Wednesday, May 23, 2012

ANTENATAL CARE



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
                                            |
Early booking, adequate ANC visits, recognition and management of complications
                                            |
Normal vaginal delivery
                                            |
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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