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Traditional Antenatal Care Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Maternity Traditional Antenatal Care Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Maternity & Women’s Hospital

The Pillars of Safe Motherhood BASIC HEALTH SERVICES EQUITY EMOTIONAL AND PSYCHOLOGICAL SUPPORT Essential The Pillars of Safe Motherhood BASIC HEALTH SERVICES EQUITY EMOTIONAL AND PSYCHOLOGICAL SUPPORT Essential Obstetric Care Postpartum Care Clean/safe Delivery Antenatal Care Postabortion Family Planning SAFE MOTHERHOOD

Objectives of ANC • Promote and maintain the physical, mental and social health of Objectives of ANC • Promote and maintain the physical, mental and social health of mother and baby by providing education on nutrition, personal hygiene and birthing process • Detect and manage complications during pregnancy, whether medical, surgical or obstetrical • Develop birth preparedness and complication readiness plan • Help prepare mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially

What is Effective ANC? • Care from a skilled attendant and continuity of care What is Effective ANC? • Care from a skilled attendant and continuity of care • Preparation for birth and potential complications • Promoting health and preventing disease – Tetanus toxoid, nutritional supplementation, tobacco and alcohol use, etc • Detection of existing diseases and treatment – HIV, syphilis, tuberculosis, other co-existing medical diseases (e. g. , hypertension, diabetes) • Early detection and management of complications

What you should do… • Diagnose Pregnancy through an understanding of the presumptive, probable, What you should do… • Diagnose Pregnancy through an understanding of the presumptive, probable, and positive signs of pregnancy. • Given the date of the last menstrual period: calculate the EDC and the gestational age at any time. • Describe the interventions appropriate to the expected physiologic and psychologic changes of pregnancy. • Describe the care of the pregnant patient at the initial prenatal visit and follow up visits

 • Given the patient’s OB/GYN history, determine the gravidity and parity • Teach • Given the patient’s OB/GYN history, determine the gravidity and parity • Teach patients how to manage common pregnancy discomforts • Analyze risk factors of the pregnant patient • Consider developmental level and cultural background when planning pregnancy care and delivery.

Diagnosis of Pregnancy • Clinical Diagnosis – Symptoms of early Pregnancy – Signs • Diagnosis of Pregnancy • Clinical Diagnosis – Symptoms of early Pregnancy – Signs • Investigations • Presumptive • Probable • Positive

Presumptive Signs of Pregnancy Symptoms • Cessation of menstruation / Amenorrhea • Nausea and Presumptive Signs of Pregnancy Symptoms • Cessation of menstruation / Amenorrhea • Nausea and vomiting – Changes in appetite • Fatigue • Urinary frequency • Breast enlargement and tenderness • Mood Changes • Quickening

Signs - Vulva: Soft and violet (Jacque-Mier’s sign). - Vagina: Soft, warm, and dark Signs - Vulva: Soft and violet (Jacque-Mier’s sign). - Vagina: Soft, warm, and dark blue or purplish red (Chadwick’s sign) Cervix: soft, and violet (Goodell’s sign). By 6 -8 weeks the cervix softens and has the consistency of lips of the mouth while the nonpregnant cervix feels like the cartilage of the nose. - Uterine signs: – The uterus is enlarged and soft. • • – – At 8 weeks size of an orange. At 12 weeks the uterus is globular and about 8 cm in diameter (grape fruit size) with the fundus at the upper border of symphysis pubis Palmer’s sign: Intermittent uterine contractions felt during bimanual examination. Hegar’s sign: The body of the uterus is felt elastic above the compressible isthmus, while the cervix is felt firm below as if it is separate from the uterus which mimics an enlarged adnexa. It is positive in pregnant women beween 6 -8 weeks.

Hegar’s sign Hegar’s sign

The Breast – Enlargement of the breasts with dilated veins over it – Pigmentation The Breast – Enlargement of the breasts with dilated veins over it – Pigmentation of the areola and nipples – Appearance of the secondary areola ( slightly elevated as a mound) – Prominent Montgomery tubercles – Colostrum secretion in third month

Pregnancy Tests • Urine Pregnancy Test – Agglutination Inhibition – ELISA ( sensitive to Pregnancy Tests • Urine Pregnancy Test – Agglutination Inhibition – ELISA ( sensitive to a 50 m. IU/ ml level) • Blood Pregnancy Test – RIA – ELISA

False positive urinary pregnancy test • • Proteinuria Pelvic tuberculosis Drugs stmulating LH release False positive urinary pregnancy test • • Proteinuria Pelvic tuberculosis Drugs stmulating LH release from pituitary as penicillin and phenothiazines Immunologic diseases as systemic lupus erythematosisbecause Ig M interacts with test reagents Perimenopausal women with high LH Excessively alkaline urine HCG producing tumors as choriocarcinoma Hematuria as hemoglobin is a protein

Probable Signs of Pregnancy • • Goodell’s sign (softening of the cervix) Chadwick’s sign Probable Signs of Pregnancy • • Goodell’s sign (softening of the cervix) Chadwick’s sign (bluish vaginal tissue) Hegar’s sign (softening of the cervix) Ballottement • • – – Internal ballottement: It is present between 16 th and 28 th week. External ballottement: It can be detected after the 24 th week Positive Pregnancy Test

Sure signs of Pregnancy • Ultrasound Evidence – The concept of the discriminatory level Sure signs of Pregnancy • Ultrasound Evidence – The concept of the discriminatory level • A TVS should detect an intra-uterine gestational sac if the beta subunit h. CG level is 1500 m. IU/L. • A transabdominal • Fetal heart • Identification of Fetal parts

Ultrasonography • • The pregnancy sac can be detected at 4 -5 weeks. The Ultrasonography • • The pregnancy sac can be detected at 4 -5 weeks. The gestational ring is detected universally at 6 weeks. The embryonic echo can be seen at 7 weeks. The fetal heart can be detected at 8 weeks. – – Vaginal ultrasonography can detect a pregnancy sac of 2 mm at about 16 days gestation and fetal heart at 6 weeks. Also, the fetal heart sounds can be heard after the 10 th week by the doppler (Sonicaid).

 • Quickening – first time at which the mother percepts fetal movements. – • Quickening – first time at which the mother percepts fetal movements. – It is not a sure sign but is useful for accurate dating of the pregnancy. – It is felt earlier in multipara (16 -18 weeks) than in primigravida (18 -20 weeks) due to previous experience. • Enlargement of the abdomen: – This occurs after the 12 th week when the uterus becomes abdominal. – This is less pronounced in primigravida because in multipara the abdominal wall is more flaccid and the uterus sags forward and is more seen when she is standing.

DD • Early Pregnancy – Causes of amenorrhea – Causes of symmetrical enlargement of DD • Early Pregnancy – Causes of amenorrhea – Causes of symmetrical enlargement of the uterus • • myomas, hematometra, adenomyosis, extrauterine mass. • Late Pregnancy – Pelviabdominal swelling – Pseudocyesis

The Initial “Booking” Prenatal Visit • • Medical history Menstrual history Physical exam Investigations The Initial “Booking” Prenatal Visit • • Medical history Menstrual history Physical exam Investigations – Diagnostic tests – Screening Tests • Assess risk factors and building up a strategy for the antenatal care • Health Education with exhaustive efforts and advices

Important Demographic Data • • Age Occupation Education Residence Ethnicity Race Religion Pets Important Demographic Data • • Age Occupation Education Residence Ethnicity Race Religion Pets

Medical and Family History Includes client and her partner • Information to obtain – Medical and Family History Includes client and her partner • Information to obtain – Prior or current health issues – Medications and allergies – Possible inherited diseases in the families – Significant health issues in family members – Use of tobacco, alcohol, street drugs

Menstrual History • What is the concept of ‘Reliable Dates’ ? Menstrual History • What is the concept of ‘Reliable Dates’ ?

Expected Date of Delivery • Duration of pregnancy – 280 days or 40 weeks Expected Date of Delivery • Duration of pregnancy – 280 days or 40 weeks or 10 lunar months • Naegele’s rule – Add seven days to the first day of the LMP and subtract three months [or add 9 months] • The concept of reliable dates

Other indicators of gestational age • FHT with doppler at 10– 12 weeks • Other indicators of gestational age • FHT with doppler at 10– 12 weeks • Fetal movement felt at about 20 weeks • Fundal height correlation with gestational age • Ultrasound : Dating U/S is a first trimester US… or 2 mid-trimester, 2 weeks apart – Gestational sac – CRL – BPD

Measurement Symphyseal Fundal height • Evidence supports either palpation or S- F measurement at Measurement Symphyseal Fundal height • Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth • measurement should start at the variable point (F) and continue to the fixed point (S) • SF measurement should be recorded in a consistent manner (therefore in cms)

Between 20 and 36 weeks of pregnancy, the height of the fundus in centimeters Between 20 and 36 weeks of pregnancy, the height of the fundus in centimeters to the upper border of the symphysis pubis equals the duration of pregnancy in weeks.

 • – – – – Causes of oversized • Causes of undersized uterus • – – – – Causes of oversized • Causes of undersized uterus (larger than period uterus (smaller than of amenorrhea): period of amenorrhea): Wrong dates. Polyhydramnios. Hydatidiform mole. Macrosomic fetus. Concealed accidental hemorrhage. Twins. Tumors as fibroids and ovarian cysts. Fetal malformations as hydrocephalus. – Wrong dates – Oligohydramnios – Fetal death – IUGR or Small fetus – Pregnancy during period of amenorrhea as lactation or injectable contraception – Malpresentations as transverse lie

Gravidity and Parity • Gravida–number of pregnancies • Para–number of births after 20 weeks Gravidity and Parity • Gravida–number of pregnancies • Para–number of births after 20 weeks – Five-digit system • • • G–total number of pregnancies T–full-term pregnancies (37– 40 weeks) Preterm deliveries (20– 36 weeks) A–abortions and miscarriages (before 20 weeks) L–living children

Laboratory Analysis and Testing • Blood Work – Blood type and Rh status – Laboratory Analysis and Testing • Blood Work – Blood type and Rh status – Antibody screen (Coombs’ test) – CBC – Rubella titer – HIV Hepatitis B – Syphilis – Sickle cell – Glucose screen – Triple screen – Cystic fibrosis – Varicella • Other Testing – – – Ultrasound Urinalysis Pap smear GC culture Chlamydia culture Group B streptococci

Routine BP measurement • HT is defined when systolic BP is 140 mm. Hg Routine BP measurement • HT is defined when systolic BP is 140 mm. Hg +/or DBP is 90 mm. Hg or there is an incremental rise of 30 systolic or 15 diastolic. • Automated devices & ambulatory devices should not be used (Mercury devises seem best)

Fetal Presentation and Descent • Check presenting part beginning around 36 weeks • Descent Fetal Presentation and Descent • Check presenting part beginning around 36 weeks • Descent of presenting part is important as term approaches

Auscultation of fetal heart • Listening to fetal heart is of no known clinical Auscultation of fetal heart • Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion) • Should be offered at each visit after about 20 weeks • NST and CST ? • Asking the mother about fetal Kicks. – Counsel her to count to 10 during the last 4 weeks of pregnancy.

Urinalysis by dipstick for proteinuria - evidence • high incidence of false +ve and Urinalysis by dipstick for proteinuria - evidence • high incidence of false +ve and - ve using dipsticks of 24 hr urine collection • unreliable in detecting highly variable elevations in protein in pre-eclampsia Gribble et al AJOG 1995; 173: 214 -7

Initial recommended tests • FBS. • MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if Initial recommended tests • FBS. • MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low) • Blood group/Ab screen • HIV (level 1 evidence) • Hep B • Syphilis (ideally prior 16 weeks) • Rubella Abs

 • Urine testing- either 2 step or MSU+dipstick • PAP if due • • Urine testing- either 2 step or MSU+dipstick • PAP if due • dating US

1 -Hour Routine Screening (ACOG, 1994) 50 G Glucose screening test (GST) between 24 1 -Hour Routine Screening (ACOG, 1994) 50 G Glucose screening test (GST) between 24 and 28 weeks (non-fasting) If results <130 -140 No further screening needed. • If 130 -140 mg% 190 mg%: This is diagnostic of GDM

Determination of GDM (ACOG, 1994) 100 Grams OGTT (3 hrs) 75 Grams OGTT (2 Determination of GDM (ACOG, 1994) 100 Grams OGTT (3 hrs) 75 Grams OGTT (2 hrs) Fasting 1 hour 2 hour 3 hour Ranges of Accepted Values 95 -105 180 -190 155 -165 140 -145 - If 2 or more values met or exceeded = GDM - Consuming at least 150 grams/day for the 3 days preceding the test with 8 hours overnight fasting

Retesting (32 -34 Weeks) When? • Negative initial test, risk factors present • Obesity Retesting (32 -34 Weeks) When? • Negative initial test, risk factors present • Obesity • >33 years of age • Positive 1 hour screen followed by a negative OGTT • 3+/4+ glucosuria

Screening for Asymptomatic Bacteruria • MSU sample • Colony count >105 /ml necessitates treatment Screening for Asymptomatic Bacteruria • MSU sample • Colony count >105 /ml necessitates treatment according to Culture and sensitivity.

Hepatitis C screening • Should be offered to all at increased risk – history Hepatitis C screening • Should be offered to all at increased risk – history of injecting drugs – partner who injected drugs – tattoo or piercing – been in prison – blood t/f later positive for Hep C – long-term dialysis or organ transplant before 7/92

Leopold’s Maneuvers • The patient lies supine and you stand at her side facing Leopold’s Maneuvers • The patient lies supine and you stand at her side facing her head. • You place your hands on the fundus to determine the presence or absence of a fetal pole (vertical versus transverse lie), and the nature of the pole (vertex or breech). – The fetal breech is larger, less well defined, and less ballottable than the head

 • Still facing the maternal head, you then examine the lateral walls of • Still facing the maternal head, you then examine the lateral walls of the uterus to determine which side the fetal back and small parts occupy.

 • In cephalic presentations, a point of the fetal head may be noted • In cephalic presentations, a point of the fetal head may be noted as a protuberance that arrests the hand outlining the fetus. • As the hands are moved along the lateral walls of the fetus toward the pelvis, either the occiput or the chin will be encountered.

 • You now turn toward the patient’s feet and place your hands laterally • You now turn toward the patient’s feet and place your hands laterally above the symphysis and bring them toward the midline. • You are trying to determine the nature of the fetal pole (vertex or breech) and the degree of descent of the pole, indicating the station of the presenting part.

Nutrition • Avoidance of potential teratogens – What could be teratogenic in food ? Nutrition • Avoidance of potential teratogens – What could be teratogenic in food ? • Folic acid supplementation • Prenatal vitamin and mineral supplements • Weight gain – – Individualized according to pre-pregnancy weight Weight assessed at every visit Weight loss is never normal Excessive weight gain requires evaluation

Option I Traditional Food Pyramid • 55% carbohydrate, • 25% protein, • 20% fat Option I Traditional Food Pyramid • 55% carbohydrate, • 25% protein, • 20% fat

Option II Balanced Diet 35 -40% Carbohydrates 35 -40% Fat 20 --25% Protein Option II Balanced Diet 35 -40% Carbohydrates 35 -40% Fat 20 --25% Protein

Option III Low Glycemic Carbohydrates • More Protein • Low Carbs • Appropriate Fats Option III Low Glycemic Carbohydrates • More Protein • Low Carbs • Appropriate Fats

Diet…. • Calories: – The requirements increase from 2200 to 2500 Kcal (Kilocalories) calories. Diet…. • Calories: – The requirements increase from 2200 to 2500 Kcal (Kilocalories) calories. • The additional energy required is more than 300 Kcal but is reduced by reduced physical activity • Proteins: – Increased protein demands are needed for fetal, uterine, placental and breast growth and increased blood volume. – During the last 6 months of pregnancy 1 kg of protein is deposited amounting to 5 -6 g per day. – The majority is required as in animal form as meat, milk, eggs. Milk is the ideal source. Lactose intolerance can be prevented by eating youghort and cheese. • Fats and Carbohydrates: – Fried food, cream, sweets chocolates and sugar should be consumed sensibly to avoid excess weight gain. – Empty calories are better avoided – Jams, cakes, pastries, biscuits and large quantities of bread and potato should also be restricted.

Vitamins and Minerals Iron is the only nutrient for which requirements are not met Vitamins and Minerals Iron is the only nutrient for which requirements are not met by diet alone. Routine multivitamin is not recommended as any general diet supplies the required vitamins but women who do not consume an adequate diet need a supplement containing iron, zinc, copper, calcium, vitamin B 6, folate, vitamin C vitamin D. – Iron: • • • Daily requirement is 30 -60 mg. As Normal diet contains about 15 mg, One gram of iron is needed. – – – • • • 300 for the fetus and placenta, 500 for the increased blood volume and 200 for the uterus. 7 mg per day are needed 30 mg of a simple iron salt as ferrous sulphate, gluconate, fumarate once daily provides sufficient iron. 60 -100 mg are needed if the woman is large, has twins takes iron irregularly. Anemic women need 200 mg in divided doses. Calcium and magnesium in multivitamins reduces iron absorption so iron is best given alone iron is not needed in the first 4 months if there is no anemia. Given at bedtime is better.

Vitamins and Minerals – Sodium: Salting food to taste gives sufficient salt. • – Vitamins and Minerals – Sodium: Salting food to taste gives sufficient salt. • – There is no evidence that excess salt predisposes to pregnancy induced hypertension but some restriction is required if the woman is hypertensive. Iodine: Deficiency may lead to congenital goitre and maternal goitre. – Calcium: calcium supplementation is unlikely to be of benefit. Two glasses of milk are sufficient

– Vitamin A: daily requirement in pregnancy is 5000 I. U. • – – – Vitamin A: daily requirement in pregnancy is 5000 I. U. • – – Vitamin B 6 deficiency may cause vomiting Folic acid: about 1 mg (1000 mcg) provides very effective prophylaxis against megaloblastic anemia. • – – – Vitamin A in excess amount is teratogenic Folic acid supplementation before and early in pregnancy significantly reduces the risk of neural tube defects. Vitamin B 12: Its deficiency only occurs in strict vegetarians. Vitamin C: Deficiency leads to postpartum hemorrhage and scurvy (100 mg/d). Vitamin K: Deficiency leads to postpartum hemorrhage and it may cause hemorrhage in the fetus

Routine weighing at A/N visits - evidence • weighing at every antenatal visit routine Routine weighing at A/N visits - evidence • weighing at every antenatal visit routine practice for many years • No conclusive evidence for weighing at each visit. Maternal weight not clinically useful screening tool for detection of IUGR, macrosomia or pre-eclampsia. • Weighing at booking or other times may be indicated eg anaesthetic risk assessment (done BIV at RWH) or maternal weight concerns

Body Mass Index (BMI) • A commonly used measure to differentiate underweight, normal weight, Body Mass Index (BMI) • A commonly used measure to differentiate underweight, normal weight, overweight and obesity. • Obtained by dividing the weight of the subject (in kilos) by the square of his (her) height in meters. • A BMI of approximately 25 kg/m 2 corresponds to about 10 percent over ideal body weight.

Body Mass Index Definitions Classification Underweight Healthy Weight BMI <18. 5 to 24. 9 Body Mass Index Definitions Classification Underweight Healthy Weight BMI <18. 5 to 24. 9 Overweight Class I obesity Class III obesity 25. 0 to 29. 9 30. 0 to 34. 9 35 to 39. 9 > 40. 0

Body Mass Index and Recommended Weight Gain Pre-pregnant weight status A. Twin Pregnancy Recommended Body Mass Index and Recommended Weight Gain Pre-pregnant weight status A. Twin Pregnancy Recommended range of weight gain 15 - 20 Kg. B. Underweight (BMI<18. 5) 12 - 17 kg. C. Normal Weight (BMI 18. 5 to 24. 9) 11 - 15 Kg. D. Overweight (BMI 25. 0 to 29. 9) 6 - 11 Kg. E. Obese (BMI > 30. 0) 6 Kg.

Smoking: • • • Birth weights are lower , IUGR, increased perinatal deaths and Smoking: • • • Birth weights are lower , IUGR, increased perinatal deaths and preterm labor are present in smoking mothers. This is due to effect of carbon monoxide, the vasoconstricting effect of nicotine on the fetal vessels in the placenta, which decreases placental perfusion, reduced appetite and decreased maternal blood volume expansion. Passive smoking is also very harmful to women. It leads to ptyalism, nervousness and increased hyperemesis gravidarum.

Alcohol Consumption • Fetal alcohol syndrome (FAS) is a birth defect syndrome caused by Alcohol Consumption • Fetal alcohol syndrome (FAS) is a birth defect syndrome caused by the mother's intake of alcohol during pregnancy. • In order to receive a diagnosis of FAS from a physician, three criteria must be present: – Characteristic facial features include - a flattened midface, thin upper lip, indistinct/absent philtrum and short eye slits – Growth retardation - lower birth weight, disproportional weight not due to nutrition, height and/or weight below the 5 th percentile. – Central Nervous System neurodevelopmental abnormalities such as - impaired fine motor skills, learning disabilities, behavior disorders or a mental handicap (the latter of which is found in approximately 50% of those with FAS)

 • Sleep: Adequate rest of about 8 hours at night and 1 or • Sleep: Adequate rest of about 8 hours at night and 1 or 2 hours in the afternoon is recommended. • Exercise: – – – • It is not necessary to limit exercise as long as she does not get excessively fatigued or there is a risk to injury herself. Women accustomed to exercise before pregnancy should be allowed to continue but avoid starting new exercise programs walking is the best to recommend. Regular exercise improves metabolic efficiency. Exercise does not increase risk of spontaneous abortion, shortens active labor and leads to fewer cesarean sections. Exercise is avoided in women with twin pregnancies, pregnancy induced hypertension, growth restricted fetuses and severe heart and lung diseases. Work: – – Birth weights of women who worked during the third trimester are 150 -400 gm less than those who do not work. It is greatest if the woman is underweight, with low weight gain and whose work requires standing. Standing was also associated with increase in preterm births. Heavy work defined as sufficient to cause sweating was not deleterious. Any occupation that causes severe physical strain is avoided. No work that causes undue fatigue should be allowed and adequate periods of rest during the working day should be allowed.

 • Traveling: This has no harmful effect. – – – • Coitus: – • Traveling: This has no harmful effect. – – – • Coitus: – – • Coitus should only be avoided in threatened abortion, PROM, threatened preterm delivery or if there is a placenta previa Sexual intercourse does not do harm before the last 4 weeks of pregnancy. Clothing: – – • Air travel is also safe but in long trips of more than 6 hours the woman should walk about every 2 hours to prevent deep venous thrombosis. The greatest risk is to travel away from proper medical facilities or to areas with infectuous diseases Seat belts are advised but the lap belt should be placed under the abdomen and across the thighs and the shoulder belt between the breasts. should be practical and non-restricting. High heels are avoided to prevent loss of balance and prevent increased lordosis and backache. Care of teeth: – – Pregnancy is not a contraindication for any dental treatment. The concept that pregnancy aggravates dental caries is not true.

 • Breasts: – – – • Bowels: – – – • Bowel habits • Breasts: – – – • Bowels: – – – • Bowel habits become irregular due to relaxation of the bowel smooth muscles and compression of the lower bowel by the pregnant uterus. Passage of hard stools can cause bleeding and fissures in the edematous rectal mucosa. Hemorrhoids are more common. Prevention of constipation is by drinking sufficient amount of fluid, daily exercise, foods containing roughage as fruit and salad. Harsh laxatives and enemas are avoided. Bathing: – • Well fitting supporting brassieres are required as breasts become painful and pendulous. Crusts or dried secretion over the nipples are washed by warm wateror boric acid. The nipples are drawn for a short time daily by the thumb and fingers and painted with a lubricant during the last 6 weeks. There are no restrictions but the mother should be careful not to slip in the tub and showers are safer. Douching: – – Use of hand bulb syringes are contraindicated. The douche bag should not be raised more than 60 cm above the hips and the nozzle not more than 7 cm in the vagina.

Immunization: – – – Live attenuated virus vaccines as measles, rubella, mumps, poliomyelitis are Immunization: – – – Live attenuated virus vaccines as measles, rubella, mumps, poliomyelitis are contraindicated. Inactivated virus vaccines as influenza, and rabies are safe to be given. Inactivated bacterial vaccines as cholera, meningococcus, and typhoid are safe to be given. Toxoids as tetanus and diphtheria toxoid are safe to be given. Immune globulins as for hepatitis, tetanus and rabies can be given.

Tetanus Vaccination Campaign Dose Protection Immunity After the 3 rd month 0% 0% 2 Tetanus Vaccination Campaign Dose Protection Immunity After the 3 rd month 0% 0% 2 nd Dose At least 4 weeks after the first shot and 2 weeks before delivery 80% 3 years 1 st Dose Given 3 rd Dose -6 months after the 2 nd dose -Or during the next pregnancy ( within 5 years) 95% 5 years 4 th Dose -1 year after the 3 rd Dose -Or During the next pregnancy ( within 5 years) 99% 10 years 5 th Dose - 1 year after the 4 th Dose -Or During the next pregnancy ( within 5 years) 99% Lifelong

Warning signs: The pregnant woman must immediately report if any one of the following Warning signs: The pregnant woman must immediately report if any one of the following signals occur: – – – – – Vaginal bleeding. Swelling of the face, fingers and limbs. Swollen tender calf muscles Severe headache. Blurring of vision. Abdominal pain. Persistent vomiting. Chills and fever. Escape of fluid from the vagina.

Visit Schedule • The return visits are – Every 4 weeks until 28 weeks Visit Schedule • The return visits are – Every 4 weeks until 28 weeks then – Every 2 weeks until 36 weeks then – Weekly thereafter. A more flexible schedule is at times better. • Perinatal outcome benefits were more pronounced with antenatal care after 30 weeks. • The mother is advised to call or come when she feels undue worry. In each visit the well being of mother and fetus are assessed. • The WHO recommends at least 4 antenatal visits

First appointment The first appointment needs to be earlier in pregnancy (prior to 12 First appointment The first appointment needs to be earlier in pregnancy (prior to 12 weeks) than may have traditionally occurred and, because of the large volume of information needs in early pregnancy, two appointments may be required. At the first (and second) antenatal appointment: – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by written information (on topics such as diet and lifestyle considerations, pregnancy care services available, maternity benefits and sufficient information to enable informed decision making about screening tests) – identify women who may need additional care and plan pattern of care for the pregnancy – check blood group and Rh. D status – offer screening for anaemia, red-cell alloantibodies, Hepatitis B virus, HIV, rubella susceptibility and syphilis – offer screening for asymptomatic bacteriuria (ASB) – offering screening for Down’s syndrome – offer early ultrasound scan for gestational age assessment – offer ultrasound screening for structural anomalies (20 weeks) – measure BMI, blood pressure (BP) and test urine for proteinuria.

 • 16 weeks – review, discuss and record the results of all screening • 16 weeks – review, discuss and record the results of all screening tests undertaken; reassess planned – pattern of care for the pregnancy and identify women who need additional care – investigate a haemoglobin level of less than 11 g/dl and consider iron supplementation if indicated – measure BP and test urine for proteinuria – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.

18– 20 weeks – If the woman chooses, an ultrasound scan should be performed 18– 20 weeks – If the woman chooses, an ultrasound scan should be performed for the detection of structural anomalies. – For a woman whose placenta is found to extend across the internal cervical os at this time, another scan at 36 weeks should be offered and the results of this scan reviewed at the 36 -week appointment. 25 weeks – At 25 weeks of gestation, another appointment should be scheduled for nulliparous women. At this appointment: – measure and plot symphysis–fundal height – measure BP and test urine for proteinuria – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.

 • 31 weeks Nulliparous women should have an appointment scheduled at 31 weeks • 31 weeks Nulliparous women should have an appointment scheduled at 31 weeks to: – measure BP and test urine for proteinuria – measure and plot symphysis–fundal height – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information – review, discuss and record the results of screening tests undertaken at 28 weeks; reassess planned pattern of care for the pregnancy and identify women who need additional care.

34 weeks At 34 weeks, all pregnant women should be seen in order to: 34 weeks At 34 weeks, all pregnant women should be seen in order to: – offer a second dose of anti-D to rhesus-negative women – measure BP and test urine for proteinuria – measure and plot symphysis–fundal height – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information – review, discuss and record the results of screening tests undertaken at 28 weeks; reassess planned pattern of care for the pregnancy and identify women who need additional care

36 weeks At 36 weeks, all pregnant women should be seen again to: – 36 weeks At 36 weeks, all pregnant women should be seen again to: – – measure BP and test urine for proteinuria measure and plot symphysis–fundal height check position of baby for women whose babies are in the breech presentation, offer external cephalic version (ECV) – review ultrasound scan report if placenta extended over the internal cervical os at previous scan – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.

38 weeks Another appointment at 38 weeks will allow for: – measurement of BP 38 weeks Another appointment at 38 weeks will allow for: – measurement of BP and urine testing for proteinuria – measurement and plotting of symphysis–fundal height – information giving, with an opportunity to discuss issues and ask questions; verbal information supported by antenatal classes and written information. 40 weeks For nulliparous women, an appointment at 40 weeks should be scheduled to: – measure BP and test urine for proteinuria – measure and plot symphysis–fundal height – give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.

 • 41 weeks For women who have not given birth by 41 weeks: • 41 weeks For women who have not given birth by 41 weeks: – a membrane sweep should be offered – induction of labour should be offered – BP should be measured and urine tested for proteinuria – symphysis–fundal height should be measured and plotted – information should be given, with an opportunity to discuss issues and ask questions; verbal information supported by written information.

Evidence-Based Evaluation – Beneficial forms of care – Forms of care likely to be Evidence-Based Evaluation – Beneficial forms of care – Forms of care likely to be beneficial – Forms of care with trade-off between benefit and harm – Forms of care unlikely to be beneficial – Forms of care that are ineffective or harmful

Beneficial forms of care: Effectiveness demonstrated by clear evidence from controlled trials • • Beneficial forms of care: Effectiveness demonstrated by clear evidence from controlled trials • • • Pre- and Periconceptional Folic acid supplementation to prevent recurrent neural tube defects. Folic acid supplementation (or high folate diet) for all women contemplating pregnancy Iodine supplementation in populations with a high incidence of endemic cretinism.

Beneficial forms of care: • • • Antihistamines for nausea and vomiting of pregnancy Beneficial forms of care: • • • Antihistamines for nausea and vomiting of pregnancy if simple measures fail. Local imidazoles for candida infection. Anti-D postpartum and at 28 weeks for Rh –ve women. Antibiotic treatment for asymptomatic bacteriuria. Tight as opposed to strict or moderate control of blood glucose levels in diabetic women.

Beneficial forms of care: • • • External cephalic version at term to avoid Beneficial forms of care: • • • External cephalic version at term to avoid breech presentation at birth. Corticosteroids to promote fetal lung maturation before preterm birth. Offering induction of labor at 41+ weeks of gestation

Ineffective or Harmful forms of care: • Dietary restriction to prevent pre-eclampsia (including salt Ineffective or Harmful forms of care: • Dietary restriction to prevent pre-eclampsia (including salt restriction). • Ante-natal breast or nipple care for women who plan breast feeding. • Contraction stress test. • Non-stress test.

Ineffective or Harmful forms of care: • DES during pregnancy. • External cephalic version Ineffective or Harmful forms of care: • DES during pregnancy. • External cephalic version before term to avoid breech presentation at birth. • Progestogens to stop preterm labor. • Routine enema in labor. • Routine pubic shaving in preparation for delivery. • Screening for Toxoplasmosis.

Forms of care unlikely to be beneficial: • • • Advise to restrict sexual Forms of care unlikely to be beneficial: • • • Advise to restrict sexual activity during pregnancy. Imposing dietary restrictions during pregnancy. Routine vitamin supplementation in well nourished populations. Routine ultrasound use in late pregnancy

Forms of care unlikely to be beneficial: • Screening for pre-eclampsia by: l Roll-over Forms of care unlikely to be beneficial: • Screening for pre-eclampsia by: l Roll-over test, Cold-pressor test, Edema, Isometric exercise, Measuring uric acid. • Diuretics, Diazoxide for pre-eclampsia. • Screening for gestational diabetes: l Routine glucose challenge test, routine measurement of blood glucose.

Forms of care unlikely to be beneficial: • Calcium supplementation for leg cramps. • Forms of care unlikely to be beneficial: • Calcium supplementation for leg cramps. • Bed rest for threatened abortion. • Hospitalization or cervical cerclage for twin pregnancy. • Prophylactic tocolysis with preterm premature rupture of membranes.

Forms of care unlikely to be beneficial: • Regular leucocyte counts for PROM. • Forms of care unlikely to be beneficial: • Regular leucocyte counts for PROM. • Betamimetics for preterm labor in women with heart disease or DM. • Hydration to arrest preterm labor. • Diazoxide for preterm labor.

Summary Antenatal care includes goal-directed interventions • • Skilled attendant. Preparation for birth and Summary Antenatal care includes goal-directed interventions • • Skilled attendant. Preparation for birth and complications. Health promotion. Detection of complications. Guided by Evidence.