Case: A 35 year old lady G4 P2 A1 comes to you for the first time for her pregnancy check up. She does not clearly remember her LMP. She says she hasn’t been menstruating for a few months. On PA examination you find uterus palpable 4cm above the pubic symphysis. What would you like to do the next?
What is antenatal care ?
Why is it important , what is the aim of doing ANC?
What do we do in antenatal care?
Definition
It is the clinical assessment and care of mother and fetus during pregnancy for the purpose of obtaining the best possible outcome for both mother and child
Ideal situation
Women to be seen prepregnancy, take advise offered and enter pregnancy in optimum health and mental condition
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Early booking, adequate ANC visits, recognition and management of complications
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Normal vaginal delivery
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Healthy baby and healthy mother
AIM
- To promote ,protect and maintain the health of the mother during pregnancy
- To detect high risk cases and give them special attention
- To forsee complications and manage them
- Maternal education regarding elements of child care, nutrition, personal hygiene , birth preparedness
- To remove anxiety and fear associated with pregnancy and childbirth
Decrease the maternal and infant mortality
Ensure that the whole pregancy and childbirth is a happy and fruitful experience
What do we do in ANC ?
- EVALUATE : history, examination, investigations
- RECOGNIZE /ADVICE / TREAT
recognize complications,
give advice /educate mother,
treat complications , treat specific
conditions, supplement deficiencies etc
Women comes to hospital
DETAILED HISTORY
Identification, education, occupation
Menstrual history : LMP
calculate her POG and EDD (Naegeles formula: 9months +7 days from the first day of LMP)
Presenting complaint : early/late pregnancy
Obstetric History: Parity,gravida,year of birth, spacing, abortions, ANC ,labour , delivery and outcome of each preceding pregnancy in detail
G P A L
Contraception used
Booking visit
Medical history : HTN, DM,Anaemia,bleeding disorders,Heart disease etc
Surgical history : any previous surgery on uterus eg myomectomy,pelvic surgery,VVF repair
Family History: congenital anomalies,inherited disorders , twinning, HTN,DM etc
Personal history : allergies, diet, smoking , drugs and alcohol intake
EXAMINATION
GENERAL EXAMINATION
height, weight , nutrition status
vitals
Pallor,oedema,jaundice
Neck
CHEST EXAMINATION
Lung, Heart
breast examination
OBSTETRIC EXAMINATION
PA: size of uterus (corresponding or not with POG) ,diagnose pregnancy, any scar
If 20 weeks and more, palpate fetal parts, FHS
PS : examine cervix/vagina
PV: to diagnose pregnancy, size of uterus, exclude any other pelvic pathology , pelvic size assessment not done at this time
INVESTIGATION
Blood : Hgb, ABO and Rh
blood sugar /OGT esp in high risk cases
VDRL, HBsAg, HIV
Urine : routine
Stool : routine
USG : bleeding PV,not sure of dates,previous history of nonviable fetus, twin history,disparity between POG and clinical assessment
Subsequent visits
- Monthly till 28 weeks, then 2 weekly till 36 weeks and then weekly till delivery
- History: Fetal movement, danger symptoms and signs ( bleeding PV, pain abdomen, persistent headache, persistent vomiting, leaking PV, marked swelling of hands and legs)
- EXAMINATION: weight, BP ,pallor , edema ,Obstetric examination : SFH , lie, presentation, FHS , engagement etc as the pregnancy advances
PV : after 37 weeks to assess the size of the pelvis, assess cervix (bishops scoring) if planning induction.
INVESTIGATION
Urine alb and sugar at every visit
Blood sugar after 28 weeks
Anti D titre in case RH negative at 28 and 36
weeks
USG at 16-20 weeks
INTERVENTION
* check all investigations and treat accordingly
* maintain record at every visit : ANC card
* Supplementation
i) Iron : 60mg of elemental iron (ferrous sulphate tabs) daily, start after 20 weeks
anaemia is very common in pregnancy
symptomless
easily correctable
adverse effect on fetus
ii) folic acid supplementation : 500 microgram daily also to combat anaemia
iii) calcium : 1000mg /daily
iv) vitamins : vit C 50mg/day, thiamine, riboflavin , vit B 12 etc
* Immunization: to prevent neonatal tetanus with 2 doses of 0.5ml adsorbed TT injection
first dose at 16-20weeks and the second dose after 4 weeks
if already immunized then single booster dose can be given
* Reinforce advice on nutrition ,personal care and hygiene, FP (Family Planning) method usage, Fetal movement
As the pregnancy reaches term ,advise regarding signs of labor, symptoms of complications , birth preparedness
* Referral in case of anticipated complications where facilities are not available
* Special attention to high risk cases
High risk cases
Elderly primi (> 35 years),grand multipara (>5 births)
APH (Antepartum hemorrhage)
PIH (Pregnancy Induced Hypertension)
Malpresentation
Anaemic
Twins
Previous LSCS
Previous SB (Still birth), IUFD (Intrauterine Fetal Death), MTP (Medical Termination Of Pregnancy)
Associated any medical conditions
Simple advises
Diet : increased demand of pregnancy
Daily calorie requirement :
2200KC nonpregnant state
2500KC in pregnancy
2900KC during lactation
The diet should be healthy and nutritious, affordable and should contain protein (55g/day)and also include milk(1/2 liter to 1 liter /day) ,vitamins ,plenty of water, green leafy vegetables, fruits and nuts.
Help to achieve adequate weight gain ~12 kg
Personal hygiene
Activity : can do all normal activities,avoid hard work towards the end of pregnancy
Adequate rest with 8hrs sleep at night and 2
hr rest in day time
Preventing constipation: plenty of fluids, fibre in diet , try and avoid laxatives
Care of teeth, breast
Coitus : preferably avoided in first trimester and in the last 6 weeks
Smoking : to be avoided
risk of LBW, hypoxia in fetus
Alcohol : to be avoided as increased risk of teratogenicity, spontanous abortion, MR (Mental Retardation) , IUGR (Intra-uterine Growth Retardation)
Drugs: to avoid use of any drugs in pregnancy specailly those that are teratogenic eg gentamycin, sodium valprotae, tetracycline, LSD etc . To change to safer alternatives in case of any medical conditions needing treatment
Avoid Radiation of any kind
Conclusion
- ANC is an integral part of maternal and fetal health helping to ensure that the mother and fetus are in optimum health before going into labour .
- Helps prepare the patient mentally and physically for labour
- Every pregnant women should be encouraged to attend ANC
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