Routine Antenatal care part 2

Routine antenatal care for women of child bearing age in primary health care

1. ANTENATAL CARE FAMILY MEDICINE DEPARTMENT AKTH KANO DR OGECHUKWU MBANU 1

2. OUTLINE DEFINITION INTRODUCTION OBJECTIVE GOALS COMPREHENSIVE MATERNITY CARE MODELS OF ANTENATAL CARE THE PROCESS INVOLVED IN ANTENATAL CARE WARNING SYMPTOMS MITIGATING FACTORS AGAINST ANC REFERENCES 3

3. DEFINITION Antenatal care is a planned program of observation, education, and medical management of pregnant women directed toward making pregnancy and delivery a safe and satisfying experience OR Antenatal care can also be defined as the care that is given to an expected mother from time conception is confirmed until the beginning of labor 4

4. INRODUCTION Every year there are an estimated 200million pregnancies in the world . Each of these pregnancies is at risk for an adverse outcome for the woman and her infant. While risk cannot be totally eliminated ,they can be reduced through effective ,and acceptable antenatal care Globally 85% of pregnant women access antenatal care with a skilled health personnel at least once. only six in ten (58%)receive at least four ANC visits According to WHO as of 2015 the maternal mortality in Nigeria is 814 per 100000 lifebirths ,and skilled attendance at birth (% of births) is 45% 5

5. INRODUCTION CONT’D As of 2015 developing regions account for about 99% of maternal mortality ,with sub – saharan africa accounting for 66% Nigeria and India are estimated to account for over one third of all maternal deaths world wide in 2015 with 19% and 15% respectively The sustainable developmental goal 3 (SDG 3) has the agenda to reduce the global maternal mortality rate to less than 70% per 100000 life births by 2030 6

6. OBJECTIVE The overall objective of antenatal care is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother 7

7. GOALS To reduce maternal mortality and morbidity rates To improve the physical and mental health of women and indeed the entire family To prevent and identify maternal and fetal abnormities that can affect pregnancy outcome To decrease financial burden for care of mothers especially in developing countries To remove the fear about the delivery and to gain confidence before labour 8

8. GOALS (CONT’D) These goals can be achieved by Early screening tests Prevention, detection and treatment at any earliest complication Continued medical surveillance and prophylaxis Educating the mother about the physiology of pregnancy and labour by demonstrations , charts and diagrams so that fear is removed and psychology is improved 9

9. GOALS (CONT’D) 5.To predict problems on the basis of the medical , socio-economic , obstetrics history and physical examination 6 .Discussion with the couple about the place, time and expected mode of delivery and care of the newborn 7. Motivation of the couple about need for family planning 8. Counseling the mother about breast –feeding , post-natal care and immunization 10

10. Comprehensive maternity care The type of maternity care given in this hospital is the comprehensive maternity care. Comprehensive maternity care comprises of Preconception care Antenatal care Intrapartum care Postnatal care Antenatal care comprises of : Careful history taking, examination, investigations', prophylaxis and treatments Counseling given to the pregnant woman at different stages of the pregnancy 11

11. Models of Antenatal Care Provision Traditional ANC model(s) Began two hundred years ago and instituted programs and interventions that were traditionally thought to benefit the mother and her fetus Activities were not scientifically tested as to their effectiveness or benefit Followed a visit pattern of 4 weeks until 28 th week; then every 2 weeks until 36 th week and a weekly visit with many interventions at each visit Led to upto 14 visits and cost incurred for many investigations that were not necessarily warranted It was suggested that the traditional ANC practice be replaced by new models of focused ANC programs 12

12. Models of ANC – Continued Focused ANC- FANC : INTRODUCED IN 2002 FANC is providing goal oriented care that is timely , friendly , simple, ,beneficial and safe to pregnant women in order to achieve a good outcome for the mother and baby and prevent any complications that may occur in pregnancy, labour, ,delivery and postpartum Suggested four routine visits only at different gestations with a few evidence based diagnostic and intervention modalities performed at each visit Visits were at <16,28,32 and 36 weeks Additional visits were individualized depending on patients need 13

13. Focused ANC Program Activities Visit First Visit Second visit Third visit Fourth visit Gestational age <16 weeks 28 weeks 32 weeks 38 weeks Activities Classification to either the basic or specialized component Clinical exam Hgb test Gestational age determination Blood pressure Weight/Height Syphilis/STIs Urinalysis ABO/RH TT administration Iron /FA supplementation Document on ANC card Clinical exam for anemia Gestational age; FH; FHB exam Blood pressure Weight- only if underweight at initial visit Urinalysis- for nullipara or previous preeclampsia Iron / FA supplementation Complete on ANC card Hgb test TT second dose Instructions for birth planned Recommendations for lactation/contraception Document on ANC card Examine for breech presentation Document on ANC card Asheber Gaym, 2009

14. WHAT's NEW? 2016 WHO ANC MODEL

15. A minimum of eight contacts Is now been recommended This recommendation was informed by evidence suggesting There was increased perinatal deaths in 4-visit ANC model It improved safety during pregnancy through increased frequency of maternal and fetal assessment to detect complications It improved health system communication and support around pregnancy for women and families that more contact between pregnant women and doctor is more likely to lead to a positive pregnancy experience

16. 2016 WHO ANC model

17. The process involved in antenatal care Booking visit – Detailed evaluation through history, physical exam and laboratory work-up as required Based on the results further work up and a program of care is planned on individual basis Maternal or fetal factors that may require special care for the specific mother are identified and noted Subsequent visits- Are conducted based on the plans made at initial visit Newly developing situations during follow up are also noted and management plans modified accordingly 18

18. HISTORY TAKING Bio-data of the patient . This comprises of – Name Age Address Her occupation Marital status , duration of marriage Religion Partners name , and occupation etc Presenting complaints and history of presenting complaints Gynaecological history- LMP(in some places they use LNMP ie last normal menstrual period) ,menarche ,menstrual period pattern ,menstrual cycle 19

19. HISTORY(CONT’D) History of index pregnancy Obstetrics history – gravida , parity, details of previous pregnancies ,determination of GA and EDD .EDD is determined using NAEGELE’S FORMULA Contraceptive history Drug history ,history of immunization Past medical and surgical history Family and social history NB: Even if there is no complaint, enquiry is to be made about the sleep, appetite, bowel habit and urination 20

20. GENERAL SYSTEMIC REVIEW CNS GIT GENITALIA URINARY SYSTEM MUSCULOSKELETAL SYSTEM 21

21. PHYSICAL EXAMINATION General examination Abdominal examination Systemic examination Physical examination is important because – It exposes the patients current state It helps to detect previously undiagnosed physical problems that may affect the pregnancy To establish baseline levels that will guide the treatment of the expectant mother and the fetus throughout pregnancy 22

22. Important to note before physical examination Before examination , explain to the patient the need and the nature of the proposed examination Obtain a verbal consent The examiner (either male or female)should be accompanied by another female. Respect her privacy and examine in a private room. Expose only relevant parts of her anatomy for examination Ensure the patient is comfortable and warm Ask her to empty the bladder. 23

23. IMPORTANT TO NOTE (CONT’D) Patient should lie in the dorsal position with thighs slightly flexed . Stand to her right. She is slightly rolled to the left side to prevent compression of the inferior vena cava by the enlarged uterus (inferior venacaval syndrome or supine hypotensive syndrome) . Ask for any tender area before palpating the abdomen 24

24. General Examination GENERAL APPEARANCE FACIAL FEATURE/EXPRESSION NUTRITIONAL STATUS HEIGHT WEIGHT BMI SKIN ICTERUS LEGS NECK BREAS T

25. Neck - Diffuse swelling - common- 50 % cases of pregnancy Abnormal swelling

26. BREAST Normal in pregnancy Abnormal in pregnancy

27. ABDOMINAL EXAMINATION The abdomen is examined in three parts Inspection Palpation Auscultation 29

28. INSPECTION Size of uterus If the length and breadth are both increased Multiple gestation , polyhydramnios If the length is increased only Large baby Shape of the uterus Length should be large than broad. This indicates longitudinal lie. But if the uterus is low and broad it indicates transverse lie . Pendulous abdomen in a primigravida is a sign of inlet contraction 30

29. INSPECTION (CONT’D) If there is lateral implantation of the placenta then the uterine enlargement will be asymmetrical – piskacek’sign. look for fetal movements (more prominently seen in 3 rd trimester / less in oligohydramnios ) Look for scars Herniations Cutaneous signs such as linea nigra , striae gravidarum , is umbilicus flat or everted ,superficial viens Skin conditions ; scabies ,fungal infection 31

30. LINEA NIGRA Dark vertical line appearing on the abdomen from the pubis to above the umbilicus during pregnancy due to increase melanocyte stimulating hormone made by the placenta

31. STRIAE GRAVIDARUM Specific scarring of the skin due to sudden weight gain during pregnancy. Caused by tearing of the dermis and results in atrophy

32. PALPATION Aim Palpation of fetal parts Height of the uterus(symphysis – fundal height) Foetal lie Presentation Position Attitude Level of engagement Active foetal movements To assess fetal position,lie,presentation , attitude and engagement, LEOPOLD’S MANOUEVRE is followed or the classical method 34

33. PALPATION(CONT’D) Height of the uterus( symphysio –fundal height) This is the distance from the symphysis pubis to the uterine fundus (top of the uterus) TECHNIQUE Place the ulnar border of the left hand on the highest part of the uterus(fundus) Mark this point with a pen after obtaining permission The distance between the upper border of the symphysis pubis up to the marked point is measured by tape This usually corresponds to gestational age 35

34. FUNDAL REGION SYMPHYSEAL REGION TAPE

35. PALPATION(CONT’D) LEOPOLD’ MANOUEVRE – this is done by four obstetrics grips Fundal grip Lateral grip or umbilical grip – to assess fetal lie Pawliks grip – to assess presenting part Deep pelvic grip – to assess engagement and attitude of fetal head 37

36. 1) Fundal grip: Both hands placed over the fundus and the contents of the fundus determined. A hard smooth, round pole indicates a fetal head . Broad, soft and irregular mass suggestive of breech . In transverse lie no parts are palpated.

37. Lateral Grip

38. 2) Lateral Grip or umbilical grip: Move both hands in a downward direction from the fundus along the sides of the uterus to determine the "lie" of the fetus. "Lie" is the relationship btw the longitudinal axis of the fetus and the longitudinal axis of the mother. The "lie" is usually longitudinal, hence baby is lying length-wise in the same direction as mother's longitudinal axis.

39. Pawliks grip:

40. 3) Pawliks grip: (second pelvic grip ) The thumb and four fingers of the right hand are placed over the lower pole of uterus keeping the ulnar border of palm on the upper border of the suprapubic area to determine the presenting part . Presenting part of fetus is the lowest part of the fetus at the inlet of the pelvis .

41. Note made as to which hand first touches the fetal head (This point called cephalic prominence). Cephalic prominence helps determine the attitude (i.e. flexion, deflexed or extended) of fetal head.

42. 4) Deep pelvic grip: ( first pelvic grip ) Determines two points about the fetus 1) The attitude of the fetal head 2) Engagement of the fetal head 1) The attitude of the fetal head : The examiner turns around to face patients feet. Each hand placed on either side of the fetal trunk lower down. The hands moved downwards towards the fetal head.

43. If cephalic prominence is the sinciput and is on the opposite side of fetal back, fetal head is well flexed (Normal Position). If cephalic prominence is the occiput and is on the same side as fetal back, fetal head is extended (abnormal position). If examiners hands reach the fetal head equally on both sides ie both sinciput and occiput then the fetal head is deflexed (Military position, indicating mal-position)

44. POSITION •The position of the foetus is described by the relationship of the presenting part to the maternal pelvis •The denominator for the presenting part for a Cephalic presentation = occiput and for a Breech presentation = sacrum 48

45. Direct occipito -anterior (DOA) Occiput directly faces the front.Fetal spine is in alignment with mothers spine . 49

46. The description for a cephalic presentation with the occiput lying directly lateral to the left . This is –LEFT OCCIPITO-LATERAL 50

47. Left occiput-Anterior (LOA) Fetal spine is in the same plane as the mother’s spine, This is a longitudinal lie 51

48. Right occipito -lateral (ROL) The Occiput points to the mother’sRight.The fetal spine is in alignment with the mother’s spine 52

49. Direct occipito -posterior (DOP) Fetal spine is in alignment with the mother’s spine 53

50. Left occipito-posterior (LOP) Occiput here is slightly to the Mother's left -It is nearly a Direct Occipito posterior-It may be difficult to palpate the fetal back 54

51. Right occipito -posterior(ROP) Fetal spine is in alignment with mother’s spine . 55

52. Other "lies" are : Transverse Lie: fetus lies across the longitudinal axis of mother and oblique lie: fetus lies at an oblique angle to the mother's longitudinal axis. Can also determine which side the foetal back is situated by feeling the firm regular surface of the foetal back on one side and the irregular, lumpy surface as the foetal limbs on the other side. This can help us determine the position of the fetus

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55. PALPATION(CONT’D) Estimate foetal weight The Following methods can be used : 1- Fetal Growth Velocity : Normal growth-26.9 gm/ day More during 32-36 weeks Declines by 24 gm/day after 36 weeks ** individual fetal growth varies 2- Johnsons Formula: Fundal height (cm)- 12 (if Vertex above Ischial Spine ) × 155 = weight Fundal height (cm)- 11 (if vertex below Ischial Spine) × 155 = weight 59

56. 2)Engagement of the fetal head: Engagement of the fetal head is defined as having occurred once the widest transverse diameter of the fetal head (bi-parietal diameter) has passed through the pelvic inlet into the true pelvis. Procedure : Continue moving both hands down around the fetal head, determine how far around the head you can get. Examiner should be able to palpate part of fetal head still in the lower abdomen (also called the 'false' pelvis but cannot palpate the part of fetal head in the true pelvis).

57. Abdominal palpation to determine engagement of the head A- Divergence of fingers- Engaged Head B- Convergence of fingers- Not Engaged

58. If you divide the fetal head into five-fifths, you estimate how many fifths of the fetal head can be felt. If 5,4 or 3 fifths can still be palpated, most of the head is still up, hence the widest part of the head has not engaged into the pelvis. If only 2,1 or 0 fifths of fetal head felt, the widest part of the head has engaged into the pelvis.

59. PALPATION(CONT’D) AUSCULTATION : FHS is maximum below the umbilicus in cephalic presentation and FHS is maximum around the umbilicus in breech Auscultation can be done using : Pinnard's Foetal Stethoscope and sonicaid Regular stethoscope : useful in monitoring heart beat after 18 to 20 weeks (same as pinnards fetoscope) . Ultrasound fetoscope: 64

60. Vaginal Examination A vaginal examination (speculum or digital examination) can be used to To detect anatomical abnormalities To detect FGM if present and the type to see any rupture of membranes, to determine onset of labour by checking cervix cephalopelvic disproportion. Can be done bimanually by hands and by speculum.

61. Vaginal examination: PRE-REQUISITS: EXPLANATION EMPTY BLADDER DORSAL POSITION FULL ASEPSIS Equipment are present Contraindications : Placenta praevia . Abruptio placentae

62. Pelvic assessment This is done to assess for the adequacy of the pelvis Check ischial spines if prominent or not Diagonal conjugate distance from lower border of the symphysis pubis to the sacral promontory (pelvic inlet) Shape of the sacrum Side walls of the pelvis

63. OTHER SYSTEMIC EXAMINATIONS This will be determined from the patients presenting complaint and the finding on general physical examination 68

64. INVESTIGATIONS DURING ANTENATAL CARE Diagnostic procedure Gestation al age Hemoglobin/hematocrit determination Initial visit; repeat at 28-32 weeks ABO and RH typing Initial visit VDRL Initial visit; repeat at 28 weeks if negative Urinalysis At each visit to detect proteinuria Urine culture and sensitivity Initial visit to detect asymptomatic bacteriuria Serum alpha-fetoprotein test 16-18 weeks Routine ultrasonography 10-13 ,18-20,28,36 weeks Screening test for gestational diabetes 24-28 weeks Pap smear Initial visit especially if not done in the past 2 years Cervical smear gram stain and culture Initial visit HBsAg; HIV tests Initial visit 69

65. INVESTIGATIONS(CONT’D) OTHER INVESTIATIOS INCLUDE FBS OGTT 70

66. Ultrasound scan At BOOKING: for dating Localize fetus in the uterus Detect multiple gestation Screening for Downs syndrome At18 -20 weeks for fetal anomaly At 28 weeks for placenta localization if earlier suspected to be low lying At 36 weeks for estimated birth weight, AFI, presentation November 10, 2019 71

67. Assurance of fetal well being at ANC Progressive increase in maternal weight Progressive fundal height growth as per expectations Adequate maternal perception of fetal movement ( at least 10 in 12 hours) Fetal well being tests – from 28 weeks onwards (specific timing of follow up initiation depends on the individual risk profile concerned) Non stress test Contraction stress test Fetal biophysical profile score Doppler ultrasound velocimetry Ultrasonographic fetal scan for anomalies 72

68. Routine medical interventions Folic acid supplementation(0.4mg) daily Iron supplementation (30-60mg) daily of elemental iron Intermittent preventive treatment for malaria with fansidar twice during pregnancy Tetanus toxoid injection The following are not recommended : ,supplementation with multiple micronutrients , Vit 6 (pyridoxine),VIT E, VIT C , VIT D 73

69. EDUCATION AND COUNSELLING OF THE PREGNANT WOMAN www.freelivedoctor.com

70. Diet The daily requirements are: * Calories: 2500 Kcal. * Proteins: 60 gm. * Carbohydrates: 200- 400 gm. * Lipids: should be restricted. * Vitamins: o Vitamin A: 5000 IU. o Vitamin B1 (Thiamine): 1mg. o Vitamin B2 (Riboflavin): 1.5 mg. o Nicotinic acid: 15mg. o Ascorbic acid ( vit . C): 50mg. o Vitamin D: 400 IU. * Minerals: o Iron: 15 mg. o Calcium: 1000 mg.

71. So the suggested daily diet should include: * One litre of milk or its derivatives, * 1-2 eggs, * fresh vegetables and fruits. * 2 pieces of red meat replaced once weekly by sea fish and once weekly by calf ’s liver. * Cereals and bread are recommended also. Coffee and tea: should be restricted. www.freelivedoctor.com

72. COUNSELLING ON DAY TO DAY ACTIVITIES Smoking : should be avoided as it may cause intrauterine growth retardation or premature labour. Rest and sleep : 2 hours in the midday and 8 hours at night. Exercises : violent exercises as diving and water sports should be avoided. House work short of fatigue and walking are encouraged. ON CLOTHINGS Lighter and looser clothes of non synthetic materials are better due to increased BMR and sweating Clothes which hang from the shoulders are more comfortable than that requiring waste bands Breast support is required. 77

73. Counseling cont’d Bathing : Shower bathing is preferable than tube bathing for fear of ascending infection. Vaginal douching should be avoided Shoes: High - heeled shoes should be discouraged as they increase lumbar lordosis , back strain and risk of falling Bowels : Constipation is avoided by increasing vegetables, fluids and mild exercise. Liquid paraffin should not be used for long period as it interferes with absorption of fat- soluble vitamins (A and D 78

74. Counseling cont’d Coitus : Whenever abortion or preterm labour is a threat, coitus should be avoided. Otherwise, it is allowed with less frequency and violence. Abstinence in the last 4 weeksof pregnancy to prevent ascending infections Travelling : long and tiring journeys should be avoided particularly if the woman is prone to abortion or preterm labour. Flying is not contraindicated but not the long ones and near term Medications : not to be taken without doctors advice due to risk of teratogenicity Exposure to irradiation : is to be avoided whether diagnostic or therapeutic 79

75. WARNING SYMPTOMS vaginal bleeding, gush of fluid per vagina, severe or persistent abdominal pain, persistent headache, blurring of vision, severe oedema of lower limbs or swelling of the face, persistent vomiting. 80

76. Mitigating factors against ANC Inadequate accessibility to health care facilities Poor female education Economic factors Lack of adequate facilities in our health institutions Inadequate public awareness Cultural practices e.g. early marriage ,use of local untrained birth attendants Poor staffing of medical facilities in terms of both number and qualification. 81

77. THANK YOU FOR LISTENING 82

78. REFERENCES ABC of antenatal care ,fourth edition ,Geoffrey Chamberlain. Obstetrics examination ,clinical skills resource centre university of Liverpool uk WHO recommendations on antenatal care for a positive pregnancy experience 7 November 2016 D.C. Dutta’s texbook of obstetrics, 8 th edition-2015- Google eBook Oxford handbook of clinical examination and practical skills, 1 st edition (vishal) Textbook of Obstetrics and Gynaecology for Medical Students .second edition , Akin Abgoola WHO guideline on antenatal care (2016) overview Antenatal care presentation,Asheber Gaym M.D. ,January 2009 Obstetrics history and examination presentation. Rajeev Baham Examination of an obstetrics case presentation ,Dr Vamshikrishna Dussa,16 th March 2016 www .freelivedoctor.com Google images 83