Prenatal care is a type of preventive healthcare with the goal of providing regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child. The availability of routine prenatal care has played a part in reducing maternal death and miscarriages as well as birth defects, low birth weight, and other preventable health problems.
Importance of antenatal care
· Reduce the risk of pregnancy complications. Following a healthy, safe diet; getting regular exercise as advised by a health care provider; and avoiding exposure to potentially harmful substances such as lead and radiation can help reduce the risk for problems during pregnancy and ensure the infant's health and development. Controlling existing conditions, such as high blood pressure and diabetes, is important to avoid serious complications in pregnancy such as preeclampsia.
Reduce risk for infant's complicati · R alcohol use during pregnancy have been shown to increase the risk for e Sudden Infant Death Syndrome. onsTobacco smoke and. Alcohol use also increases the risk for fetal alcohol spectrum disorders, which can cause a variety of problems such as abnormal facial features, having a small head, poor coordination, poor memory, intellectual disability, and problems with the heart, kidneys, or bones. According to one recent study supported by the NIH, these and other long-term problems can occur even with low levels of prenatal alcohol exposure.
In addition, taking 400 micrograms of folic acid daily reduces the risk for neural tube defects by 70%. Most prenatal vitamins contain the recommended 400 micrograms of folic acid as well as other vitamins that pregnant women and their developing fetus need. Folic acid has been added to foods like cereals, breads, pasta, and other grain-based foods. Although a related form (called folate) is present in orange juice and leafy, green vegetables (such as kale and spinach), folate is not absorbed as well as folic acid.
· Help ensure the medications women take are safe. Certain medications, including some acne treatments and dietary and herbal supplements, are not safe to take during pregnancy
Advice for Pregnant Women
• first of all, follow your instincts. If you want the fetus to grow normally, be physically active. You should move a lot. If the mother’s heart works actively, the child receives more of the useful substances which her blood contains.
• · keep in mind: each infection is really dangerous for a fetus. Of course it’s very difficult not to catch a cold during 9 months, but try to prevent it by avoiding places with a lot of people. The most dangerous virus for a pregnant woman is German measles, which influences a fetus badly. Avoid visiting children hospitals. Don’t eat products which may cause diarrhea (be careful with the food you eat and don’t forget to wash your hands);
• · don’t treat any illness yourself, such as a heavy cold or indigestion, with the help of various pills;
• · don’t travel a lot during the last months of pregnancy. A plane or a train is not the best alternative to a maternity hospital.
Generally consists of:
• monthly visits during the first two trimesters (from week 1–28)
weekly visits after 36th week until delivery (delivery at week 38–42)
• Assessment of parental needs and family dynamicPrenatal Examina tion
Ultrasound s, ultrasounds are used to:
• Diagnose pregnancy (uncommon)
• Check for multiple fetuses
• Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
• Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)
• Determine if an intrauterine growth retardation condition exists
• Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other
amniotic fluid and umbilical cord for possible problems
• Determine due date (based on measurements and relation developmental progress)
Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:
• 7 weeks — confirm pregnancy, ensure that it's neither molar or ectopic, determine due date
• 13–14 weeks (some areas) — evaluate the possibility of Down Syndrome
• 18–20 weeks — see the expanded list above
• 34 weeks (some areas) — evaluate size, verify placental position
Prenatal care is important in screening for various complications of pregnancy. This includes routine office visits with physical exams and routine lab tests
First trimester
• Complete blood count (CBC)
• Blood type
• General antibody screen (indirect Coombs test) for HDN
• Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease.
• Rapid plasma reagin (RPR) to screen for syphilis
• Rubella antibody screen
• Hepatitis B surface antigen
• Gonorrhea and Chlamydia culture
• PPD for tuberculosis
• Pap smear
• Urinalysis and culture
• HIV screen
First trimester screening varies by country. Women are typically offered: Complete Blood Count (CBC), Blood Group and Antibody screening (1Group and Save), Syphilis, Hepatitis B, HIV, Rubella immunity and urine microbiology and sensitivity to test for bacteria in the urine without symptoms. Additionally, women under 25 years of age are offered chlamydia testing via a urine sample, and women considered high risk are screened for Sickle Cell disease and Thalassemia. Women must consent to all tests before they are carried out. The woman's blood pressure, height and weight are measured, and her Body Mass Index (BMI) calculated. This is the only time her weight is recorded routinely. Her family history, obstetric history, medical history and social history are discussed.
Women usually have their first ultrasound scan at around twelve weeks. This is a trans-abdominal ultrasound. This is the scan from which the pregnancy is dated and the woman's 1estimated due date (or EDD) is worked out. At this scan, some NHS Trusts offer women the opportunity to have screening for Down's Syndrome. If it is done at this point, both the 1nuchal fold is measured and a blood test taken from the mother. The result comes back as an odd's risk for the fetus having Down's Syndrome. This is somewhere between 1:2 (high risk) to 1:100,000 (low risk). High risk women (who have a risk of greater than about 1:150) are offered further tests, which are diagnostic. These tests are invasive and carry a risk of miscarriage.
Second trimester
• sound either abdominal or trannsvaginal to assess cervix, placenta, fluid and baby
• Amniocentesis is the national standard (in what country) for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history.
. The woman's blood pressure is measured and a urinalysis done. The woman has the opportunity to ask questions.
At around twenty weeks, the woman has an 1anomaly scan. This trans-abdominal ultrasound scan checks on the anatomical development of the fetus. It is a detailed scan and checks all the major organs. As a consequence, if the fetus is not in a good position for the scan, the woman may be sent off for a walk and asked to return. At this scan, the position of the placenta is noted, to ensure it is not low. Cervical assessment is not routinely carried out.
Third trimester
• [Hematocrit] (if low, the mother receives iron supplements)
• Group B Streptococcus screen. If positive, the woman receives IV penicillin or ampicillin while in labor—or, if she is allergic to penicillin, an alternative therapy, such as IV clindamycin or IV vancomycin.
• Glucose loading test (GLT) - screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; a fasting glucose > 105 mg/dL suggests gestational diabetes.
During the third trimester, women have further blood tests. Blood is taken for Full Blood Count (FBC) and a Group and Save to confirm her blood group, and as a further check for antibodies. This may routinely be done twice in the third trimester. A Glucose Tolerance Test (GTT) is done for women with risk factors for Gestational Diabetes. This includes women with a raised BMI, women of certain ethnic origins and women who have a first degree relative with diabetes. A vaginal swab for Group B Streptococcus (GBS) is only be taken for women known to have had a GBS-affected baby in the past, or for women who have had a urine culture positive for GBS during this pregnancy
Imaging is another important way to monitor a pregnancy. The mother and fetus are also usually imaged in the first trimester of pregnancy. This is done to predict problems with the mother; confirm that a pregnancy is present inside the uterus; estimate the gestational age; determine the number of fetuses and placentae; evaluate for an ectopic pregnancy and first trimester bleeding; and assess for early signs of anomalies.
X-rays and computerized tomography (CT) are not used, especially in the first trimester, due to the ionizing radiation, which has teratogenic effects on the fetus. obstetric ultrasonography is the imaging method of choice in the first trimester and throughout the pregnancy, because it emits no radiation, is portable, and allows for realtime imaging.
Ultrasound imaging may be done at any time throughout the pregnancy, but usually happens at the 12th week (dating scan) and the 20th week (detailed scan).
Fetal assessments
• Fetal hematocrit for the assessment of fetal anemia, Rh isoimmunization, or hydrops can be determined by percutaneous umbilical blood sampling (PUBS), which is done by placing a needle through the abdomen into the uterus and taking a portion of the umbilical cord.
• Fetal lung maturity is associated with how much surfactant the fetus is producing. Reduced production of surfactant indicates decreased lung maturity and is a high risk factor for infant respiratory distress syndrome. Typically a lecithin:sphingomyelin ratio greater than 1.5 is associated with increased lung maturity.
• Nonstress test (NST) for fetal heart rate
• Oxytocin challenge test
. Measurement of weight and body mass index
7.2. Breast examination
Breast examination at the first antenatal appointment was traditionally used to determine whether any problems with breastfeeding could be anticipated. In particular, women were examined for the presence of flat or inverted nipples as potential obstacles to breastfeeding so that breast shields or nipple exercises could be prescribed to remedy the situation
7.3. Pelvic examination
Pelvic examination during pregnancy is used to detect a number of clinical conditions such as anatomical abnormalities and sexually transmitted infections, to evaluate the size of a woman’s pelvis (pelvimetry) and to assess the uterine cervix so as to be able to detect signs of cervical incompetence (associated with recurrent mid-trimester miscarriages) or to predict preterm labour .
Pregnant Abdomen Examination
I - General Examination
The obstetric examination begins by looking at the patient. Pay particular attention to:
• General appearance – fatigue/exhausted, anxious, depressed, nausea
• Does she appear pallor or breathlessness?
• Does she have difficulty getting up and walk from the waiting room to the clinic room?
Measure the mother’s height and weight if this has not been done. Generally:
• Smaller women tend to have smaller babies
• Patients with a high BMI are more likely to develop gestational diabetes, macrosomnia, and polyhydramnios
Measure the mother’s blood pressure and check her urine dipstix if this has not been done. This is to identify:
• Hypertension
• Proteinuria
• Glucosuria
• UTIs
On inspection, there are 5 signs that you should focus and comment on (see FIG 1).
Size
• The uterus is normally visible in the abdomen at 12-14 weeks of gestation
• It will reach the level of the umbilicus at around 20 weeks of gestation
• The uterus will reach maximum height at the level of the xiphisternum at 36 weeks
Note: the size and shape of the uterus should be regular and symmetrical unless there are multiple pregnancies or polyhydramnios.
Scars
• The most important scar to look for is the Pfannenstiel scar, which is a transverse scar across the lower abdomen. The Pfannenstiel scar indicates a previous Caesarean-section.
• Other scars to look for are laparoscopic scars and laparotomy scars, if indicated in the patient’s previous surgical history.
Skin Changes
• Striae gravidarum, or stretch marks, are caused by pregnancy hormones of the current pregnancy. They appear red and inflamed and occur early in the pregnancy. Patients may complain of discomfort and pruritus around the area.
• Striae albicantes are stretch marks from previous pregnancies. They appear as white and silvery. These stretch marks are more common in the lower abdomen, upper thighs and buttocks.
• Linea nigra is the hyperpigmentation of the midline linea alba. Similarly, the hyperpigmentation is caused by the pregnancy hormones of the current pregnancy.
Fetal movements
• Fetal movements are visible after 24 weeks – which can be used as a way to confirm viability of the fetus
Umbilicus
• The umbilicus becomes flattened as the pregnancy progresses to term (i.e. normal).
• May become flattened and everted in multiple pregnancy and polyhydramnios.
III - Palpation
Palpation of the pregnant abdomen must be gentle and careful, as pregnant woman can be quite sensitive about the health of the fetus. It is quite useful to start with a general palpation of the four quadrants of the abdomen. However, before you place your hands on the abdomen, always ask about areas of pain and tenderness. As a general rule: always palpate these areas last.
The palpation of the abdomen serves several purposes; by the end of palpation, you should be able to comment on:
• Fetal growth
• Liquor volume
• Multiple pregnancies
• Fetal lie and presentation
IV - Percussion and Auscultation
Percussion
There is no significance of percussion in the examination. However, if you suspect polyhydramnios, you can confirm by a showing a positive fluid thrill with a negative shifting dullness.
Auscultation
You will need a hand-held Doppler monitor or a Pinard stethoscope (see Fig 4). It is recommended that you should use a Pinard stethoscope after 28 weeks.
• Place the Doppler transducer or the Pinard stethoscope over the anterior shoulder, usually between the symphysis pubis and the umbilicus.
Interpretation: the fetal heart rate is between 110-160 b.p.m. You can simultaneously feel for the maternal’s radial pulse to distinguish between the two individuals.
Complications and emergencies
The main emergencies include:
• Ectopic pregnancy is when an embryo implants in the uterine (Fallopian) tube or (rarely) on the ovary or inside the peritoneal cavity. This may cause massive internal bleeding.
• Pre-eclampsia is a disease defined by a combination of signs and symptoms that are related to maternal hypertension. The cause is unknown, and markers are being sought to predict its development from the earliest stages of pregnancy. Some unknown factors cause vascular damage in the endothelium, causing hypertension. If severe, it progresses to eclampsia, where seizures occur, which can be fatal. Preeclamptic patients with the HELLP syndrome show liver failure and Disseminated intravascular coagulation (DIC). The only treatment is to deliver the fetus. Women may still develop pre-eclampsia following delivery.
• Placental abruption is where the placenta detaches from the uterus and the woman and fetus can bleed to death if not managed appropriately.
• Fetal distress where the fetus is getting compromised in the uterine environment.
• Uterine rupture can occur during obstructed labor and endanger fetal and maternal life.
• Prolapsed cord can only happen after the membranes have ruptured. The umbilical cord delivers before the presenting part of the fetus. If the fetus is not delivered within minutes, or the pressure taken off the cord, the fetus dies.
• Obstetrical hemorrhage may be due to a number of factors such as placenta previa, uterine rupture or tears, uterine atony, retained placenta or placental fragments, or bleeding disorders.
• Puerperal sepsis is an ascending infection of the genital tract. It may happen during or after labour. Signs to look out for include signs of infection (pyrexia or hypothermia, raised heart rate and respiratory rate, reduced blood pressure), and abdominal pain, offensive lochia (blood loss) increased lochia, clots, diarrhea and vomiting.
Intercurrent diseases
In addition to complications of pregnancy that can arise, a pregnant woman may have intercurrent diseases, that is, other diseases or conditions (not directly caused by the pregnancy) that may become worse or be a potential risk to the pregnancy.
• Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus (not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage, growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects.
• Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus.
• Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy, and may cause a previously unnoticed thyroid disorder to worsen.
• Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis (blood clots). Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability), as a physiologically adaptive mechanism to prevent post partum bleeding However, when combined with an additional underlying hypercoagulable states, the risk of thrombosis or embolism may become substantial.
Recommended texts
• Douglas G, Nicol F, Robertson C (eds). Macleod’s Clinical Examination. 11th ed. Churchill Livingstone. 2009
• Impey L, Child T. Obstetrics and Gynaecology. 3rd ed. Wiley Blackwell: London. 2008
• Beckman C, Ling F et al [in collaboration with ACOG]. Obstetrics and Gynecology. 6th ed. Lippincott Williams and Wilkins. 2009
