Antenatal care warda [compatibility mode]

By
Osama M. Warda MDOsama M. Warda MD
Professor of OB/GYN
Mansoura University
Thursday, May 09, 2013 O Warda

Definition
Antenatal care is the program of
preventive obstetrics in which
regular visits are used to detect andregular visits are used to detect and
manage any health problems and
complications during pregnancy.

The Objectives of Prenatal Care
Healthy baby & healthy mother.
Promotion of medical, physical & mental
health .
Avoid and treat medical or obstetric
conditions that are dangerous to the mother
or fetus.
Ensure adequate dietary intake .
Instructions for the hygiene of pregnancy.
Preparation for breast feeding.

COMPONENTS OF A.N. CARE
-Pre-conception care
-Frequency of antenatal visits
-The initial visit-The initial visit
-Follow-up visits
-Health education; diet-hygiene-
physiology of pregnancy and labor

Preconception care
Should be an integral part of
prenatal care because healthprenatal care because health
during pregnancy depends on
health before pregnancy.

Frequency of Visits
During the first 7 months: Every month.
During the 8th month : Every 2 weeks.
During the 9th month : Weekly.During the 9th month : Weekly.
The median number of visits made by women is 13.
In cases of high-risk pregnancy ; frequency is
increased according to circumstances.

The Initial Visit
The goals:
1. Detection of high risk pregnancy.
2. Determine the GA and EDD. (HOW??)2. Determine the GA and EDD. (HOW??)
3. To define the health status of the mother and
fetus.
4. Initiate a plan for continued care until
delivery.

The Initial Visit; components
A. Diagnosis of pregnancy and accurate
dating
B. Obstetric case taking [History taking+
Clinical exam + Bedside tests]Clinical exam + Bedside tests]
Certain points should be put in mind;
The examiner must be aware of the normalnormalnormalnormal
changes found in pregnancy as well as the
pathologicpathologicpathologicpathologic changes that may develop during
pregnancy.

The Initial Visit; SPECIAL NOTE S:
a. External genitalia : Evidence of previous obstetric injury.
b. Vagina:
Screening for bacterial vaginosis is done only for women at
high risk for preterm labor (Hx)high risk for preterm labor (Hx)
No treatment for increased vaginal discharge unless
diagnosis of specific infection is made
c. Cervix:
Pap. smear and culture for gonorrhea routinely in
areas where sexually transmitted diseases (STD) are
prevalent.
Clamydia culture performed in high risk population.

Investigations Done at First Visit:
1. Routine initial screen:
Complete blood picture CBC.
ABO/Rh typing.
Complete urine analysis for bacteriuria,Complete urine analysis for bacteriuria,
glucosuria, proteinuria and culture if
needed
HBV surface antigen and test for syphilis.
Rubella titer.
Other investigation according to the case.

2. Specialized screening tests :
HIV infection for high risk group.
HB electrophoresis.
Urine or blood toxicology screen.
Only when indicated

3. Mid trimester screening tests:
Maternal serum Alfa-fetoprotein (AFP)
between 16-18 weeks. NTD
1 hour glucose screening between 24 & 28
weeks. Value equal to or greater than 140
mg/dl is evaluated by 3 hours oral glucose
tolerance.

Repeated tests
Hb% and Hct 26 to 30 weeks.
Serology of syphilis at 28 to 32 weeks for
high risk group.
Antibody screen in Rh-ve women betweenAntibody screen in Rh-ve women between
28-30 weeks and(Rh D Ig) is administered if
needed.
3rd trimester screening for gonorrhea and
chlamydia is recommended in high risk
group.

Risk Factors
Pre-existing medical disease.
Previous pregnancy complications:
Perinatal mortality, prematrity, IUGR,
congenital fetal malformation and obstetric hge.
Evidence of poor nutrition.

Risk Factors
Genetic counseling is indicated in the
following conditions
Maternal age >35 years at the time of
birth.birth.
Family history of congenital anomalies
or inherited disorders.
Abnormal development or mental
retardation of previous child.
Exposure to teratogens.
Habitual 1ST trimester abortionThursday, May 09, 2013 O Warda

Education of the Pregnant Mother
1. DIET:
A. Calories:
The requirements increase from 2200 toThe requirements increase from 2200 to
2500 Kilocalories (Kcal). The additional
energy required is more than 300 Kcal
but is reduced by reduced physical
activity.

-DIET-
B. Proteins:
Increased protein demands are needed for fetal,
uterine, placental and breast growth and increased
blood volume.blood volume.
During the last 6 months of pregnancy 1 kg of protein
is deposited amounting to 5-6 grams per day.
The majority is required as animal proteins (meat,
milk, eggs). Milk is the ideal source. Lactose
intolerance can be prevented by eating yoghurt and
cheese.

C. Fats and Carbohydrates:
Fried food, cream, sweets, chocolates and
sugar should be consumed sensibly to avoid
excess weight gain.excess weight gain.
Jams, cakes, pastries, biscuits and large
quantities of bread and potatoes should also
be restricted.

D. Vitamins and Minerals:
Iron is the only nutrient for which requirements
are not met by diet alone.
Daily requirement is 30-60 mg of which only 30%
are absorbed. Daily elemental iron requirement isare absorbed. Daily elemental iron requirement is
7mg.
Total requirement allover pregnancy is 1GRAM.
Iron should NOT be prescribed before 14th week

Calcium: Two glasses of milk every day are
sufficient.
Multivitamin routine prescription is notMultivitamin routine prescription is not
recommended. Balanced diet is sufficient.
Sodium: Salting food to taste gives
sufficient salt.
Iodine: Deficiency may lead to congenital
goiter and maternal goiter.

Vitamin A: Daily requirement in pregnancy
is 5000 I.U. over-dosage is teratogenic
Vitamin B6: Deficiency may cause
vomiting. It is only found in animal proteinsvomiting. It is only found in animal proteins
Folic acid: About 1 mg provides very
effective prophylaxis against megaloblastic
anemia. Folic acid supplementation before
pregnancy significantly reduces the risk of
neural tube defects (NTD).

E. Coffee and Tea:
There is no association with birth defects or
low birth weight but excess consumption can
increase irritability and disturb sleep. Caffeineincrease irritability and disturb sleep. Caffeine
present in coffee, tea and chocolate reduces
iron absorption.

F. General dietary instructions
1. Advise mothers to eat what she wants in the
amounts she desires and salted to taste.
2. Ensure she is gaining ample weight. Weight gain
during pregnancy: About 12 kg.during pregnancy: About 12 kg.
Recommended Daily Diet
Protein: meat or fish 120 gm / day.
Milk: 0.75 Liter / day. Egg: 1 / day.
Bread: 2 - 3 slices. Potato or rice 2/ day.
+ Fresh vegetables and fruits

Sleep:
Adequate rest of about 8 hours at night and 2 hours in
the afternoon is recommended.
Exercise:Exercise:
Regular exercise improves metabolic deficiency.
Exercise does not increase the rate of spontaneous
abortion, it shortens active labor and is associated with
fewer C.S.
Exercise is avoided in women with twin pregnancies,
pregnancy-induced hypertension, growth restricted
fetuses and severe heart and lung diseases.

Work:
Birth weights of women who work during the third
trimester are 150-400 gm less than those who do not
work.work.
Standing was also associated with increase in preterm
births. Any occupation that causes severe physical
strain is avoided.
Pregnant women who should properly not work include:
History of two preterm deliveries.
Incompetent cervix.
Fetal loss secondary to uterine abnormalities.
Cardiac disease greater than class II.Thursday, May 09, 2013 O Warda

Traveling:
This has no harmful effect. Air travel is also safe but in
long trips of more than 6 hours the woman should
walk about every 2 hours to prevent deep venouswalk about every 2 hours to prevent deep venous
thrombosis. The greatest risk is to travel away from
proper medical facilities.

Coitus:
There is no restriction for the patient
without complication. It is contraindicatedwithout complication. It is contraindicated
when pregnancy complication occurs as
undiagnosed pPROM or known placenta
previa

Clothing:
It should he practical and non-restricting. High heels
are avoided to prevent loss of balance and prevent
increased lordosis.increased lordosis.

Care of Teeth:
Pregnancy is not a contraindication for any dental
treatment. The concept that pregnancy aggravates
dental caries is not true.dental caries is not true.

Breasts:
Well fitting supporting brassieres are required as
breasts become heavy and pendulous.
Crusts or dried secretion over the nipples areCrusts or dried secretion over the nipples are
washed by warm water or boric acid.
The nipples are drawn for a short time daily by the
thumb and fingers and painted with a lubricant
starting at the 36th week.

Bowels:
Bowel habits become irregular due to relaxation of' the
bowel smooth muscles and compression of the lower
bowel by the pregnant uterus.bowel by the pregnant uterus.
Hemorrhoids are common.
Prevention of constipation is by drinking sufficient
amounts of fluid, daily exercise, food containing
roughage as fruit and salad.
Strong laxatives and enemas are avoided

Bathing:
There are no restrictions but the mother should be
careful not to slip. Showers are safer.
Douching:Douching:
Douching is condemned either in pregnant (risk of
ascending infection and persistent vaginitis) or non-
pregnant (risk of PID and ectopic pregnancy) and just
the ordinary vulvar washing with good gentle dryness
is recommended

Smoking:
Should be discontinued during pregnancy.
More than 10 cigarettes/day can have a pronounced
affect on birth weight. Low birth weights, IUGR,affect on birth weight. Low birth weights, IUGR,
increased peri-natal deaths and preterm labors are
higher in smokers.

Immunization:
Live attenuated virus vaccines as measles, rubella,
mumps, poliomyelitis are contraindicated.
Inactivated virus vaccines as influenza, and rabies areInactivated virus vaccines as influenza, and rabies are
safe.
Inactivated bacterial vaccines as cholera,
meningococcus, and typhoid are safe.
Toxoids as tetanus and diphtheria toxoid are safe.
Immuneglobulins as for hepatitis, tetanus and rabies can
be given whenever needed..

Warning Signs:
Swelling of the face, fingers
and limbs.
Vaginal bleeding.
Persistent vomiting.
Chills and Fever.
Escape of fluid from theSevere headache.
Blurring of vision.
Abdominal pain.
Escape of fluid from the
vagina.
Preterm labor.

Antenatal care warda [compatibility mode]

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