Copy of Antenatal care, ppt obstetrics and gynaecology

Obstetrics and gynaecology

2. Definition
Antenatal care refers to the care that is given to an
expected mother from time of conception to the
beginning of labor

3. Goals of antenatal care
To reduce maternal and perinatal mortality
and morbidity rates.
To improve the physical and mental health of
women .
To prepare the woman for labor, lactation, and
care of her infant.
To detect early and treat properly complicated
conditions that could endanger the life or
impair the health of the mother or the fetus.

4. Objectives
To ensure a normal pregnancy with delivery of a healthy
baby from a healthy mother
Criteria of a normal pregnacy-
Delivery of a single baby at term with good fetal wt
with no maternal complications

6. During the firs visit, assessment and
physical examination must be completed.
Including:
history.
Physical examination.
Laboratory data.
Psychological assessment.
Nutritional assessment.

7. History
 Woman’s name
Age
Education
Occupation
SE status
Address
Obstetric Formula – G P L D A
Duration of pregnancy

8. Definition
NulligravidaNot now and never has been pregnant
Gravida Is or has been pregnant, irrespective of the pregnancy outcome
 Primigravida
: with the establishment of the first pregnancy
 Multigravida
: successive pregnancies
♣ Paritydetermined by the number of pregnancies reaching 28weeks
NulliparaNever competed a pregnancy to viability
May have had a spontaneous or elective abortion(s)
PrimiparaHas been delivered only once of a viable fetus
Fetuses born alive or dead with an estimated length of gestation
of≥28weeks
MultiparaHas had 2 or more viable pregnancies

9. Menstrual history:
A compete menstrual history is important to establish
the estimated date of delivery. It includes:
-Last menstrual period (1
st
day of LMP).
-Regularity and frequency of menstrual cycle.
-Contraception method.
-Expected date of delivery (EDD) is calculated as
by Naegele”s rule

10. Current problems with pregnancy :
Ask the patient if she has any current problem
- Nausea & vomiting.
-Abdominal pain.
-Headache.
-Urinary complaints.
-Vaginal bleeding.
-Edema.
-Backache.
-Heartburn.
-Constipation.

11. Previous obstetric history:
This provides essential information about the
previous pregnancies that may alert the care
provider to possible problems in the present
pregnancy. Which includes:
Length of gestation, mode of delivery, location
of birth
Baby details
Maternal complications – antepartum ,
intrapartum and postpartum

12. Medical and surgical history:
Chronic condition such as diabetes mellitus,
hypertension, and renal disease can affect the
outcome of the pregnancy and must be
investigated.
Prior operation, allergies, and medications should be
documented.
Accidents involving injury of the bony pelvis

13. Family history:
Family history provides valuable information about
the general health of the family, and it may reveal
information about genetic or congenital anomalies.

-D.M.
-Hypertension.
-Heart disease.
-TB
- Blood dyscrasia
-Twinning
- Hereditory disease

14. PERSONAL HISTORY:
Diet
Appetite
Bowel ,Bladder
Sleep
Addictions

15. General Examination
It should be started from the moment the pregnant
woman walks into the examination room.
Examine general appearance:
Built
Nutrition
Gait
Height
Weight
BMI

16. BREAST : Assess breast size, symmetry,
condition of nipple, and the presence of
colostrum.
NECK: thyroid gland.
OEDEMA of legs

17. Blood pressure:
1.It is taken to ascertain normality and provide a
baseline reading for a comparison throughout
the pregnancy.
2.In late pregnancy, raised systolic pressure >
140 mm Hg or raised diastolic pressure >90
mm Hg on at least two occasions of 6 or more
hours apart indicates gestational HTN.
Pulse:
The normal pulse rate = 60-90 BPM.
Tachycardia is associated with anxiety,
hyperthyrodism, or infection.

18. Respiratory rate:
The normal is 16-24
Tachypnea may indicate respiratory infection, or
cardiac disease.
Temperature:
normal temperature during pregnancy is 36.2C to
37.6C.
Increased temperature suggests infection.

19. Cardiovascular system:
Venous congestion:
Which can develop into
varicosities, venous congestion
most commonly noted in the
legs, vulva, and rectum.
Edema:
Edema of the extremities or face
necessitates further
assessment for signs of
pregnancy-induced
hypertension.

20. OBSTETRIC EXAMINATION
Inspection:
Shape of the abdomen
Umbilicus
 Skin changes such as linea nigra, striae
gravidarum,dilated veins and scars of previous
operations.
Height of the fundus, which determines the period of
gestatiion

21. 2-Palpation
• The uterus will be palpable per abdomen after the
12th week of gestation
Abdominal palpation includes
Estimation of the period of gestation. This is done by
determination of fundal height.

22. 12 weeks :the uterus fills the
pelvis so that the fundus of the
uterus is palpable at the
symphysis pubis .
16 weeks, the uterus is
midway between the
symphysis pubis and the
umbilicus.
20 weeks, it reaches the
umbilicus

23. The uterus may be higher than expected :
1.Full bladder
2.Large fetus
3.Multiple gestation
4.Polyhydramnios
5.Mistaken date of last menstrual period
6.Pelvic tumors
7.Hydatiform mole
8.Concealed accidental haemorrage

24. The uterus may be lower than expected :
1.Small fetus
2. Intrauterine growth restriction
3.Oligohydramnios
4. IUFD
5. Mistaken date of last menstrual period.

25. Ht of the fundusHt of the fundus
McDonald’s method: Measure from symphysis McDonald’s method: Measure from symphysis
pubis to top of fundus in cm.pubis to top of fundus in cm.
After 24 wks distance measured in cm normally After 24 wks distance measured in cm normally
corresponds to period of gestation in wkscorresponds to period of gestation in wks

27. Schedual of antenatal care:
Medical check up every four weeks up
to 28 weeks gestation
Every 2 weeks until 36 weeks of
gestation
Visit each week until delivery
More frequent visits may be required
in high risk cases
WHO - 4 antenatal viists
16 wks
24-28wks
32wks and 36wks

28. Subsequent antenatal visit:
History: new symptoms
Maternal wt gain
Pallor
Pedal edema
BP
Assessment of the size of the uterus and ht of
fundus
Lie and presentation of the fetus
Clinical assessment of liquor
Girth of the abdomen in last trimester

29. Pelvic measurement:
The pelvic assesement is done beyond 37 wks to
determine whether the diameters are adequate to
permit vaginal delivery.

30. Laboratory data
Test Purpose
Blood group To determine blood type.
Hb% To detect anemia.
VDRL To screen for syphilis
HIV,HBsAg For screening
Urine analysis To detect infection or renal disease.
protein, glucose, and ketones
Thyroid profile To detect thyroid disorders
Glucose To screen for gestational diabetes.

31.  Hemoglobin will be repeated:
 At 28 wks,36 wks.
 Every 4 weeks if Hb is<9g/dl.
 Urine is tested (dipstick) for protein and sugar at
every antenatal visit
Screening for GDM is done at 24 – 28 wks

32. Ultrasound
Ist Trimester scan:
 To detect early pregnancy
Accurate dating.
Gross fetal anomalies.
Detect the multifetal pregnancy,ectopic pregnancy
Uterine / adnexal pathology

33. Ultrasound
Booking(TIFFA) scan:
Detailed fetal anatomical survey.
Placental localisation
Cervical length.
Done between 18-22 wks.

34. Danger signs of pregnancy
Vaginal bleeding including spotting.
Persistent abdominal pain.
Severe & persistent vomiting.
Sudden gush of fluid from vagina.
Absence or decreased 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.

35. Fetal kick count:
The pregnant woman reports at least 10
movements in 12 hours.
* Absence of fetal movements precedes
intrauterine fetal death by 48 hours.

37. DIET
Daily requirement in pregnancy about 2500 kilo
calories.
Caloric increase of 100 to 300 kcal per day is
recommended during pregnancy
Diet should be light, nutritious , easily digestible and
rich in proteins ,minerals and vitamins
Purpose:
Good maternal health
Optimal fetal growth
Physical strength & vitality in labor.
Successful lactation.

39. FOLIC ACID
500 microgm /day is recommended
High risk-4mg/day
Prevents neural tube defects , cong heart disease ,
cleft lip

40. Iron
Iron requirement of normal pregnancy : total approximately 1000mg
300 mg : transferred to the fetus and placenta
200 mg : lost through various normal routes of excretion, primarily
the gastrointestinal tract
500 mg : into the expanding maternal hemoglobin mass,
nearly all is used after midpregnancy.
the diet seldom contains enough iron to meet this demand.
→ at least 60 mg of ferrous iron supplement be given daily

41. Iron
during the first 4 months of pregnancy
not necessary to provide supplemental iron
the risk of aggravating nausea and vomiting.
Ingestion of iron at bedtime or on an empty stomach

42. Calcium
1000mg of calcium /day is required
80% of which is deposited in the fetus late in pregnancy
Multivitamins - given from 20 wks onwards
.

43. HYGIENE
Daily all over wash is necessary because it is
stimulating, refreshing, and relaxing.
Warm shower or sponge baths is better than tub
bath.
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.

44. Sleep:
The pregnant woman should lie down to relax or
sleep for 1 or 2 hours during the afternoon.
At least 8 hours sleep should be obtained every night
& increased towards term, because the highest level
of growth hormone secretion occurs at sleep.
Advise woman to use natural sedatives such as:
warm bath & glass of warm milk.

45. Breast care:
Advise the pregnant woman to expresses colostrums
during the last trimester of pregnancy to prevent
congestion.
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

46. Dental care:
Good dental and oral hygiene should be
maintained.
Encourage the woman the to see her dentist
regularly for routine examination & cleaning.
A tooth can be extracted during pregnancy if
necessary in 2
nd
trimester, but local anesthesia is
recommended.

47. Dressing:
Woman should avoid wearing tight cloths such as
belt or constricting bans on the legs, because
these could impede lower extremity circulation.
High heel shoes should be avoided.
Loose, and light clothes are the most
comfortable.

48. Travel by vehicles having jerks are better
avoided-first trimester, last 6 wks of pregnancy
Rail route is preferable to bus route.
 Travel in pressurized air crafts is safe up to 36
wks.
Air travel is CI - Pl previa , Anemia ,PE and sickle
cell anemia.
TravelTravel

49. Sexual activity:
Sexual intercourse is allowed with moderation.
 woman with increased risk of abortion,preterm
labour and placenta previa-should avoid sexual
intercourse

50. Exercises:
Exercise should be simple. Walking is ideal, but
long period of walking should be avoided.
The pregnant woman should avoid lifting heavy
weights
She should avoid long period of standing
because it predisposes her to varicose vein.
She should avoid sitting with legs crossed
because it will impede circulation.

51. Purpose:
1. To develop a good posture.
2. To reduce constipation & insomnia.
3. To reduce postural back ache& fatigue.
4. To ensure good muscles tone& strength pelvic
supports.
5. To develop good breathing habits, ensure good
oxygen supply to the fetus.
6 .To prevent circulatory stasis in lower extremities
(lessen the possibility of venous thrombosis)

52. SMOKING AND ALCOHOL
Smoking is avoided –prevent the risk of IUGR
Alcohol avoided – prevent fetal maldevelopment and
GR

53. Immunization:
All pregnant women should be immunized against
tetanus
Given in 2 doses-1
st
at 16-20 wks,2
nd
at 20-24wks
Live viral vaccines like MMR , Yellow fever are
contraindicated
Rabies , Hep A, B vaccines can be given

55. Nausea and Vomiting
common complaints during the first half of pregnancy
tend to be worse in the morning, continue throughout the day-morning
sickness
High levels of hcg

commence between the first and second missed menstrual period
continue until about 14 to 16 weeks
Nausea and vomiting : three fourths of pregnant women
lasted an average of 35 days
50% : relief by 14 weeks, 90 % : by 22 weeks.
80 % : nausea lasted all day

56. Nausea and Vomiting
Treatment
eating small feedings at more frequent intervals
Fatty foods are avoided.
smell of certain foods often precipitates or aggravates the
symptoms → avoid
vomiting may be so severe that dehydration, electrolyte and acid–
base disturbances, and starvation ketosis become serious problems.
→ hyperemesis gravidarum

57. Heartburn
Causes:
- progesterone hormone relaxes the cardiac sphincter of
the stomach and allows reflex of gastric contents into the
esophagus.
- the pressure of the growing uterus on the stomach from
about 30-40 weeks.
Management:
- avoid lying flat.
- sleeping with more pillows and lying on the right side.
- small frequent meals.
- take antacids.
Avoid fried ,spicy, and fatty food
Avoid citrus juices

58. Backache
Cause:
It may be due to increased lordosis
during pregnancy in an effort to
balance the body.
•The pregnancy hormones sometimes
soften the ligaments to such a degree
that some support is needed.
Management:
- exercise.
- sit with knee slightly higher than the
hips.
-The pregnant woman is reassured that
once birth has occurred, the ligaments
will return to their pre-pregnant
strength.

59. Urinary frequency
Cause:
Occur due to the pressure of the growing uterus on
the bladder.
Management:
The problem will resolved when the uterus rises
into the abdomen after the 12
th
week.
Kegel exercises are some times recommended .

60.  Intestinal motility decreased during pregnancy
- progesterone.
 Iron supplementation.
Management:
- the food should have amount of fruit & green
vegetables which contain fibers.
- drinking a lot of water.
- exercise & walking.
- laxatives could prescribed .
constipation

61. Varicosities
Causes:
- progesterone relaxes the smooth muscles of the
veins and result in sluggish circulation.
The valves of the dilated veins become inefficient
& varicose veins result.
- Obstruction in the venous return by the pregnant
uterus.
Seen in legs , vulva and rectum.

62. Varicosities
Management:
- lying flat on the bed with the feet elevated.
- elastic crepe bandage during movement
Hemorrhoids – regular use of laxative, local app
of hydrocortisone
surgical treatment is better to be withheld.

63. LEG CRAMPS
Due to deficiency of diffusible serum ca , elevation of
serum phosphorus.
Management:
Supplementary Ca
Massaging the leg
Application of local heat
Vit B1

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