•
•
SUBJECTIVE SYMPTOMS
.AMENORRHOEA
.MORNING SICKNESS
.FREQUENCY OF MICTURATION
.BREAST DISCMFORT
OBJECTIVE SIGNS
BREAST CHANGES
PER ABDOMEN
• PELVIC CHANGES
• JACQUEMIERS OR CHADWICKS SIGN
•
DUSKY HUE OF VESTIBULE AND ANTERIOR
VAGINAL WALL 8TH WK OF PREGNANCY
• .VAGINAL SIGN
• BLUISH DISCLOURATION OF ANT VAGINAL WALL
• SOFT WALLS
• OSIANDERS SIGN
•
INCREASED PULSATION FELT THROUGH
LATERAL FORNICES
•
•
•
•
•
•
•
•
•
•
CERVICAL CHANGES
GOODELLS SIGN
SOFTENING OF CERVIX
UTERINE SIGN
SIZEOF HEN AT 6TH WEEK
SIZE OF CRICKET BALL 8TH WEEK
FETAL HEAD 12TH WEEK
GLOBULAR 12TH WEEK
PISKACEKS SIGN
ASSYMETRICAL ENLARGMENT OF UTERUS
• HEGARS SIGN
• 6 TO 10 WKS
• VARIATION IN CONSISTENCY ON BIMANUAL
EXAMINATION
• UPPER PART OF BODY OF UTERUS IS
ENLARGED BY GROWING FETUS
• LOWER PART OF BODY EMPTY AND SOFT
• CERVX IS FIRM
• PALMERS SIGN
• REGULAR RHYTHMIC CONTRACTIONS
ELICITED BY BIMANUAL EXAMINATION BY 4 TO
8 WKS
IMMUNOLOGICAL TEST
• DETECTION OF HCG IN MATERNAL BLOOD
AND URINE BASIS OF THE TEST
• .SANDWICH TYPE IMMUNOASSAY
•
BASED ON ONE MONOCLONAL ANTIBODY
THAT BINDS HCG SECOND ANTIBODY LINKED
WITH ENZYME ALKALINE PHOSPHATASE TO
SANDWICH THE HCG
• DETECTED BY COLOUR CHANGE ATER BINDING
ULTRASOUND
•
•
•
•
GESTATIONAL SAC AND YOLK SAC BY 5WKS
FETAL POLE AND CARDIAC ACTIVITY 6WKS
EMBRYONIC MOVEMENTS 7WKS
GESTATIONAL AGE MEASURED BY CRL
BETWEEN 7 AND 12 WEEKS
• DOPPLER PICKS FETAL HEART BY 10TH WK
PROCEDURE AT FIRST VISIT
•
•
•
•
•
•
•
•
HISTORY TAKING
NAME
DATE OF 1ST EXAMINATION
ADDRESS
AGE
GRAVIDA PARITY
DURATION OF MARRIAGE
RELIGION
•
•
•
•
•
•
•
•
OCCUPATION
OCCUAPATION IF HUSBAND
PERIOD OF GESTATION
COMPLAINTS
HISTORY OF PRESENTING ILLNESS
HISTORY OF PRESENT PREGNANCY
OBSTETRIC HISTORY
MENSTRUAL HISTORY
•
•
•
•
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
FAMILY HISTORY
PERSONAL HISTORY
EXAMINATION
•
•
•
•
•
•
•
BUILT
NUTRITION
HEIGHT,
WEIGHT
PALLOR JAUNDICE
TOUNGE,TEETH,GUMS
OEDEMA OF LEGS
• PULSE
• BP
• BREAST
• ABDOMINAL
• TONE,INCISION,SCARS,HERNIATION
• FUNDUS OF UTERUS WILL BE JUST PALPABLE
ABOVE SYMPHYSIS PUBIS AT 12 WKS
• VAGINAL
• TO DIAGNOSE PREGNANCY
• CORROBRATE SIZE OF UTERUS WITH PEROID
OF AMENORRHOEA
• .TO EXCLUDE PEVIC PATHOLOGY
INVESTIGATIONS
•
•
•
•
HAEMOGLOBIN,ABO,RH TYPING
HIV,HBSAG,VDRL
URINE ROUTINE
ULTRASOUND
PROCEDURE AT SUBSEQUENT VISITS
• CHECK UP IS DONE AT INTERVALS OF 4WKS UPTO
28 WKS;AT INTERVALS OF 2KWSUPTO 36WKS
AND THERAFTER WEEKLY TILL THE EXPECTED
DATE OF DELIVERY
• .WHO RECOMMENDATION
• ATLEAST 3
• 1ST AROUND 2OWKS
• 2ND 32WKS
• 3RD 36WKS
OBJECTIVE
• FETAL WELL BEING
• LIE,PRESENTATION,POSITION.NUMBER OF
FETUSES
• ANAEMIA,PRE ECLAMPSIA,AMNIOTIC FLUID
VOLUME,GROWTH
DANGER SIGNS
•
•
•
•
•
•
•
•
•
BLEEDING PER VAGINA
ABDOMINAL OR PELVIC PAIN
SWELING OF FACE OR LIMBS
BURRING OR DIMUNITION OF VISION
FEVER
PERSISTENT VOMITING
DYUSURIA
ESCAPE OF FLUID FROM VAGINA
MARKED CHANGE IN FREQUENCY OR INTENSITY OF
FETAL MOVEMEMNTS
EXAMINATION
•
•
•
•
•
AT EVERY VISIT
WEIGHT
PALLOR
OEDEMA OF LEGS
BLOOD PRESSURE
ABDOMINAL EXAMINATION
•
•
•
•
•
•
INSPECTION
LINEA NIGRA
STRIAE GRAVIDUM
PALPATION
FUNDAL HEIGHT
TOP OF SYMPHISIS PUBIS TO UPPERMOST
PART OF FUNDUS 20 TO 31 WKS
CORRESPONDS TO PERIOD OF GESTATION
•
•
•
•
•
•
UTERUS FELLS SOFT AND ELASTIC
BRAXTON-HICKS CONTRACTION
PALPATION IF FETAL PARTS
ACTIVE FOETAL MOVEMENTS
EXTERNAL BALLOTMENT
INTERNAL BALLOTMENT
OBSTETRIC GRIPS
• FUNDAL GRIP
• LATERAL OR UMBILICAL GRIP
• FIRST PELVIC GRIP
PAWLIKS GRIP(2ND PELVIC GRIP)
AUSCULTATION
• FHS MOST CONCLUSIVE CLINICAL SIGN OF
PREGNANCY
• 140 TO 160 PER MINUTE
VAGINAL EXAMINATION
•
•
•
•
CONFIRMATION OF PRESENTING PART
STATION OF PRESENTING PART
CLINICAL ASSESMEMNT OF PELVIC CAPACITY
CONSISTENCY,EFFACEMENT,DILATATION OF
CERVIX
INVESTIGATONS
• GCT 24 TO 28WKS
• REPEAT HB 18 TO 20 WKS ,24 TO 28WKS AND
36 WKS
• URINE FOR PROTEIN AT EVERY VISIT
.INDIRECT COOMBS TEST
DONE AT 12WKS,28WKS,36WKS
ULTRASOUND EXAMINATION
• 18 TO 20 WKS
•
FETAL ANATOMY,PLACENTAL
LOCALISATION
• GESTATIONAL AGE MEASURED BPD,HC,AC,FL
• ACCURATE WHEN DONE BETWEEN 12 AND 20
WKS(+/_8 DAYS)
• BPD,HC,FL,AC DETERMINES GESTATIONAL
AGE(+/_ 3 WKS)
• AMNIOTIC FLUID VOLUME
• PLACENTAL ANATOMY
ANTENATAL ADVICE
•
•
•
•
NUTRITION
TO MAINTAIN MATERNAL HEALTH
MEET NEEDS OF GROWING FETUS
STRENGTH AND VITALITY REQUIRED DURING
LABOUR
• SUCCESSFUL LACTATION
• CALORIE REQUIRMENT IS
2200KCAL,INCREASED 3OO KCAL IN SECOND
HALF OF PREGNANCY AND 55O KCAL DURING
LACTATION
• PROTEIN
•
REQUIRED FOR CELL GROWTH,REPAIR OF
FETUS,PLACENTA,UTERUS AND BREASTS
• SECOND HALF OF PREGNANCY 1000g OF
PROTEIN ARE DEPOSITED,AMOUNTING FOR
5TO 6gm/DAY
SUPPLEMENTARY NUTRITONAL
THERAPY
•
•
•
•
•
IRON
REQUIRMENT DURING PREGNANCY 1000mg
300mg iron TRANSFERRED TO FETUS AND PLACENTA
200MG LOST THROUGH EXCRETION
500mg INCORPATED INTO MATERNAL
HAEMOGLOBIN MASS
• 6TO 7mg/day is REQUIRMENT IN MIDPREGNANCY
• 2OOmg iron GIVEN ,CONTAINS 60mg ELEMENTAL
IRON
• CALCIUM
• 1000 TO 1200mg of CALCIUM IS REQUIRED
• THIRD TRIMESTER 200mg CALCIUM
DEPOSITED PER DAY INTO FETAL SKELETON
• TOMEET THE INCREASED DEMANDS
CALCIUM DEMANDS CALCIUM TABLETS ARE
GIVEN FROM SECOND TRIMESTER
VITAMINS
• FOLIC ACID400micrograms IS REQUIRED
DURING PREGNANCY
• 5MG TABLETS ARE GIVEN IN THE FIRST
TRIMESTER TO PREVENT NEURAL TUBE
DEFECTS
• ZINC
• DEFICENCY LEADS TO PPOR
APPETITE,SUBOPTIMAL GROWTH,IMPAIRED
WOUND HEALING
• DWARFISM,HYPOGONADISM,ACRODERMAMT
ITIS ENTEROPATHICA
• 12mg recommended during PREGNANCY
IODINE
• IODISED SALT IS RECOMMENDED DURING
PREGNANCY DUE TO INCREASED FETAL
REQUIREMENTS AND MATERNAL RENAL
LOSSES
• SELENIUM
• DEFENSIVE COMPONENT AGAINST FREE
RADICAL DAMAGE
• DEFICENCY CAUSES FATAL CARDIOMYOPATHY
• POTASSIUM
• CONCENTARATION OF POTASSIUM IN
MATERNAL PLASMA DECREASES BY
.5mEQ/L
• PROLONGED NAUSEA VOMITING CAUSES
HYPOKALEMIA
• SODIUM
• NORMAL DIET PROVIDES ABUNDANCE
OF SODIUM
• VITAMIN A
• ROUTINE SUPPLEMENTATION IS NOT
REQUIRED
• VERY HIGH DOSES CAUES BIRTH DEFECTS
• VITAMIN C
• 80 TO 85 mg/day IS REQUIRED
• CITRUS FRUITS PROVIDES THE DAILY NEED
• VITAMIN B6
•
WOMEN AT HIGH RISK FOR INADEQUTE
NUTRITION Eg SUBSTANCE
ABUSE,ADOLOSCENTS,MULTIFETAL GESTATION
DAILY SUPPLEMENT 2Mg IS RECOMMENDED
COMMON CONCERNS
• REST AND SLEEP
• HARD STRENOUS WORK IS AVOIDEDIN 1ST
TRIMESTER AND LAST 4 WKS
• SLEEP FOR 8HRS AT NIGHT AND 2HRS AT NOON
• BOWEL
• CONSTIPATON PRESENT
• PLENTY OF FLUIDS,VEGETABLES,MILD LAXATIVES
AT BED TIME
• BATHING
• DAILY BATH AND GOOD HYGIENE SHOULD BE
MAINTAINED
• CLOTHING
• LOOSE FITTING COMFORTABLE CLOTHES
• DENTAL CARE
• CONSULT DENTIST EARLIEST
• CARE OF BREASTS
• CLEAN NIPPLES,IF RETRACTED CORRECTION
HAS TO BE DONE
• COITUS
• AVOID DURING 1ST TRIMESTER LAST 6 WEEKS
• RISK OF ABORTION,OR PRETERM LABOUR
•
•
•
•
•
•
TRAVEL
AVOID TRAVEL BY VEHICLES HAVING JERKS
LONG JOURNEY IS LIMITED
RAIL ROUTE IS PREFERRED,AIRCRAFT LESS RISK
SMOKING AND ALCOHOL
STOP SMOKING ,SMOKERS HAVE SMALL
BABIES,INCREASED CHANCE OF ABORTION
• ALCOHOL CAUSeS GROWTH RESTRICTION
• EXERCISE
• INCREASED UTEROPLACENATL FLOW,MORE
OXYGEN IS DELIVERED TO GROWING
FETUS,HELPS IN BETTER GROWTH
• DESTRESSES THE MOTHER
IMMUNISATION
• LIVE VACCINES
(RUBELLA,MEASLES,MUMPS,VARICELLA,YELLOW
FEVER) ARE CONTRAINDICATED
• RABIES,HEPATIS A AND B VACINES,TOXOIDS CAN
BE GIVEN
• IMMUNISATION AGAINST TETANUS .5ML
TETANUS TOXOID GIVEN IM AT 6 WKS INTERVAL
,FIRST DOSE BETWEEN 16 TO 24 WKS.
• BOOSTER DOSE .5ML FOR WOMEN IMMUNISED
IN PAST IN LAST TRIMESTER
COMMON AILMENTS
• NAUSEA AND VOMITING
•
EARLY PREGNANCY’MORNING SICKNESS’
• COMMENCES BETWEEN FIRST AND SECOND
MISSED PERIOD CONTINUES TIL 14 TO 16WKS
• VARICOSITIES
• ENLARGED VEINS ARE EXAGGERATED BY
PROLONGED STANDING,PREGNANCY
• VENOUS PREESURE INCREASES AS
PREGNANCY ADVAVCES
• BACKACHE
• INCREASED LUMBAR LORDOSIS WITH CHANGE IN
POSTURE CAUSES PAIN
• INCREASED LAXITY OF PELVIC LIGAMENTS
• HEMORRHOIDS
•
VARICOSITIES OF RECTAL VEINS ,INCREASED
PRESSURE OF RECTAL VEINS
• OBUSTRUCTION OF VENOUS RETURN BY LARGE
UTERUS
• CONSTIPATION
• HEARTBURN
•
REFLUX OF GASTRIC CONTENTS INTO
LOWER ESOPHAGUS
• UPWARD DISPLACEMENT AND
COMPRESSIONOF STOMACH BY UTERUS,WITH
RELAXATION OF LOWER ESOPHAGEAL
SPHINETER
• PICA
• CRAVINGS(PICA)FOR STRANGE FOODS AND
NONFOODS
ICE(PAGOPHAGIA),STARCH(AMYLOPHAGIA),CL
AY(GEOPHAGIA)
• TRIGGERED BY IRON DEFICIENCY ANAEMIA
• VAGINAL DISCHARGE
•
COMMON IN PREGNANCY
• INCREASED MUCUS SECRETION BY CERVICAL
GLANDS IN RESPONSE TO
HYPERESTROGENEMIA
• INFECTION SHOULD BE RULED OUT
CARPAL TUNNEL SYNDROME
• TINGLING AND NUMBNESS(PARASTHESIA)
OVER THE THUMB AND MEDIAL TWO AND A
HALF FINGERS
• COMPRESSION OF MEDIAN NERVE AND
PERINEURAL OEDEMA
LIMITATIONS
• EVEN WITH FULL ANTENATAL
SUPERVISION,UNEXPLAINED AND
UNPREDICTED COMPLICATIONS MAY ARISE
VAGINAL BLEEDING IN PLACENTA
PRAEVIA,PREMATURE RUPTURE OF
MEMBRANES,UNEXPLAINED IUDS,CORD
PROLAPSE,POSTPARTUM HAEMORRAGE
THANK YOU