Antenatal Care

Aims of antenatel care

• To prevent, detect, manage factors which might adversely affect mother or baby’s health
• To provide advice and reassurance to mother and family
• To plan with mother the circumstances of delivery
• To deal with minor ailments of pregnancy
  • Nausea
  • Heartburn
  • Constipation
  • SOB
  • Dizziness
  • Swelling
  • Backache
  • Abdominal discomfort
  • Headaches
• To provide general health screening
• To help women limit harmful behaviour such as smoking and alcohol consumption (smoking is associated with fetal growth restriction, preterm labour, abruption and fetal uterine death).

Classification of Antenatal Care

Shared antenatel care

• Provided by a hospital maternity team, GP and community midwives
• Women are bookedn under a named consultant and seen in the hospital for the booking visit by a member of the consultant’s team
• Most low risk women are not reviewed again by the hospital team until after they have pasted their EDD
• All other routine check ups are carried out by community team
• Women who are high risk or experience problems can be referred back for hospital care

Community based antenatel care

• Booking appointment carried out by community midwife
• Routine scans and investigations are also done by community midwife and interpreted by community team
• Generally offered to low risk women
• Provides greater degree of continuity of care

Hospital based antenate care

• An extension of shared care
• Involves a structured program of visits to antenatal clinic

Whichever mode of care is chosen the women is issued with a set of patient-held records in which all healthcare professionals write in.

The Antenatel visit

1) Confirmation of pregnancy

• A positive serum of urinary pregnancy test along with symptoms of pregnancy are sufficient. Symptoms of pregnancy include
  • Itching
  • Symphisis pubis dysfunction
  • Abdo pain
  • Heartburn
  • Bachache
  • Constipation
  • Ankle oedema
  • Leg cramps
  • Carpal tunnel syndrome
  • Vaginitis
• The women may be refered for a ‘dating scan’ which confirms pregnancy and dates it
• Dopler can be used to hear FH from 12 weeks

2) Dating Pregnancy

• EDD is important for preterm and post term pregnancies
• Naegele’s rule states that EDD is calculatd by adding one year and seven days to the first day of the LMP and taking away three months. Assumes a 28 day cycle and ovulation at day 14. Also requires an accurate LMP
• Dating by ultrasound requires to be done before week 14-15. Uses measurement of crown rump length (CRL), biparietal diameter (BPD) and femur length (FL). It becomes less accurate as pregnancy progresses

3) Booking History

• Note age and racial origin
• Previous Medical history
  • Meds may be teratogenic or alter fetal physiology
  • Pregnancy may cause a deterioration (or improvement) in a coexisting medical condition
  • Other health problems may increase pregnancy risk
• Past obstetric history
  • Previous pregnancy complications
  • Details of previous labours and deliveries
• Previous gynaecological history
  • Infertility or recurrent miscarriage
  • Gynaecological surgery? e.g. cone biopsy may cause cervical incompetence
• Family history
  • Diabetes increases risk of gestational diabetes
  • Pre-eclampsia
  • Thromboembolic disease increases risk of DVT or PE
  • Autoimmune disease?
• Social history
  • Smoking?
  • Alcohol?
  • Illegal drugs
  • Social deprivation increases risk of pregnancy complication
  • Domestic violence

The Antenatel Examination

For most healthy low risk women this will include the following

• Blood pressure
• Abdo examination to record the size of the uterus
• Inspection of abdo scars indicating previous surgery
• BMI measurement
• Urine examination (asymptomatic ascending bacteriuria more likely to cause pyelonephritis. This predisposes to pregnancy loss and preterm labour)

Antenatel investigations

• FBC
• Blood group and red cell antibodies
• Rubella immunity
• Hep B- presence of surface Ag ‘e’ represents recent infection or carrier status. Vertical transmission may occur (mostly at labour)
• HIV – less than ½ of all women pregnant women infected with HIV know their status. In HIV positive mothers, the use of anti virals, elective caesarean section and avoidance of breast-feeding reduces risk from 30% to 5%
• Syphilis – incidence is rising vertical transmission can be prevented by treating mother with antibiotics
• Haemoglobin studies – thalassaemia and sickle cell disease
• Gestational diabetes
• Screening for infections implicated in preterm labour – Chlamydia, bacterial vaginosis

Antental Screening for fetal abnormalities – optional

• Nuchal translucency scanning (11-13wks) or serum screening (15-19wk) for Down’s
• Maternal serum alpha fetoprotein (15-19wk) for neural tube defects
• ‘detailed’ ultrasound scan for structural congenital abnormalities

Follow up antenatal visits

• Minimum number of visits recommended by Royal college of Obstetricians and Gynaecologist is 5, at 12, 20, 28-32, 36 and 40-41 weeks
• At each follow up visit the following should be done
• General questions regarding maternal well being
• Any fetal movements
• Blood pressure
• Urinalysis
• Examination for oedema
• Abdominal palpation for fundal height
• Ascultation of fetal heart
• FBC and red cell antibody repeated at 28 and 36 weeks
• GTT for gestational diabetes at 28 weeks
• From 36 weeks, lie of fetus, presentation, degree of presenting part
• At 41 weeks discussion of induction. Increased mortality and morbidity means woman are recommended to deliver by 42 weeks