What possible complications to look for: Antepartum haemorrhage Pre-eclampsia proteinuria and a rise in the blood pressure. Cervical changes Symphysis-fundus height measurement below the 10th centile? above the 90th centile?

1. Antenatal
assessment:
Subsequent visits
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2. The visit at 26 weeks
• What possible complications to look for:
– Antepartum haemorrhage
– Pre-eclampsia
• proteinuria and a rise in the blood pressure.
– Cervical changes
– Symphysis-fundus height measurement
• below the 10th centile?
• above the 90th centile?
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3. The visit at 26 weeks
• What possible complications to look for:
– Anemia
– A glucose profile needs to be done on all
women at risk for gestational diabetes
– Umbilical artery Doppler
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4. Measuring the height of the
mother’s uterus
• Baby growing?
• Do you remember what the domed
region at the top of the uterus is
called?
• - The fundus
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5. • At about three months (13-14 weeks), the top of the
uterus is usually just above the mother’s pubic bone
(where her pubic hair begins).
• At about five months (20-22 weeks), the top of the uterus
is usually right at the mother’s bellybutton (umbilicus or
navel).
• At about eight to nine months (36-40 weeks), the top of
the uterus is almost up to the bottom of the mother’s ribs.
• Babies may drop lower in the weeks just before birth
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6. How to measure the fundal height
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7. How to measure fundal height
using the finger method
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8. • Look at the diagrams below (a) and
(b). How many weeks pregnant is the
woman in each case, based on the
finger method of measuring fundal
height?
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9. How to measure fundal height
using a soft tape measure
• During the second half of pregnancy, the size of the uterus in
centimetres is close to the number of weeks that the woman has been
pregnant. For example, if it has been 24 weeks since her last normal
menstrual period, the uterus will usually measure 22-26 cm. The uterus
should grow about 1 cm every week, or 4 cm every month.
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10. Larger than normal uterus
• Signs of twins are
that:
– The uterus grows faster or
larger than normal.
– You can feel two heads or
two bottoms when you feel
the mother’s abdomen.
– You can hear two
heartbeats. This is not easy
to detect, but it may be
possible in the last few
months.
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11. What would you expect to find it
the woman has:
• Diabetes?
• Too much water in the uterus?
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12. Case Study: Abby
• Abby is a pregnant woman, whose duration of gestation
based on her last normal menstrual period (LNMP) is six
months. When you examine her, you can feel that the
fundus is four finger-widths above her bellybutton and
you can hear a fetal heartbeat clearly.
– a. What is your assessment of the gestational age of Abby’s
baby using fundal height measurement?
– b. How many centimetres would Abby’s abdomen measure from
her pubic bone to the top of her uterus in order to confirm your
fundal height measurement?
– c. Is the gestational age of Abby’s baby based on fundal height
measurement consistent with the gestational age calculated from
her LNMP?
– d. What possible explanations can you give for your findings in
Abby’s case, and what actions should you take?
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13. Why is an antepartum
haemorrhage a serious sign?
• Abruptio placentae causes many perinatal
deaths.
• It may also be a warning sign of placenta
praevia.
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14. How should you monitor the
fetal condition?
• All women should be asked about the frequency of fetal
movements and informed that they must report immediately if the
movements suddenly decrease or stop.
• If a patient has possible intra-uterine growth restriction or a history of
a previous fetal death, umbilical artery Doppler needs to be done to
assess placental function.
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16. The visits at 30, 34
and 36 weeks:
Why are these visits important?
• All the risk factors of importance at 26 weeks
are still important and must be excluded.
• If the first syphilis and HIV screens were negative,
they should be repeated at 30 weeks gestation
to detect infections during pregnancy.
• The lie of the fetus is now very important and
must be determined at 34 weeks. If the
presenting part is not cephalic, then an external
cephalic version must be attempted at 38
weeks if there are no contraindications. A
grande multipara who goes into labour with an
abnormal lie is at high risk of rupturing her
uterus.
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17. The visits at 30, 34
and 36 weeks:
Why are these visits important?
• Patients who have had a previous Caesarean section
must be assessed at 36 weeks with a view to the safest
method of delivery. A patient with a small pelvis, a previous
classical Caesarean section, as well as other recurrent
causes for a Caesarean section must be booked for an
elective Caesarean section at 39 weeks. A patient’s
preference regarding the route of delivery also needs to be
determined. If all the requirements for vaginal birth after
previous Caesarean section could be met, the final decision
lies with the patient’s preference.
• The patient’s breasts must be examined again at 36 weeks
for flat or inverted nipples, or eczema of the areolae which
may impair breastfeeding. Eczema should be treated with
steroid ointment.
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18. Why is the visit at 40 weeks important?
• A patient whose pregnancy extends
beyond 41 weeks has an increased
risk of developing the following
complications:
– Intrapartum fetal distress.
– Meconium aspiration.
– Intra-uterine death.
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19. How should you manage a patient
who is 40 weeks pregnant?
• A patient with a complication such as intra-
uterine growth restriction or pre-eclampsia must
have labour induced.
• A patient who booked early and was sure of her
last menstrual period and where, at the booking
visit, the size of the uterus corresponded to the
duration of pregnancy by dates must have the
labour induced on the day she reaches 41
completed weeks.
• The same applies to a patient whose duration of
pregnancy was confirmed by ultrasound
examination before 24 weeks.
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20. How should you manage a patient
who is 40 weeks pregnant?
• A patient who is unsure of her dates, or who
booked late, must have an ultrasound
examination on the day she reaches 41
completed weeks to determine the amount of
amniotic fluid present.
• If the amniotic fluid index (AFI) is 5 or more (or if
the largest pool of liquor measures 3 cm or more)
and the patient reports good fetal movement, she
should be reassessed in 1 week’s time.
• If the AFI is less than 5 (or if the largest pool of
liquor measures less than 3 cm), labour must be
induced.
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21. How should the history, clinical findings and results of the
special investigations be recorded in low-risk patients?
• Maternity Case Record that includes an
antenatal record which records all the patient’s
antenatal information.
• The clinic need only record the patient’s
personal details such as name, address and age
together with the dates of her clinic visits and the
result of any special investigations.
• The page of the Maternity Case Record is for the
patient’s personal details, history, estimated
gestational age, examination findings, results of
the special investigations, plan of management,
and proposed future family planning.
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22. What topics should you discuss with patients
during the health education sessions?
• Dangerous symptoms.
• Dangerous habits, e.g. smoking, drinking
alcohol or illicit drug usage.
• Healthy eating.
• Family planning.
• Breastfeeding.
• Care of the newborn infant.
• The onset of labour and labour must also be
included when the patient is a primigravida.
• Avoiding HIV infection or the importance of
adherence with antiretrovirals if living with HIV.
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23. What symptoms, which may indicate the
presence of serious complications, must be
discussed with patients?
Symptoms that suggest
abruptio placentae
• Vaginal bleeding.
• Persistent, severe
abdominal pain.
• Decreased fetal
movements.
Symptoms that suggest
pre-eclampsia
• Persistent headache.
• Flashes before the eyes.
• Sudden swelling of the
hands, feet or face.
• Shortness of breath
(dyspnoea).
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24. What symptoms, which may indicate the
presence of serious complications, must be
discussed with patients?
Symptoms that suggest
preterm labour
• Rupture of the
membranes.
• Regular uterine
contractions before the
expected date of
delivery.
Supplements to be taken
• Iron supplements
• Calcium
supplementation
• Folic acid
supplementation
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25. Finding the baby’s position in
the uterus
• Healthy signs
– There is only one baby in the uterus.
– The baby is head down at the time of
birth.
• Warning signs
– The baby is feet or bottom down at the
time of birth.
– The baby is lying sideways at the time
of birth.
– The mother has twins or triplets.
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26. Feeling the mother’s abdomen
• It may be difficult to find the position of the baby before
the sixth or seventh month of gestation, and it is not
important until 36 weeks (eight months) because it is
normal for the baby to move around until the final month
Once the pregnancy is at six or seven months, it will be
easier to feel the baby and find its position in the uterus.
• To begin, help the mother lie on her back and give her
support under her knees and head. Make sure she is
comfortable. The questions you are trying to answer
when you examine her are:
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27. Is the baby vertical?
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28. Is the baby facing the mother’s
front, or her back?
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29. Is the baby head down or
bottom down?
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(a) Cephalic presentation. (b) Breech presentation.

30. Feeling for the baby’s head
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31. Feeling for the baby’s head
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32. Asking the mother about the
baby’s kicks
• Doctors and midwives refer to fetal
kick (not kicks) as an indicator of
fetal wellbeing, and it may also
indicate the fetal lie.
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33. Listening for the baby’s
heartbeat
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34. Finding the baby’s position by
listening to the heartbeat
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35. • Baby is breech
– Breech babies are often born without any trouble,
especially if the mother has had other children and
her births were easy. But breech babies are more
likely to get stuck, or have other serious problems.
• Baby is lying sideways
– Sideways babies cannot fit through the mother’s
pelvis to be born (Figure 11.13). If you try to deliver
the baby without surgery, the mother’s uterus will
rupture during labour, and she and the baby will die
without medical care.
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37. After the antenatal check-up
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38. • A Listening to the fetal heartbeat using a
stethoscope is called auscultation.
• B When the fetal head is down and the
bottom of the fetus is up in the fundus, it is
called a vertical lie.
• C In a vertex presentation, the presenting
part is the baby’s bottom.
• D The fetal heart rate is normally 120 to
160 beats a minute.
• E If the fetal heartbeat sounds loudest
below the mother’s bellybutton, the fetal
lie is probably breech.
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39. • Bernie came for her antenatal check-up at the eighth month of
pregnancy. When you palpated her abdomen, you found a hard,
round mass in the fundus of the uterus, and a soft, irregular, bulky
mass towards the symphysis pubic. Bernie told you that in the past
week the baby’s kick had decreased, and when you listened to her
abdomen with a fetoscope you could not hear the fetal heartbeat.
– a.Is the fetal lie in Bernie’s case vertical or transverse? Explain how you reached
your conclusion.
– b.What is the presenting part in this case?
– c.What do you call a fetus presenting in such a manner?
– d. Where would you listen to the fetal heartbeat to confirm your diagnosis of how
Bernie’s baby is presenting, and why?
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40. • Examples of health education given
throughout the antenatal visits?
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41. Reference list
• https://www.researchgate.net/figure/The-
normal-umbilical-artery-Doppler-
waveform-is-characterized-by-alternating-
systole-and_fig1_348654883
• https://clinicalgate.com/doppler-flow-
studies/
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