Antenatal services

ANTENATAL SERVICES AND PELVIMETRY

1. ANTENATAL CARE SERVICES BY DR.CHINEDU IBEH Thursday ,16 TH APRIL 2015

2. From inability to let well alone; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us. Sir Robert Hutchison, 20th century physician, British Medical Journal (1953), 1: 671.

3. OUTLINE INTRODUCTION OBJECTIVES FREQUENCY OF VISITS ANTENATAL SERVICES FOCUSED ANC GOALS OF FOCUSED ANC DANGER SIGNS DURING PREGNANCY ROLE OF FATHERS IN ANC POST NATAL CARE SUMMARY

4. INTRODUCTION Antenatal services entail the holistic assessment of mother and fetus during pregnancy for the purpose of obtaining the best possible outcome for both the mother and the child Series of appointments with a Doctor or sometimes with a Midwife[in resource constraint regions] is offered. Women and their families are equiped with appropriate information and advice for a healthy pregnancy, safe child birth and adequate postnatal recovery. An effective ANC depends on competent health care providers, functioning health system with referral services, adequate supplies & laboratory support.

5. OBJECTIVES OF ANC To promote, protect and maintain the health of the mother during pregnancy To detect high risk cases and give them special attention To take decision regarding timing and mode of delivery To ensure the baby has a good start in life To teach the mothers elements of child care To reduce maternal and infant mortality and morbidity and to provide opportunities for health education of both parents with respect to their children’s well being.

6. FREQUENCY OF VISITS[TRADIONAL MODEL] 4 weekly---------- 28 weeks 2 weekly --------- 36 weeks weekly ------------ delivery Frequency could be increased if need arises ANC activities should be carefully planned to ensure the most effective use of time, to exclude meaningless routines and to include examinations to detect major problems, especially those of local importance.

7. Schedule of Key Antenatal Visits[FANC] -Multi-country randomized trial by W.H.O showed that essential interventions can be provided over 4 visits at specified intervals. 8-14 week visit 20-24 week visit 36-38 week visit 41-42 week visit -The trend is towards reducing the number of visits, while at the same time establishing clearly defined objectives to be achieved at each visit . -There appears to be little difference between a four-visit approach and a fourteen-visit schedule.

8. ANTENATAL SERVICES Screening for high risk pregnancy Health Promotional Services Preventive Services Curative/ Rehabilitative Services Natal Care/ Care at Delivery

9. A. SCREENNING FOR HIGH RISK PREGNANCY Factors associated with high risk pregnancy must be identified as early as possible and appropriate referrals made. Age of mother < 18yrs, > 35 yrs at 1st Pregnancy Height / Stature - <145cm or< 5ft in height Booking Weight<45kg or >90kg Parity - lst preg > 4[ grandmultip ] Birth interval < 2yrs since the last birth Multiple gestation Abnormal lie/Presentation . SFH inconsistent with dates Proteinuria

10. A. SCREEENING FOR HIGH RISK PREGNANCY CONTD Previous bad obstetric hx eg previous CS/ myomectomy , post natal depression, congenital anomaly, cervical cerclage , late pregnancy loss[14-24wks], hx of low birth wt baby< 2.5kg or macrosomia [>4.5kg], premature births, miscarriage or abortion, still birth, APH, PPH, manual placenta removal Gynecological history- infertility>2 years, fibroid/ovarian cyst at booking, IUCD in situ Pre – existing medical conditions e.g HBP, cardiac, renal, diabetes, SCD . Conditions developing during pregnancy e.g Hepatitis, HIV/AIDS, malaria, severe anaemia Extreme social deprivation/disruption (Teenager, single mother, unsupported mother)

11. B. HEALTH PROMOTIONAL SERVICES Health Education: - The content would include educating the women on the value of rest and recreation, discouraging smoking and alcohol ingestion, allaying anxiety, infant feeding, contraception techniques. Nutrition education - aimed at encouraging the mother to take an adequate diet based as far as possible on locally available food which are cheap- eg ; Ebiti,Ukwa , okpa . Education on sinister signs and symptoms in pregnancy. Education on improved personal hygiene and environmental sanitation .

12. C. PREVENTIVE SERVICES ( i )Anti malarials / Malaria prophylaxis Malaria is one of the major causes of anaemia in pregnancy. Prevention of malaria: -Intermittent preventive treatment (IPT) -Use of insecticide-treated nets (ITNs) -Other methods (environment free of breeding sites for mosquito), personal protection ( ii) Haematinics - Folic acid, fersolate , multivite . Good compliance to haematinics has been shown to protect pregnant women from risk of anaemia especially in developing countries where poor nutrition and helminthiasis are prevalent.

13. D. CURATIVE/ REHABILITATIVE SERVICES Early diagnosis and prompt treatment of medical conditions that may arise in pregnancy. Emotional and social problems should be promptly diagnosed and managed ( I don’t want this baby) Teenagers and single mothers may need emotional support.

14. E. NATAL CARE SERVICES Aimed at ensuring that every delivery is attended by appropriately trained personnel under sterile conditions which should result in a healthy mother and the birth of a healthy child .

15. FOCUSED ANTENATAL CARE Is an approach to ANC that emphasizes:   Evidence-based, goal-directed actions Family-centered care Quality, rather than Quantity of visits Care by skilled providers

16. GOALS OF FOCUSED ANTENATAL CARE To promote maternal and newborn health and survival through : Early detection and treatment of problems and complications Prevention of complications and disease Birth preparedness and complication readiness Health promotion

17. GOAL 1; EARLY DETECTION AND TREATMENT OF PROBLEMS Malaria – history and physical exam, fever and accompanying signs/symptoms, region where woman lives, complicated vs. uncomplicated cases Severe anaemia – physical exam, testing Pre- eclampsia / eclampsia – measurement of blood pressure HIV – voluntary counseling and testing

18. GOAL 1- EARLY DETECTION AND TREATMENT OF PROBLEMS CONTD Sexually transmitted infections, including syphilis – testing, HBV, HCV Rhesus incompatibility

19. GOAL 2 –PREVENTION OF DISEASES AND COMPLICATIONS Intermittent preventive treatment (IPT ) and Use of insecticide – treated nets (ITNs ) to prevent malaria Tetanus toxoid immunization to prevent maternal and neonatal tetanus Iron/ folate supplements to prevent anaemia Nutrition Specific interventions as appropriate

20. GOAL 3: BIRTH PREPAREDNESS AND COMPLICATION READINESS This is the process of planning for safe delivery and anticipating the actions needed in case of emergencies Develop individual birth plan – exact plan for normal birth and possible complications : -Arrangements made in advance by woman and family (with help of a skilled provider )

21. GOAL 3: BIRTH PREPAREDNESS AND COMPLICATION READINESS CONTD - Reviewed/ revised at every visit as need arise -Minimizes disorganization at time of birth or in an emergency -Ensures timely and appropriate care  

22. ESSENTIAL ELEMENTS OF INDIVIDUAL BIRTH PLAN 1.Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies 2.Skilled provider: to attend birth -Provider/facility contact information 3.Transportation: reliable, accessible, especially for odd hours

23. ESSENTIAL ELEMENTS OF INDIVIDUAL BIRTH PLAN 4.Funds: personal savings, emergency funds, community loan schemes, e.t.c 5.Decision – making: who will make decisions, especially in an emergency 6.Family and community support: Care for woman’s family in her absence and birth companion during labour

24. ESSENTIAL ELEMENTS OF INDIVIDUAL BIRTH PLAN CONTD 7.Blood donor: In case of emergency 8.Needed items: for clean and safe birth and for new born care

25. GOAL 4- HEALTH EDUCATION Inform and educate the woman with health messages and counseling appropriate to : -Individual needs, concerns, circumstances -Gestational age -Most prevalent health issues Support the woman in making decisions and solving actual or anticipated problems Involve partner and family in supporting/adopting healthy practices

26. Health Education: Topics to be addressed   Prevention of malaria: -Intermittent preventive treatment (IPT) -Use of insecticide-treated nets (ITNs) -Other methods (environment free of breeding sites for mosquito), personal protection Nutrition Care for common discomforts

27. Health Education topics contd Use of potentially harmful substances (avoid herbs, unperceived drugs ) Hygiene Rest and activity Importance of delivery by skilled attendant Sexual relations and safer sex Early and exclusive breastfeeding

28. Health Education topics contd Prevention of tetanus and anaemia HIV/AIDs prevention and care Prevention of other endemic diseases/deficiencies Child spacing Post-natal care

29. Danger signs during Pregnancy - Vaginal bleeding or discharge -Difficulty in breathing - Fever -Severe abdominal pain -Severe headache/blurred vision -Swelling of the feet -Convulsions/loss of consciousness - Labour pains before 37 weeks

30. The role of Fathers in Antenatal care The role of men/fathers include: Support and encourage women throughout pregnancy Provide financial support Help the woman to make a birth plan

31. Role of Fathers contd Encourage pregnant women to attend the antenatal clinic and take their SP under provider supervision Ensure mothers sleep under insecticide-treated nets (ITNs), buying the net & retreating when necessary Ensure that they remain faithful (or use condoms consistently and correctly) to prevent STIs/HIV Accompany their wives/ partners to the health facility and during childbirth  

32. INTERCONCEPTIONAL CARE OR POST NATAL CARE: - Early detection and Rx of puerperal sepsis and other puerperal conditions . Encouragement and support to initiate and continue Breast feeding till at least 2 years. Counseling on proper diet for adequate lactation and about the need for rest. Family planning education and service

33. SUMMARY Good Antenatal Care ensures; - that pregnant women remain healthy throughout pregnancy - that medical illnesses and pregnancy-related complications are detected early and treated promptly -early detection and referral of high risk cases

34. SUMMARY 34 Current Approach to Reduction of Maternal Mortality A skilled attendant at childbirth is the most effective intervention! WHO 1999.

35. MERCI! ANY CONTRIBUTION?

36. Further Reading Stuart Campbell, Chritopher Lees. Antenatal Care in Obstetrics by Ten Teachers. 2000 17 th Edition. ELST with Arnold Publishers, New Delhi. K. Park. Preventive Medicine in Obstetrics, Pardiatrics and Geriatrics in Preventive and Social Medicine. 2011; 21 st Edition. M/s Banarsidas Bhanot Publishers, Jabalpur India Adetokunbo Lucas, Herbert Gilles. Family Health in Short Textbook of Public Health Medicine for the Tropics. 2003; 4 th Edition, Arnold Publishers Malta. Ornella Lincetta , Seipati Mothebesoane-Anoh , Patricia Comez , Stephen Munjanja . Antenatal Care, WHO publications, Geneva http://www.who.int/pmnch/media/publications/aonsectionIII_2.pdf [accessed 12/04/15]

37. Further Reading contd Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel BJ, Farnot U et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. The Lancet 2001;357:1551-1564. Villar J, Carroli G, Khan- Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001; Issue 4. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, World Health Organization, 2006. Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan- Neelofur D, Piaggio GGP. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD000934; DOI: 10.1002/14651858.CD000934.pub2

38. PELVIMETRY BY DR CHINEDU IBEH Thursday ,16 TH APRIL 2015

39. OUTLINE Introduction Methods of Pelvimetry When to do pelvimetry Pelvic Anatomy Pelvic Types How pelvimetry is Done Obstetric Prognostic Factors Radiological Pelvimetry Role of Pelvimetry in CPD diagnosis Problems Associated with Pelvimetry Research Findings Conclusion

40. INTRODUCTION Pelvimetry is the assessment of the dimensions and capacity of adult female pelvis in relation to the birth of a baby. Traditional obstetrical services used to rely heavily on pelvimetry in leading decision of natural, operative vaginal delivery or Caesarean Section. All pelvic measurements relate to bony points; as the pelvic ligaments loosen in pregnancy, the pelvis is often more flexible than the measurements would suggest which is why pelvimetry may not be clinically useful.

41. METHODS OF PELVIMETRY Clinical Pelvimetry a] External/Indirect Pelvimetry ; -measures diameters of false pelvis -little value, unreliable, no longer used. b]Internal/Direct Pelvimetry Radiographic Pelvimetry a] Xray Pelvimetry c]CT Pelvimetry b] MRI Pelvimetry

42. When is Pelvimetry done? At first prenatal visit screen In late Pregnancy[preferable]-around 36-37wks GA or at onset of labour . [soft tissues are more distensible thus making the procedure more accurate and less uncomfortable when done around this time]

43. PELVIC ANATOMY Bony Pelvis Pelvic Planes Pelvic Diameters

44. BONY PELVIS

45. BONY PELVIS CONTD

46. PELVIC PLANES AND DIAMETERS Pelvic inlet is bordered by; -symphysis pubis anteriorly, - ilio -pectineal line of the innominate bone laterally, -ala of sacrum and sacral promontory posteriorly. The transverse diameter of the pelvic inlet measures 13.5 cm while the anterior-posterior diameter is 11cm The fetal head enters the pelvis through this plane in the transverse position

47. PELVIC INLET

48. PELVIC ANATOMY CONTD Pelvic Mid-cavity[plane of greatest diameter] bordered by : -posterior midpoint of the symphysis pubis anteriorly, -pubic bone, obturator fascia and inner aspect of the ischial bone and spines laterally, - jxn of the 2 nd and 3 rd pieces of the sacrum posteriorly. Transverse Diameter = Anterior posterior Diameter=12cm; it is the largest part of the pelvic cavity Fetal Head rotates to the anterior position in this plane

49. PELVIC ANATOMY CONTD Plane of least diameter is bordered by -Lower edge of the pubis symphysis anteriorly - Ischial Spines and Sacrospinous Ligament laterally -Lower Sacrum Posteriorly This is the most important plane from the clinical standpoint because most instances of arrest of descent[low transverse arrest] occur at this level.

50. PELVIC ANATOMY CONTD Pelvic outlet is formed by two triangles with a common base at the level of ischial tuberosities . Anterior triangle is bordered by -subpubic angle at the apex -pubic rami on the sides - bituberous diameter at the base Posterior triangle is bordered by - Sacrococcygeal joint at its apex - Sacrotuberous Ligaments on the sides - Bituberous diameter at the base. Anterior posterior diameter=13.5cm while the Transverse Diameter= 11cm. This plane is the site of low pelvic arrest.

51. PELVIC ANATOMY CONTD

52. PELVIC DIAMETERS Represent the amount of space available at each level The key measurements of assessing the capacity of the maternal pelvis include; -Diagonal Conjugate Diameter -Obstetric conjugate of the inlet - Bispinous Diameter - Bituberous Diameter -Posterior Sagittal Diameters at all levels -Curve and length of the Sacrum -Subpubic angle

53. PELVIC PLANE DIAMETERS

54. Diagonal conjugate is the distance from undersurface of pubic arch to sacral promontory 12.5cm). OC=DC-1.5CM PELVIC PLANE DIAMETERS CONTD

55. Pelvic Diameters contd

56. CALDWELL MOLOY CLASSIFICATION OF PELVIC TYPES Traditional obstetrics characterizes four types of pelvises: Gynecoid :[50%] Ideal shape, with round to slightly oval inlet, most common and most favourable for normal vaginal delivery. Android : [20 %]triangular inlet, and prominent ischial spines, more angulated pubic arch. At risk of deep transverse arrest. Anthropoid :[ 25%] the widest transverse diameter is less than the anteroposterior (obstetrical) diameter. At risk of persistent occipitoposterior position. Platypelloid : [5 %]Flat inlet with shortened obstetrical diameter. At risk of obstructed labour .

57. How Pelvimetry is Done Diagonal Conjugate -is measured from the lower border of the pubis to the sacral promontory using the tip of the second finger and the point where the index finger meets the pubis -it is normally 12.5cm and cannot be reached -if it is felt, the pelvis is contracted - Obstetric Conjugate =Diagonal Conjugate-1.5cm -Not done if the head is engaged.

58. PELVIC INLET MEASUREMENTS- SACRAL PROMONTORY PROMINENCE ESTIMATION, DIAGONAL CONJUGATE,OBSTETRIC CONJUGATE, TRUE CONJUGATE AND TRANVERSE DIAMETERS

59. PELVIC INLET SUBPUBIC ANGLE

60. SUBPUBIC ANGLE

61. PELVIC OUTLET MEASUREMENTS- COCCYX PROMINENCE ESTIMATION, SUBPUBIC ANGLE, BITUBEROUS DIAMETER

62. OBSTETRIC PROGNOSTIC FACTORS Size and Shape of bony pelvix [influenced by hereditary, Vitamin D deficiency, history of pelvic fracture, stage of pregnancy] Size of the fetal head Force exerted by uterine contractions Moldability of the head Presentation and position. Of these, only size and shape of the bony pelvis can be fairly measured and it is the object of pelvimetry to eliminate this one factor from the category of unknown.

63. RADIOLOGICAL PELVIMETRY Indications Clinical Evidence or Obstetric History suggestive of pelvic abnormalities History of Pelvic Trauma

64. RADIOLOGICAL PELVIMETRY Types Radiological Pelvimetry ; Xray : high radiation exposure, limited value & no role in guiding management CT: ease of performance & interpretation; 10% less radiation exposure to the fetus MRI [method of choice]: lack of ionizing radiation, higher resolution and contrast, higher cost.

65. CT Pelvimetry

66. MRI Pelvimetry

67. Cephalopelvic Disproportion CPD is obstructed labour resulting from disparity between the size of the fetal head and maternal pelvis eg , small pelvis, nongynecoid pelvis, large fetus, or more commonly a combination of these factors. True CPD is rare, 1in 250 pregnancies or 0.4% of the time Failure to Progress: Lack of progressive cervical dilatation or lack of descent: Mostly due to asynclitism , malpresention or ineffective uterine contraction

68. Role of Pelvimetry Diagnosis of CPD Research indicates that pelvimetry is not a useful diagnostic tool for CPD and that in all cases[except in obvious abnormal pelvis], spontaneous labour and birthing should be facilitated. This is because a ‘ ’trial of labour ’’ is the only true way to diagnose CPD for it is difficult to anticipate how well the fetal head will mold and woman's pelvis loosens up and adjust before birth (with the help of hormones ). A n upright and/or squatting position will open the pelvis by atleast 33% causing a woman to birth a considerably larger baby unlike lithotomy positon

69. Role of Pelvimetry Diagnosis of CPD If the Doctor is absolutely certain that there is a CPD, then a CS is the only option for delivery But if diagnosis is doubtful, a ‘’trial of labour ’’ should always be offered; if after sufficient time, symptoms of prolonged labour or fetal distress begins to develop, a CS needs to be carried out.

70. PROBLEMS WITH PELVIMETRY I t increases the caesarean section rate and is a poor predictor of the outcome of labour Theoretically, X ray pelvimetry poses a danger to the fetus both in the immediate and in future life in the production of childhood leaukamia There is also danger to the gonads of the baby with a risk of producing an increase in the incidence of congenital malformation

71. RESEARCH FINDINGS In a systematic review, Cochrane collaboration stated that ‘’for women whose baby is presenting cephalic, review of trials found too little evidence to show whether pelvimetry is beneficial’’. Cochrane Collaboration [independent, premier evidence based clinical decision support resource trusted worldwide by health care practioners to help them make the right decision at the point of care]

72. RESEARCH FINDINGS CONTD In a similar vein, a retrospective review in 2004 by Blackadar , C.S. & Viera , A.J in conclusion stated thus: ‘’Our study indicates that clinical pelvimetry does not change management of pregnant patients. Current practice is to allow all women a trial of labor regardless of pelvimetry results. This makes the routine performance and recording of pelvimetry a waste of time, a potential liability, and an unnecessary discomfort for patients .”

73. RESEARCH FINDINGS CONTD Also in reviewing research findings on usefulness of pelvimetry from 1937-1987, Cunningham etal in Williams Obstetrics ( 2009) concluded that; ‘’There is little rationale or current research related to the utility of pelvimetry in obstetrical care’’

74. CONCLUSION I n cases of definite and certain CPD [ ht <145cm, hx of pelvic fracture, hx of rickets], Caesarean Section should be done. Otherwise in every other case; proper management is a good trial of labour .

75. Gracias! Any Contribution? THANK YOU FOR LISTENING! ANY CONTRIBUTION?

76. REFERENCES Stuart Campbell, Chritopher Lees .[2000] Labour in Obstetrics by Ten Teachers . 17 th Edition. ELST with Arnold Publishers, New Delhi . Gray Cunningham etal [2009]. Pelvimetry in William Obstetrics, 23 rd Edition. McGraw Hill Professional Publishing , New York Pattinson RC, Farrell E-ME [2009] Pelvimetry for fetal cephalic presentation at or near term Cochrane Collaboration http://www.cochrane.org/search/site/pelvimetry [accessed 13/04/15 ]

77. REFERENCES CONTD Rasha Dabbagh [2011] Fetal Head, Maternal Pelvis and Pelvimetry , Slideshare . http :// www.slideshare.net/RashaDabbagh/fetal-head-maternal-pelvis-pelvimetry [accessed 13/04/15 ] Blackadar , C.S., Viera , A.J. (2004) A Retrospective Review of Performance and Utility of Routine Clinical Pelvimetry , Fam Med http://www.ncbi.nlm.nih.gov/pubmed/15243832 [accessed 13/04/15]