antenatal and postnatal care.pptx related to obg

Antenatal care

1. Antenatal care

2. ANC has the potential to reduce maternal morbidity and mortality as well as improving newborn survival, esp in developing countries Antenatal care helps in recognition and appropriate intervention for the complications that may arise. 

3. GOALS OF ANC Early,accurate estimation of gestational age Identification of RF Existing risks (e.g., diabetes)  Risks that develop during pregnancy ( e.g hypertension, fetal growth restriction) Regular evaluation of mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication

4. THE FIRST VISIT OR BOOKING VISIT Ideally, the first or booking visit should be before 12 weeks’ gestation.  thorough history and physical examination must be carried out.  Investigations specific to the first visit must be performed.  Advice must be offered with emphasis on diet and nutrition,  hematinics , exercise, travel, intercourse, and management of common signs and symptoms of pregnancy.

5. Categorize the pregnant woman into a low- or high-risk group.  Crucial in preventing both maternal and perinatal complications, and adverse events. Helps in planning appropriate level of care.

6. The assessment of risk factors starts during antenatal care.  Simple determinants (e.g., maternal age, height, and parity) and obstetric history of complications (e.g., previous stillbirth or cesarean section) will help place the woman in a low- or high-risk category.  Subsequent visits might reveal abnormalities in the present pregnancy, such as hypertension, severe anemia, multiple pregnancy, antepartum hemorrhage, or abnormal lie.

7. Tests and inv. AT FIRST BOOKING A standard panel of laboratory tests should be obtained on every pregnant woman at the first prenatal visit. Additional testing may be required in women at risk for specific conditions.

8. Standard panel of investigations Hb, hematocrit, blood picture and mean corpuscular volume Tests for hemoglobin, hematocrit, blood picture, and mean corpuscular volume (MCV) are done to identify anemia. The MCV differentiates between iron-deficiency anemia (MCV < 80  fL ) and B12-deficiency anemia (MCV > 115  fL ).  Blood picture reveals microcytic hypochromic red cells in iron deficiency, and macrocytes in B12 and folic acid deficiencies.

9. BLOOD GROUPING AND RH TYPING All pregnant women should have their blood group and Rh typing done and these should be documented.  If a woman is identified as Rh(D) negative, her husband’s/partner’s Rh typing must be done to determine if he is Rh(D) positive.  If he is Rh(D) positive, she could be at risk for Rh alloimmunization in pregnancy and her baby could have hemolytic disease of the newborn .  All Rh(D)-negative women should be tested for the presence of alloantibodies.

10. TEST FOR SYPHILIS Either the rapid plasma  reagin  (RPR) test or the Venereal Disease Research Laboratory (VDRL) test is done to rule out syphilis.  Although syphilis is rare, the consequences of congenital syphilis are severe and so this test should be done for all women.

11. TEST FOR HEP B SURFACE AG Hepatitis B antigen screening is recommended for all pregnant women to prevent perinatal transmission to the newborn.  Women who have been vaccinated should also undergo testing because no screening is done prior to vaccination to rule out carrier status.

12. TESTS FOR HIV Universal screening for human  immunodeficiency virus (HIV) is recommended for all pregnant women.  Screening is usually done with an enzyme-linked immunosorbent assay ( ELISA ) test for the presence of HIV antibodies.  If this test is reported as positive, HIV infection is confirmed with the  Western blot  test.

13. Rubella susceptibility screening The pregnant woman is tested for the presence of IgG antibody to rubella. If the test is positive, she is immune to rubella. If it is negative, she is susceptible to rubella.  She will require vaccination in the postnatal period for the protection of future pregnancies.

14. Screening for torch infections Routine screening for TORCH infections in pregnancy is  not  advised.  The TORCH panel consists of serum  tests  for   TO xoplasmosis ,   R ubella,   C ytomegalovirus  and   H erpes  simplex.  It is not indicated even with a history of  recurrent  pregnancy loss.

15. Screening for gdm Screening for diabetes is performed at the booking visit for all Indian women since they are considered to be at an intermediate/high risk. If the first trimester screening test is negative, the test should be repeated at 24–28 weeks. Both fasting plasma glucose, and 75 g glucose  followed  by plasma glucose 2 hours later, are acceptable as screening tests. 

16. Screening for asymptomatic bacteriuria Asymptomatic bacteriuria is an established risk factor for preterm delivery, low birth weight, and acute pyelonephritis.  Identification and treatment of asymptomatic bacteriuria reduces the risk of such complications.  It is usually offered at the booking visit.

17. Screening for aneuploidy Screening for Down syndrome should be offered to all women at booking, and the choice whether to have the screening test done or not, is left to the couple.  The test that should ideally be offered is a first trimester screening done at 11 to 13+ 6 weeks (i.e., from the first day of the 11th week of gestation to the last day of the 13th week).  The second trimester triple test or quadruple test is reserved for those women who book later in pregnancy.

18. Dietary and nutritional advice in booking visit Obtaining a good dietary history and giving proper dietary advice are essential at the booking visit.  It is an opportunity to set right the woman’s misconceptions of food requirements in pregnancy.  It also allows recommendation of weight gain goals that are appropriate for the individual.

19. Undernourished mothers (body mass index- (BMI) <18 kg/m2), particularly low-income women, need special attention and dietary advice for meeting their dietary needs. Unless they gain adequate weight during pregnancy, they are at risk for preterm labor and delivering low birth weight infants.

20. Women who gain excessive weight are at an increased risk for preeclampsia, failed induction, cesarean delivery, and a  macrosomic  infant.  Women who gain more weight than the  recommended amount during pregnancy are three times more likely to retain 5 kg or more at 1 year postpartum. For those women whose BMI is >30 kg/m2 at the initial visit, information on the complications of obesity on fetal and maternal well-being should be given.

21. Advice on dietary supplements Iron  In countries such as India where the prevalence of anemia is nearly 70%–80% among pregnant women, iron supplementation is routinely given.  Iron-deficiency anemia may be related to preterm birth and low birth weight. 

22. Folic acid Pregnant women should be informed that dietary supplementation with folic acid before conception and throughout the first 12 weeks’ pregnancy reduces the risk of having a baby with a neural tube defect.  The recommended dose is 400  μg /day. Patients who are at risk (previously have a baby affected by neural tube defect, on anticonvulsants, pregestational diabetes) should have 4 mg daily.

23. Calcium Fetal skeletal development requires approximately 25–30 g of calcium during pregnancy, primarily in the last trimester.  Most of this calcium can be mobilized from the maternal stores.  Calcium absorption increases during pregnancy and allows progressive retention throughout gestation. 

24. The recommended dietary intake in pregnancy and lactation is 1000–1300 mg/day.  Routine calcium supplementation is not recommended in pregnancy except for women with low dietary calcium intake.  Indian women with poor dietary calcium intake are advised calcium supplementation with calcium carbonate or calcium citrate.

25. Vitamin D Severe maternal vitamin D deficiency causes neonatal hypocalcemia and seizures.  There is also an association between milder forms of deficiency and preeclampsia, gestational diabetes, and impaired growth and skeletal problems in infancy.  In women at high risk for vitamin D deficiency, 1000–2000 IU/day of vitamin D can be given as a supplement.

26. Multivitamin deficiency Possible benefit in improving pregnancy outcomes through enhancement of placental function-modulation of inflammation,oxidative stress and vascular fns In India, multivitamin deficiency is due to poor nutrition.

27. Exercise in pregnancy Exercise is safe for both mother and fetus during pregnancy, and women should therefore be encouraged to initiate or continue exercise to derive the health benefits associated with such activities.  Women should be advised to walk briskly for 30–45 minutes in a day. Women with complicated pregnancies are discouraged from excessive physical activity for fear of adverse impact on the underlying disorder or on maternal and fetal outcomes.

28. tetanus Tetanus kills an estimated 50,000 neonates/year, worldwide.  A total of 5% of all maternal deaths are due to tetanus. If at least two doses of tetanus toxoid (TT) vaccination are given during pregnancy, neonatal deaths due to tetanus can be prevented.  Immunizing the mother allows tetanus antitoxin to be actively transported by the placenta to her fetus, providing passive protection against tetanus during the neonatal period and the following 1 or 2 months of life. 

29. SMOKING AND ALCOHOL Smoking should be discouraged.  Alcohol consumption may be associated with an increased risk of miscarriage, fetal alcohol syndrome and other congenital anomalies.  There is no known safe amount of alcohol to drink while pregnant. There is also no safe time during pregnancy to drink and no safe kind of alcohol.

30. Further antenatal visits Standard antenatal visits are usually scheduled Every month till 28 weeks Every 2 weeks from 28 to 36 weeks Every week from 36 weeks till delivery

31. In under-resourced areas, the World Health Organization recommends at least four visits during the pregnancy for low-risk women (first trimester, 26, 32, and 38 weeks). This improves compliance without increasing complications.

32. antenatal visits At subsequent visits, the uterine height, fetal heart sounds are documented and other required investigations are done. Assessment of the uterine size or fundal height to assess fetal growth –  Symphysio -fundal height

33. History taking and examination of the obstetric patient Documentation of fetal cardiac activity by auscultation – Fetoscope – Stethoscope – Handheld Doppler device Maternal blood pressure and weight Urine for protein and glucose

34. Fetal presentation (in the third trimester) Follow-up of modifiable risk factors The physiological changes in the various organ systems, along with the hormonal changes of pregnancy, result in some common symptoms. 

35. Detailed ultrasound examination for screening of fetal anomalies is offered between 18 and 22 weeks. The pregnant woman should be advised to start her antenatal exercises if she has not already done so.  She should also be advised to walk briskly for 30–45 minutes each day.

36. • Hemoglobin and hematocrit  are retested to assess anemia and to modify iron  supplemen -  tation  if needed. • Screening for gestational diabetes  is offered for all women between 24 and 28 weeks unless they are pregestational diabetics or have already been found to have diabetes by earlier screening.

37. The following need to be done in visits between 32 and 36 weeks: The woman must be educated about signs of preterm labor and labor.

38. A third trimester ultrasound is not required routinely. It may be indicated in the following situations: –  Confirmation of abnormal fetal presentation –  Suspected placenta previa or follow-up of placenta previa –  Suspected small-for-gestational age fetus or  growthrestricted  fetus –  Suspected macrosomia –  Suspected abnormalities of amniotic fluid (oligohydramnios or polyhydramnios) –  Follow-up of multiple pregnancy

39. Fetal presentation is confirmed at 36 weeks. Women must be taught to do a daily fetal movement count.  The significance of decreased movements must be emphasized and explained to the pregnant woman.

40. The following need to be done in visits between 37 and 41 weeks: • The woman must be educated on signs of labor and when to seek help for labor. • When a woman goes post term, the plan for induction and the process of induction are discussed. • Motivation for breastfeeding and a discussion of contraceptive options are also initiated.