Antenatal care /objectives/history collection abdominal examination

Antenatal care is the care you get from healthcare professionals to ensure you have a healthy pregnancy. It includes information on services and support to make choices right for you. Antenatal care will include regular appointments with a midwife, ultrasound scans and screening tests for you and your baby.

1. Mrs : Babitha Mathew MSc OBG Assistant professor CON,NMC,Muvattupuzha

2. DEF I NI TION Systematic supervision (examination and advice) of a woman during pregnancy is called antenatal (prenatal) care. It starts before pregnancy and ends at delivery and the postpartum period . ANTENATAL CARE COMPRISES OF: Careful history taking and examinations (general and obstetrical). Advice given to the pregnant woman.

3. AIMS To promote, protect and maintain the health of the mother during pregnancy To screen the ‘high risk’ cases. To prevent or to detect and treat complications at the earliest . To reduce maternal and infant mortality and morbidity. To ensure continued risk assessment and to provide ongoing primary preventive health care.

4. 6. To educate the mother about the physiology of pregnancy and labor , so that fear is removed and psychology is improved. To discuss with the couple about the place, time and mode of delivery, and care of the newborn. To motivate the couple about the need of family planning and also appropriate advice to couple seeking medical termination of pregnancy. To attend to the under-fives accompanying the mother.

5. OBJECTIVE T o ensure a normal pregnancy with delivery of a healthy baby from a healthy mother. The criteria of a normal pregnancy are:- Delivery of a single baby in good condition at term (between 38–42 ), with fetal weight of 2.5 kg or more and with no maternal complication.

6. ANTENATAL CARE COMPRISES Registration of pregnancy History taking Antenatal examinations [general and obstetrical] Laboratory investigations Health education

7. FREQUENCY OF ANTENATAL VISITS At the interval of 4 weeks up to 28 weeks At interval of 2 weeks up to 36 weeks and Thereafter weekly till delivery. THE FIRST VISIT OBJECTIVES To assess the health status of the mother and fetus. To assess the fetal gestational age and to obtain baseline investigations. To organize continued obstetric care and risk assessment.

8. SECOND TRIMESTER VISIT-OBJECTIVES To assess (1) Fetal well being. (2) Lie, presentation, position and number of fetuses. (3) Anemia, pre- eclampsia , amniotic fluid volume and fetal growth. (4) To organize specialist antenatal clinics for patients with problems like cardiac disease and diabetes. ( B) To select, time for (1) Ultrasonography. (2) Amniocentesis or chorion villus biopsy if needed.

9. REGISTRATION OF PREGNANCY The registration of pregnancy must be done in an antenatal clinic within 12 weeks.

10. HISTORY

11. 1. Vital statistics Name: ........................................................ Date of first examination: .................................. Address : .................................................................... 2. Age: Elderly primi gravida (age over 30 yrs ) ( FIGO- 35 yrs ) Teenage pregnancy

12. 3. Obstetrical score:-GPLA Gravida (G) : Gravida denotes a pregnant state both present and past, irrespective of the period of gestation. Parity (P) : Parity denotes a state of previous pregnancy beyond the period of viability . Live (L) : Number of live birth Abortion (A) : Number of abortions

13. A nulligravida is one who is not now and never has been pregnant . Primigravida A primigravida is one who is pregnant for the first time . multigravida is one who has previously been pregnant. She may have aborted or have delivered a viable baby. Terminology

14. A nullipara is one who has never completed a pregnancy to the stage of viability. She may or may not have aborted previously. A primipara is one who has delivered one viable child. Parity is not increased even if the fetuses are many (twins, triplets ). Multipara is one who has completed two or more pregnancies to the stage of viability or more.

15. Grand multipara is a pregnant woman with a previous history of four births or more. A parturient is a women in labor. A puerpera is a woman who has just given birth

16. 4. Duration of marriage 5. Religion 6. Occupation 7. Occupation of the husband 8. Period of gestation - in terms of completed weeks

17. In calculating the weeks of gestation in early part of pregnancy, counting is to be done from the first day of last normal menstrual period ( LMP). and in later months of pregnancy, counting is to be done from expected date of delivery (EDD).

18. Naegele’s formula EDD is calculated by adding 9 calendar months and 7 days to the first day of the last normal (28 day cycle) period. EDD = LMP + 9 months + 7 days Alternatively, one can count back 3 calendar months from the first day of the last period and then add 7 days to get the EDD. Correct for year if necessary. EDD = LMP – (3 MON) + 7 days

19. Naegele's rule The result is approximately 280 days (40 weeks) from the start of the last menstrual period . Example: LMP :- 20 September 2013(20/10/2013) + 9 months = 20 June 2014 + 7 days = 27 June 2014 EDD = 27 June 2014(27/07/2014) LMP=24/02/2020 EDC= 1/12/2020 LMP=12/04/2020 EDC=19/01/2020 LMP=25/07/2020 LMP=20/05/2020 Example: LMP = 8 /05/2009 − 3 months = 02 +7 days = 15 So EDD=15/02/2010 LMP=22/01/2020 LMP=27/08/2020

20. McDonald’s rule Height of fundus (cm) X 2/7 = gestation in lunar months 28cmX2/7=8months Height of fundus (cm) x 8/7 = gestation of pregnancy in weeks 28cmX8/7=32weeks

21. 9. Chief Complaints 10. Present obstetric history Past Obstetric history

22. Present obstetric history Date of Registration No of antenatal visits FIRST TRIMESTER Ask about nausea, vomiting or any other symptoms such as fever Abdominal/pelvic/back pain, burning micturition Vaginal discharge or Bleeding per vagina Use of folic acid tablets (small yellow colored pills) Was an ultrasound done at 6 or 7wks (Dating scan) Tetanus Vaccination

23. SECOND TRIMESTER Ask about regular use of folic acid, iron and calcium supplements . Ultrasound at 18-22wks (Anomaly scan) . Quickening : first fetal movements(felt around 20 weeks) Fever , rash, abdominal pain Tetanus Vaccination (BOOSTER DOSE)

24. THIRD TRIMESTER Weight gain Regular doctor checkups Ultrasound

25. No Year and date Pregnancy events Labor events Methods of delivery Puerperium Baby • Weight and Sex • Condition at birth (Apgar score) • Breast feeding • Immunization 1 2004 May Well covered antenatally . Uneventful Uneventful Spontaneous vaginal Uneventful Baby-boy, weight 2.6 kg Cried at birth. Breastfed (6 months), alive and well. 2 2009 Jun Miscarriage at 8 weeks Evacuation done Uneventful Past Obstetric history

26. 13. Family history 14. Past medical history Past surgical history Personal history Menstrual history

27. Marital history Contraceptive history Psychosocial history

28. History on subsequent visits To note:- A ppearance of any new symptoms (headache, dysuria ). Date of quickening.

29. EXAMINATION General Systemic Obstetrical examination = abdominal & vaginal

30. EXAMINATION General Physical Examination Build: Obese/Average/Thin. Nutrition : Good/Average/Poor. Height : Short stature is likely to be associated with a small pelvis . Weight : - First trimester = 1 kg - Second trimester = 5 kg - Third trimester = 5 kg

31. Head to foot examination Pallor Jaundice Tongue , teeth, gums and tonsils Neck Edema of legs

32. Systemic examination :- Heart , Lungs, Liver and Spleen. Obstetrical examination:- : - Abdominal :- Vaginal

33. RELATION BETWEEN FETUS & PELVIS

34. LIE :- The lie refers to the relationship of the long axis of the fetus to the long axis of the centralized uterus or maternal spine. LONGITUDINAL LIE ( 99.5%) TRANSVERSE LIE OBLIQUE LIE

35. PRESENTATION: The part of the fetus which occupies the lower pole of the uterus (pelvic brim) is called the presentation of the fetus . It may be, C ephalic (96.5 %) Breech / Podalic (3%) S houlder and other (0.5 %).

36. Cephalic Presentation Podalic Presentation Shoulder Presentation

37. when more than one part of fetus present at the lower pole of the uterus it is called compound presentation

38. PRESENTING PARTS The presenting part is defined as the part of the presentation which overlies the internal os & is felt by the examining finger through the cervical opening. In cephalic presentation depending upon degree of flexion, the presenting part may be - V ertex - Sinciput - Brow - Face

39. In Breech or Podalic presentation

40. ATTITUDE The relation of the different parts of the fetus to one another is called attitude of the fetus. The universal attitude is that of flexion.

41. Attitude Presenting part Complete flexion vertex ( occipitoanterior ) Incomplete flexion Vertex ( occipitoposterior ) Deflexion Vertex ( occipitoposterior ) Extension Brow Complete extension face

42. DENOMINATOR It is the bony fixed point on the presenting part which comes in relation with the various quadrants of the maternal pelvis.

43. The denominators of the different presentations: — Occiput in vertex M entum (chin) in face F rontal eminence in brow S acrum in breech Acromion in shoulder.

44. POSITION It is the relation of the denominator to the different quadrants of the pelvis. Pelvis is divided into equal segments of 45 degree to place the denominator in each segment. So there are 8 positions with each presenting part.

45. Anterior , Posterior , right or left position is referred in relation to the maternal pelvis, with the mother in erect position.

46. ABDOMINAL EXAMINATION

47. Preliminaries Verbal consent should be taken . The patient is asked to evacuate the bladder. Give dorsal position with the thighs slightly flexed . Abdomen is fully exposed. The examiner stands on the right side of the patient.

48. STEPS Inspection Palpation Auscultation

49. Inspection :- Whether the uterine ovoid is longitudinal or transverse or oblique. Contour of the uterus—fundal notching, convex or flattened anterior wall cylindrical or spherical shape. Size of the uterus . Skin condition of abdomen. Any incisional scar mark on the abdomen.

50. Palpation Warm hands before palpation. S hould not be done with uterine contractions Conduct with utmost gentleness to avoid undue uterine irritability Abdominal girth :- Measure around abdomen at the level of umbilicus

51. Significance of abdominal girth Girth increases by about 2.5 cm per week beyond 30 weeks & at term measures about 95 cm – 100 cm

52. Palpation Height of the uterus : ( symphysio fundal height) The uterus is to be centralized if it is deviated. The ulnar border of the left hand is placed on the upper most level of the fundus and an approximate duration of pregnancy is ascertained in terms of weeks of gestation.

53. Calculation of gestation using fundal height Measure from symphysis pubis to top of fundus in cm. After 24 weeks distance in cm corresponds to gestation in weeks. A variation of 1 – 2 cm is acceptable.

54. Condition Where SFH Is Higher Than Normal Condition Where SFH Is Lower Than Normal Mistaken date of LMP Twins Polyhydramnios Big baby Pelvic tumours Hydatidiform Mole Concealed accidental hemorrhage Mistaken date of LMP Scanty liquor Amnii Fetal growth retardation Intra uterine fetal death

55. Obstetric grips (Leopold maneuvers) Fundal grip (First Leopold) Lateral or umbilical grip ( II Leopold) Pawlik’s grip (Third Leopold) Pelvic grip (Fourth Leopold)

56. What lies at the fundus?

57. LATERAL GRIP The palpation is done facing the patient’s face. The hands are to be placed flat on either side of the umbilicus to palpate one after the other, the sides and front of the uterus to find out the position of the back, limbs and the anterior shoulder.

58. Where is the fetal back, limbs & anterior shoulder?

59. Lateral palpation

60. Pelvic palpation

61. Pelvic grip (Fourth Leopold): face the patient’s feet. Four fingers of both the hands are placed on either side of the midline in the lower pole of the uterus and parallel to the inguinal ligament. fingers are pressed downwards and backwards in a manner of approximation of finger tips to know the presentation

62. Pelvic grip

63. the characteristics to note are: (1) precise presenting Part - cephalic prominence is carefully palpated and its relation to the limbs and back is noted. The cephalic prominence, being the sinciput , is placed on the same side towards which limbs lie (2) attitude - noting the relative position of the sincipital and occipital poles

64. ATTITUDE A- WELL FLEXED b- DEFLEXED In well flexed head, the sincipital pole is placed at a higher level but in deflexed state, both the poles remain at a same level

65. engagement - noting the presence or absence of the sincipital and occipital poles or whether there is convergence or divergence of the finger tips

66. Pawlik’s grip (Third Leopold) face towards the patient’s face. overstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis. When the fingers and the thumb are approximated, the presenting part is grasped distinctly (if not engaged) and also the mobility from side to side is tested.

67. Auscultation Auscultation of distinct fetal heart sounds (FHS) not only helps in the diagnosis of a live baby but its location of maximum intensity can resolve doubt about the presentation of the fetus

68. auscultation The fetal heart sounds are best audible through the back (left scapular region) in vertex and breech presentation where the convex portion of the back is in contact with the uterine wall. In face presentation, the heart sounds are heard through the fetal chest. the maximum intensity of the FHS is below the umbilicus in cephalic presentation and around the umbilicus in breech.

69. LOCATION OF FHS

70. In occipitoanterior position, the FHS is located in the middle of the spinoumbilical line of the same side. In occipitolateral position, it is heard more laterally In occipitoposterior position, well back towards the mother’s flank on the same side.

71. inferences Lie: The longitudinal lie is evident from: 1)Longitudinal uterine ovoid on inspection 2) The poles of the fetal ovoid—cephalic and podalic are placed, one at the lower and the other at the upper part of the uterine cavity, as evident from the fundal and first pelvic grips.

72. presentation The cephalic presentation is evident from the first pelvic grip—smooth, hard and globular mass. ATTITUDE: From the first pelvic grip, the relative positions of the sincipital and occipital poles are determined.

73. PRESENTING PART: Vertex is diagnosed from the first pelvic grip POSITION: The occipitoanterior position is diagnosed by: (1) Inspection—convexity of the uterine contour. (2) Lateral grip— (a) The back is placed not far from the midline to the same side of the occiput (b) The anterior shoulder is near the midline

74. 3) Auscultation—maximum intensity of the FHS is close to the spino -umbilical line on the same side of the back. Right or left position is to be determined by (1) Position of the back (2) Position of the occiput and (3) Location of the FHS.

75. ENGAGEMENT When the greatest horizontal plane, the biparietal , has passed the plane of the pelvic brim, the head is said to be engaged. FIRST PELVIC GRIP: (1) Both the poles ( sinciput and occiput ) are not felt per abdomen. (2) Divergence of the examining fingers of both the hands SECOND PELVIC GRIP : non mobile head indicate engaged head

76. Descend of head by abdominal assessment

77. PER VAGINAL EXAMINATION

78. FIRST TRIMESTER Done for first time before 12 weeks Purposes To diagnose the pregnancy Corroborate the size of uterus with period of amenorrhoea Exclude any pelvic pathology Contraindications Previous history of abortion Occassional vaginal bleeding in present pregnancy

79. steps Explain procedure Empty bladder Dorsal position with thighs flexed & buttocks placed on the foot end of the table Drape patient Handwashing & wear surgical gloves(right hand)

80. inspection Separate labia using thumb & index finger & assess character of vaginal discharge Assess cystocele , uterine prolapse by asking to do bear down as if she has bowel movements Palpate bartholin gland for any infection

81. Speculum examination Bivalve speculum is used Inspect cervix for position ( normally – Center) , Colour ,lesions, ulceration, discharge etc. Pap smear is taken in case of discharge Cervical os nulligravida – Round & Small multiparous – Slit like appearence

82. Bimanual examination Introduce index & middle finger of right hand is introduced in to Vagina Left hand is placed suprapubically Note : a) cervix – Consistency , direction & pathology b) uterus – size, shape, position & consistency c ) adnexae – any mass felt through the fornix include ovarian cysts, enlarged fallopian tube, hegars sign

83. Late pregnancy Objective to assess the pelvis Timing Any time beyond 37 th week. informative only if done with the beginning of labour or just before induction of labour

84. Bi manual examination To note State of cervix Station of presenting part in relation to ischial spine Test for cephalopelvic disproportion in nonengaged head Note the elasticity of perineal muscle

85. Sacrum - The sacrum is smooth, well curved and usually inaccessible beyond lower three pieces Sacrosciatic notch — The notch is sufficiently wide so that two fingers can be easily placed over the sacrospinous ligament covering the notch. Ischial spines — Spines are usually smooth ( everted ) and difficult to palpate Ilio-pectineal lines — To note for any beaking suggestive of narrow fore pelvis

86. Sidewalls — Normally they are not easily palpable by the sweeping fingers unless convergent Posterior surface of the symphysis pubis — It normally forms a smooth rounded curve. Presence of angulation or beaking suggests abnormality Sacrococcygeal joint — Its mobility and presence of hooked coccyx, if any, are noted.

87. Pubic arch — Normally, the pubic arch is rounded and should accommodate the palmar aspect of two fingers. Diagonal conjugate - It is the distance between the lower border of symphysis pubis to the midpoint on the sacral promontory. For practical purpose, if the middle finger fails to reach the promontory or touches it with difficulty, the conjugate is adequate

88. Transverse diameter of the outlet (TDO) — It is measured by placing knuckles of the clinched fist between the ischial tuberosities Pubic angle : In female the angle roughly corresponds to the fully abducted thumb and index fingers. In narrow angle, it roughly corresponds to the fully abducted middle and index fingers AP Diameter of the outlet —The distance between the inferior margin of the symphysis pubis and the skin over the sacrococcygeal joint can be measured

89. Laboratory investigations :- o Blood grouping, Rh typing. o Haemoglobin . o Toxoplasma and / or VDRL if needed. o Urine analysis particularly for albumin and sugar & pus cells 0 cervical cytological study

90. Special investigations Serological tests for rubella, hepatitis B virus and HIV—antibodies to detect rubella immunity and screening for hepatitis B virus and HIV Genetic Screen: Maternal Serum Alpha Feto Protein (MSAFP), triple test at 15–18 weeks for mother at risk

91. Ultrasound examination: Repetition of the investigations: (1) Hemoglobin estimation is repeated at 28th and 36th week (2) Urine is tested (dipstick) for protein and sugar at every antenatal visit.

92. ANTENATAL ADVICE

93. PRINCIPLES : To counsel the women about the importance of regular check up. To maintain or improve, the health status of the woman to the optimum till delivery. To improve the psychology and to remove the fear of the unknown by counseling the woman.

94. DIET The diet during pregnancy should be adequate to provide:- Good maternal health Optimum fetal growth The strength and vitality required during labor and Successful lactation.

95. The pregnancy diet should be light, nutritious and easily digestible. It should be rich in protein, minerals vitamins and fibres and of the required calories. Dietary advice should be given with due consideration to the socio-economic condition, food habits and taste of the individual. Supplementary iron therapy is needed for all pregnant mothers from 12 weeks onwards .

96. Energy (kcal) 2500 kcal (+300) Protein 60 gm Iron 40 mg Calcium 1000 mg Zinc 15 mg Iodine 175 µg Vitamin A 6000 IU Vitamin D 400 IU

97.   PERSONAL HYGIENE Daily all over wash is necessary because it is stimulating, refreshing, and relaxing. Warm bath. shower or sponge baths is better than tub Hot bath should be avoided because they may cause fatigue & fainting Regular washing for genital area, axilla, and breast due to increased discharge and sweating. Vaginal douches should avoided except in case of excessive secretion or infection.

98. BREAST CARE Wash breasts with clean tap water. It is not recommended to massage the breast, this may stimulate oxytocin hormone secretion and possibly lead to contraction . Advise the mother to be mentally prepared for breast feeding . Breast engorgement may cause discomfort during late pregnancy. A well-fitting brassiere can give relief

99. DENTAL CARE The teeth should be brushed carefully in the morning and after every meal . Encourage the woman the to see her Dentist regularly for routine examination & cleaning. A tooth can be extracted during pregnancy, but local anesthesia is recommended & can do preferably 0n 2 nd trimester.

100. DRESSING Woman should avoid wearing tight cloths such as belt or constricting bans on the legs , because these could impede lower extremity circulation. Suggest wearing shoes with a moderate to low heel to minimize pelvic tilt & possible backache. Loose , and light clothes are the most comfortable.

101. TRAVEL Travel by vehicles having jerks to be avoided especially in 1 st trimester and the last 6 weeks . Late in pregnancy, travel plans should take into consideration the possibility of early labor . Long distance travel better to be avoided. Rail route is preferable . Travel in pressurized aircraft is safe up to 36 weeks. Prolonged sitting should be avoided due to the risk of venous stasis and thromboembolism. Seat belt should be under the abdomen.

102. COITUS It is not restricted during pregnancy. Release of prostaglandins and oxytocin with coitus may cause uterine contractions. Women with increased risk of miscarriage or preterm labor should avoid coitus if they feel such increased uterine activity.

103. REST AND SLEEP The woman may continue her usual activities throughout pregnancy. Hard and strenuous work should be avoided. On an average, a patient should have 10 hours of sleep (8 hours at night and 2 hours at noon)

104. BOWEL As there is a tendency of constipation during pregnancy, regular bowel movement may be facilitated by regulation of diet taking plenty of fluids, vegetables and milk.

105. SMOKING AND ALCOHOL Heavy smokers have smaller babies and there is also more chance of abortion. Alcohol consumption c an lead to fetal mal-development or growth restriction & FAS.

106. IMMUNIZATION Live virus vaccines (rubella, measles, mumps, yellow fever) are contraindicated. Tetanus : Immunization against tetanus not only protects the mother but also the neonates.

107. DRUGS The pregnant women should avoid over-the counter drugs. The drugs may have teratogenic effects on the growing fetus especially during the first trimester.

108. DANGER SIGNS OF PREGNANCY Vaginal bleeding including spotting. Persistent abdominal pain. Sever & persistent vomiting. Sudden gush of fluid from vagina. Absence or decrease fetal movement. Sever headache. Edema of hands, face, legs & feet. Fever above 100 F( greater than 37.7°C). Dizziness , blurred vision, double vision & spots before eyes. Painful urination.