Antepartum Care

Antepartum Care
Dr Shaymaa Kadhim Jasim
Objectives:
1. List the components of prenatal care.
2. State the steps of prenatal physical examination &
laboratory investigation.
3. Describe how to diagnose pregnancy & confirm
viability.
4. Describe alleviating unpleasant symptoms of
pregnancy.
5. State the methods of assessment of fetal well-being.
 Control the chronic diseases of the mother

Preconception Care

• Ideally, “prenatal care” should begin before pregnancy.

Organogenesis begins early in pregnancy and placental development
starts with implantation, about 7 days after conception. Poor
placental development has been linked to preeclampsia, preterm
birth, and intrauterine growth restriction (IUGR), all of which are
associated with low birth weight (<2500 grams), and may play a role
in fetal programming of chronic diseases later in life.
In addition, obesity has become a world-wide problem associated with
metabolic dysregulation, and must be addressed before pregnancy if outcomes
are to be improved.

Prenatal Care
The three basic components of prenatal care are (1) early and continuing risk
assessment, (2) health promotion, and (3) medical and psychosocial
interventions and follow-up. Risk assessment includes a complete history, a
physical examination, laboratory tests, and assessment of gestational age and
well-being of the mother and her fetus(es).
THE FIRST PRENATAL VISIT

• Women whose health may be seriously jeopardized by

the pregnancy, such as those with Eisenmenger
syndrome or a history of peripartum cardiomyopathy,
should be counseled about the option of terminating
the pregnancy. Reproductive histories that include
preterm birth, low birth weight, preeclampsia,
stillbirth, congenital anomalies, and gestational
diabetes are important to record because of the
substantial risk of recurrence.
A complete physical examination should be performed including
assessment of the patient’s body mass index (BMI). A woman’s BMI can
increase between pregnancies by 20-30% because of excessive weight
gain in the first pregnancy. Clinicians should be familiar with physical
findings associated with normal pregnancy.
Prenatal laboratory testing should be undertaken including:
complete blood count, urinalysis, blood type and antibody
screen, rubella, syphilis, hepatitis B, HIV, cervical cytology;
screen for gonorrhea, chlamydia, and diabetes in selected
populations, thyroid-stimulating hormone.
Confirming Pregnancy and Determining Viability
About 30-40% of all pregnant women will have some bleeding
during early pregnancy (e.g., implantation bleeding), which
may be mistaken for a period. Therefore, a pregnancy test
should be performed in all women of reproductive age who
present with abnormal vaginal bleeding.
The pregnancy test detects human chorionic gonadotropin
(hCG) in the serum or the urine.
The use of transvaginal ultrasonography has improved the
accuracy of predicting viability in early pregnancies. Using
transvaginal ultrasonography, the gestational sac should be
seen at 5 weeks’ gestation or a mean hCG level of about 1500
IU/L. The fetal pole should be seen at 6 weeks or a mean hCG
level of about 5200 IU/L. Fetal cardiac motion should be seen
between 6 and 7 weeks or a mean hCG level of about 17,500
IU/L. The presence of a gestational sac of 8 mm (mean sac
diameter) without a demonstrable yolk sac, 16 mm without a
demonstrable embryo, or the absence of fetal cardiac motion
in an embryo with a crown-rump length of greater than 5
mm indicates probable embryonic demise
Estimating Gestational Age and Date of Confinement
Gestational age should be determined during the first
prenatal visit. Accurate determination of gestational age may
become important later in pregnancy for the management of
obstetric conditions . Clinical assessment to determine
gestational age is usually appropriate for the woman with
regular menstrual cycles and a known last menstrual period
that was confirmed by an early examination. Estimated date of
confinement (EDC) or “due date” may be determined by
adding 9 months and 7 days to the first day of the last
menstrual period.
Ultrasonography may also be used to estimate
gestational age. Measurement of fetal crown-rump
length between 6 and 11 weeks’ gestation can
determine gestational age to within 7 days. At 12 to 20
weeks, gestational age can be determined within 10 days
by the average of multiple measurements (e.g., biparietal
diameter, femur length, abdominal and head
circumferences). Thereafter, measurements become less
reliable with advancing gestation (±3 weeks in the third
trimester).
Advice during Pregnancy
One of the most important functions of prenatal care is to provide information and
support to the woman for self-care.
Nausea and vomiting is cause dby high hcg and
occur more in multiple pregnancies (more placenta
ALLEVIATING UNPLEASANT SYMPTOMS means more HcG ) and occur in molar pregnancies
Nausea and vomiting complicate up to 70% of pregnancies. Eating small,
frequent meals, and avoiding greasy or spicy foods may help. Also, having
protein snacks at night, saltine crackers at the bedside, and room-temperature
sodas are non pharmacologic approaches that may provide some relief. Where
medication is necessary, antihistamines appear to be the drug of choice,
though no single product has been satisfactorily tested for efficacy and safety.
Vitamin B6 (pyridoxine) may be effective. Patients with dehydration and
electrolyte abnormalities from vomiting (hyperemesis gravidarum) should be
evaluated for possible secondary causes, and they may need hospitalization for
rehydration and antiemetic therapy.
Heartburn affects about two-thirds of women at some stage
of pregnancy, resulting from progesterone- induced relaxation
of the esophageal sphincter. Avoiding lying down immediately
after meals and elevating the head of the bed may help reduce
heartburn. When these simple measures fail, antacids, such as
calcium carbonate, should be used.
Constipation is a troublesome problem for many women in
pregnancy, secondary to decreased colonic motility. Dietary
modification, including increased fiber and water intake, can help
lessen this problem. Stool softeners may be used in combination with
bulking agents. Irritant laxatives should be reserved for short-term use
in refractory cases.
Leg cramps are experienced by almost half of all pregnant women, particularly at
night and in the later months of pregnancy. Massage and stretching may afford
some relief during an attack. Both calcium and sodium chloride supplementation
appear to help reduce leg cramps in pregnancy. Recently, vitamin D deficiency in
both men and women has been associated with leg cramps and muscle pain.
‫ﺗﺼﯿﺮ ﺑﻜﻞ اﻟﺤﻮاﻣﻞ‬

Backaches are common during pregnancy and are lessened by

avoiding excessive weight gain. Additionally, exercise, sensible
shoes, and specially shaped pillows can offer relief. In cases of
muscle spasm or strain, analgesics (such as acetaminophen),
rest, and heat may lessen the symptoms.
NUTRITIONAL COUNSELING and LIFESTYLE ADVICE

Nutritional education includes counseling on weight gain, dietary guidelines,

physical activity, avoidance of harmful substances and unsafe foods.
Women should avoid fasting (>13 hours without food) or skipping meals. This
behavior is associated with accelerated ketosis and a greater risk of preterm
delivery.
They should eat five times per day (breakfast, lunch, afternoon snack,
dinner, and bedtime snack). Pregnant women should never skip
breakfast. Excessive weight gain has been associated with fetal
macrosomia.
Normal pregnancy requires an increase in daily caloric intake of 300
kcal.
Women should be advised to rest when tired and
reassured that the fatigue usually abates by the
‫ ﺗﻨﺤﺴﺮ‬/‫ﺗﻘﻞ‬

fourth month of pregnancy. Advice regarding work

should be individualized to the nature of the work,
the health status of the woman, and the condition of
the pregnancy. Work that requires prolonged
standing, shift or night work, and high cumulative
occupational fatigue has been associated with an
increased risk for low birth weight and prematurity.
Assessment of Fetal Well-Being
MATERNAL SELF-ASSESSMENT OF FETAL WELL-BEING
A simple technique (kick counting) may be used to assess
fetal well-being. The mother assesses fetal movement (kick
counts) each evening while lying on her left side. She should
recognize 10 movements in 1 hour and if she does not, she
should retest in 1 hour.
Low kick count
- low glucose .
-Fetal sleep cycle
NSTRESS TEST ASSESSMENT
The first step in the assessment of fetal well-being is the NST.
With the mother resting in the left lateral supine position, a
continuous fetal heart rate tracing is obtained using external
Doppler equipment. The mother reports each fetal
movement, and the effects of the fetal movements on heart
rate are determined. A normal fetus responds to fetal
movement with acceleration in fetal heart rate of 15 beats or
more per minute above the baseline for at least 15 seconds.
If at least two such accelerations occur in a 20-minute interval,
the fetus is regarded as being healthy, and the test is said to
be reactive.
 Normal AFI is 5-25
ULTRASONIC ASSESSMENT
The next step in prenatal assessment is to determine
the adequacy of amniotic fluid volume by real-time
ultrasonography. Reduced fluid (oligohydramnios)
suggests fetal compromise. Oligohydramnios can be
defined as an amniotic fluid index (AFI) of less than 5 cm.
The AFI represents the sum of the linear measurements
(in centimeters) of the largest amniotic fluid pockets
noted on ultrasonic inspection of each of the four
quadrants of the gestational sac.
When amniotic fluid is reduced, the fetus is more
likely to become compromised as a result of
umbilical cord compression. Excessive amniotic
fluid (polyhydramnios; AFI > 23 cm) can be a sign
of poor control in a diabetic pregnancy or an
indication that the fetus may have an anomaly.
Fetal breathing (chest wall movements) and fetal
movements (stretching and rotational movements) are
also used to assess the fetus. A fetus that has at least 30
breathing movements in 10 minutes or 3 body
movements in 10 minutes is considered healthy. A
combination of a reactive NST, adequate amniotic fluid,
adequate fetal breathing, adequate fetal movements,
and adequate tone is frequently referred to as a normal
biophysical profile. Each parameter is given a score of 2.
UMBILICAL ARTERY DOPPLER ASSESSMENT
During the ultrasonic assessment, it is relatively easy
to assess the fetal umbilical artery vascular resistance.
A high systolic/diastolic ratio (S/D) suggests abnormal
flow because of increased vascular resistance within the
fetal/placental circulation. When the flow becomes very
abnormal, diastolic flow ceases and there can be a
reversal of flow from the placenta to the fetus. When
this occurs the fetus is at high risk and delivery is usually
indicated.
Fetal heart normal range 110-160 BPM