Antenatal Care &Assessment of

Antenatal Wellbeing
 Objectives
• Outline antenatal care of
uncomplicated pregnancies.
• Outline antenatal imaging.
• Outline assessment of antenatal
wellbeing
 The aims of antenatal care (ANC) are:
• to prevent, detect and manage those factors that
adversely affect the health of mother& baby;
• to provide advice, reassurance, education & support for
the woman and her family;
• to deal with the ‘minor complaints’ of pregnancy mostly,
these represent the physiological adaptation of her body
to the pregnancy (nausea, heartburn, constipation,
shortness of breath, dizziness, swelling, backache,
abdominal discomfort & headaches).
• to provide general health screening.
Frequency of ANC visits in uncomplicated pregnancies
Tradiditional ANC model

NICE recommends 7 visits (in multiparous) 10 visits (in nulliparous) in

uncomplicated pregnancies
Focused ANC- also called “new” or “WHO” models
WHO recommends a minimum of four ANC visits
• First visit: On confirmation of pregnancy
• Second visit: 20-28 weeks
• Third visit: 34-36 weeks
• Fourth visit: before expected date of delivery
Additional visits were individualized in complicated pregnancies
 Visits of Antenatal Care – Objectives

• Initial 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

5
 Booking History & Examination
History Examination
Weight &
Age and racial
Height, BMI

Accurate
Past medical, HTN, measurement of
DM
blood pressure.

Past Obstetric and Abdominal

gynaecological, examination,
misscarige, C/S, etc. uterine size, scar

Family and social

history, eg. Systemic
Hemoglobinopathy, examination
smoker, alcohol
 HISTORY TAKING

Medical Surgical Social Obstetric Family

*Previous *Diabetes
*Allergies *Occupation Pregnancy *Hypertension
*Blood *Heart Disease
*Smoking *Pre-term
Transfusion *Previous *Renal disease
*Alcohol labour *Psychiatric
*Medical Operation *Educational *Previous *PTB
problems Level LSCS, *Multiple
Infections IUD/END Pregnancy

END =Early Neonatal Death

PTB = Pul. Tuberculosis
 Diagnostic work-up during antenatal care
Diagnostic procedure Gestational age
Hemoglobin/hematocrit determination Initial visit; repeat at 28 wks
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
Indirect Coomb’s test Initial visit
Serum alpha-fetoprotein test 16-18 weeks
Routine ultrasonography Booking and 18-21 wks
Screening test for gestational diabetes 24-28 wks
HBsAg; HIV tests Initial visit

Asheber Gaym, 2009 9

 Confirmation of the pregnancy
• Symptoms of pregnancy (breast
tenderness, nausea, amenorrhoea,
urinary frequency) combined with a
positive urinary or serum pregnancy test
or U/S scan.
• Sometimes hear the fetal heart with the
Doppler ultrasound (sonicaid)
from approx.12 wks onwards.
 Dating the pregnancy
• Setting a reliable ‘expected date of delivery’ (EDD) is done by:
1. Menstrual EDD: calculated from the first day of LMP.
2. Dating ultrasound: all women should be offered a dating scan,
ideally between 11 & 14 wks.
Before 14 weeks measure crown rump length(CRL) accuracy of
prediction ± 5 days
14 to 20 weeks use the biparietal diameter(BPD), head
circumference(HC) or femur length (FL). The accuracy of
prediction of BPD at 20 weeks ± 7 days.
• Which method is more accurate for dating? Accordingly
• What are prerequisites for reliable menstrual dating?
• Why U/S after 20 wks is not used for dating?
• What is the benefits of dating U/S.
Confirm pregnancy
 Screening for fetal abnormalities
1. Screening for Down’s syndrome includes:
Nuchal translucency scan at 11–14 weeks gestation,
with or without biochemical tests, or
Biochemical blood tests in isolation at 15–20 weeks;
2. Screening for neural tube defects (e.g. spina bifida,
anencephaly) with maternal serum alpha fetoprotein
levels at 15–20 weeks gestation. This blood test has been
mostly superseded by routine detailed structural
scanning at 18–20 weeks and is likely to become
obsolete in the near future;
3. Screening for structural congenital abnormalities by
U/S examination at 18 to 20 +6 weeks
 Gestational diabetes (GDM)
• All women should be assessed at booking for
risk factors for GDM.
• If risk factors are present, the woman should
be offered a 2-hour 75 g oral glucose
tolerance test (OGTT) at 24–28 wks gestation.
• A previous history of gestational diabetes
should prompt an OGTT, at 16–18 wks. If
results are normal, the test should be
repeated at 24–28 wks
Risk factors for screening for GDM
• BMI above 30 kg/m2.
• Previous baby weighing 4.5 kg, or above.
• Previous gestational diabetes.
• First-degree relative with diabetes.
• Family origin from high prevalence area
(South Asian, black Caribbean and Middle
Eastern).
 Identification of women at high risk of
venous thrombosis (VTE)
2 current RF prophylactic at least 10 days postpartum
LMWH
3 current RF prophylactic LMWH from 28 wks onwards & for 6 wks postnatally

4 & more current RF Prophylactic LMWH throughout the antenatal period & should be
continued postnatally for 6 wks.
Identification of women with risk of
Hypertensive disorders in pregnancy
Women are at an increased risk of
pre-eclampsia if they have one high risk factor
or more than one moderate risk factor.
Women at increased risk of pre-eclampsia
should be advised to take 75 mg of aspirin
daily from 12 wks until the birth of the baby.
(delay until after 16 wks makes treatment less
effective).
 Risk factors of preeclampsia
• High risk factors include:
1. Hypertensive disease during a previous pregnancy
2. Chronic kidney disease
3. Autoimmune disease such as SLE or antiphospholipid syndrome
4. Type 1 or type 2 diabetes
5. Chronic hypertension
• Moderate risk factors include:
1. First pregnancy
2. Age 40 years or older
3. Pregnancy interval of more than 10 years
4. BMI of 35 kg/m2 or more at first visit
5. Family history of pre-eclampsia
6. Multiple pregnancy.
Blood pressure should be measured as
outlined below:
• remove tight clothing, ensure arm is relaxed and
supported at heart level
• use cuff of appropriate size
• inflate cuff to 20–30mmHg above palpated
systolic blood pressure
• lower column slowly, by 2mmHg per second or
per beat
• read blood pressure to the nearest 2mmHg
• measure diastolic blood pressure as
disappearance of sounds (phase V).
 Screening for preterm labour
• Women without a history of preterm birth
should not be routinely offered screening
tests for preterm labour, such as bacterial
swabs, or cervical length scans.
What vaccination are required during
pregnancy?
 Common issues requiring advice and
education during pregnancy
•Food hygiene, dietary advice, vitamin supplementation.
• The risks of smoking during pregnancy???
• Use of medications.
• Exercise and sexual intercourse.
• Foreign travel, DVT prophylaxis and correct use of seatbelts.
• Screening for fetal problems (Down’s syndrome, anomalies).
• Screening for maternal conditions (diabetes, hypertensive
disorders, UTI, anaemia).
• Management of prolonged pregnancy.
• Place of birth and labour.
• Pain relief in labour.
• Breastfeeding and vitamin K prophylaxis.
• Care of the new baby and newborn screening.
 Food hygiene, dietary advice, vitamin
supplementation.
Food-acquired infections
Pregnant women should be offered information on how to
reduce the risk of listeriosis by:
• drinking only pasteurised or UHT milk
• not eating ripened soft cheese
• not eating uncooked or undercooked ready-prepared
meals.
Pregnant women should be offered information on how to
reduce the risk of salmonella infection by:
• avoiding raw or partially cooked eggs or food that may
contain them (such as mayonnaise)
• avoiding raw or partially cooked meat, especially poultry.
 nd
Diet &vit. of a woman during pregnancy (2
half)
Food element pregnancy

Kilocalories 2500

Protein 60 gm.

Iron 40 mg

Folic acid 400 μg

Calcium 1000 mg

Vitamin A 6000 I.U.

 Supplementation
Folic acid, before conception and throughout the
first 12weeks, reduces the risk of having a baby
with a neural tube defect. The recommended dose
is 400micrograms per day.
Iron supplementation
Vit D :All women should be informed at the booking
appointment about the importance for their own
and their baby's health of maintaining adequate
vitamin D stores during pregnancy and whilst
breastfeeding. In order to achieve this, women
should be advised to take a vitamin D supplement
(10micrograms of vitamin D per day)
Calcium
 Important dietary advice
• Pregnant women should be informed that
vitamin A supplementation (intake above
700micrograms) might be teratogenic and
should therefore be avoided. Pregnant
women should be informed that liver and liver
products may also contain high levels of
vitaminA, and therefore consumption of these
products should also be avoided.
• Air travel: Pregnant women should be informed that long-haul air travel is
associated with an increased risk of venous thrombosis, although whether
or not there is additional risk during pregnancy is unclear.
• In the general population, wearing correctly fitted compression stockings
is effective at reducing the risk.
• Car travel: Pregnant women should be informed about the correct use of
seatbelts (that is, three-point seatbelts 'above and below the bump, not
over it').
• Vaginal discharge :An increase in vaginal discharge is a common
physiological change that occurs during pregnancy. If it is associated with
itch, soreness, offensive smell or pain on passing urine there may be an
infective cause and investigation should be considered.
• Rest and sleep:
• 8 hour sleep at night
• At least 2 hour sleep after mid-day meal
• Hard strenuous work should be avoided in first trimester and last 4 weeks
 Summary of antenatal imaging
The early pregnancy scan (11–14 wks)
The principal aims of this scan are:
• to confirm fetal viability;
• to provide an accurate estimation of gestational age;
• to dx multiple gestation & determine chorionicity;
• to identify markers which would indicate an increased risk
of fetal chromosome abnormality such as Down’s syndrome;
• to identify fetuses with gross structural abnormalities.
 U/S DETERMINATION OF CHORIONICITY

❖Number of sacs
❖Placenta
❖Sex

❖Intertwin membrane
Thick (DC), thin(MC)

❖Lambda sign (DC)

❖ T sign (MC)

Ideal time for assessing of chorionicity is before 14wk

 Nuchal thickness
• A fluid filled area may be seen on posterior surface
of the fetal neck, the measurement of NT may be
associated with chromosomal and cardiac defect.
 The 20 week scan (18–22 weeks)

The principal aims of this scan are:

• to provide an accurate estimation of gestational age if an early scan
has not been performed;
• to carry out a detailed fetal anatomical survey to detect any fetal
structural abnormalities or markers for chromosome abnormality;
• to locate the placenta and identify the 5 per cent of women who
have a low-lying placenta for a repeat scan at 34 weeks to exclude
placenta praevia;
• to estimate the amniotic fluid volume.
Also, in some centres:
• to perform Doppler ultrasound examination of maternal uterine
arteries to screen for adverse pregnancy outcome, for example
pre-eclampsia;
• to measure cervical length to assess the risk of preterm delivery.
 Ultrasound in the third trimester
The principal aims of ultrasound in the third trimester are:
• to assess fetal growth; Large HC compared to AC is seen in
IUGR and the opposite is seen in diabetic pregnancy. These
measurements when used in equation can give more accurate
estimate of fetal weight
• to assess fetal well-being (biophysical profile & Doppler of fetal
umbilical vessels)
Other uses:
• Confirmation of intrauterine death;
• Measure cervical length in patient at risk of PTL.
• confirmation of fetal presentation in uncertain cases;
• DX of uterine and pelvic abnormalities e,g fibroid & ovarian cysts.
• Guide invasive diagnostic procedures such as amniocentesis, chorion villus
sampling and cordocentesis, and therapeutic procedures.
 Fetal growth and well-being
• Symphysis-fundal height (SFH)measurements should be
performed wit h a tape-measure at every antenatal appointment
from 25 weeks gestation and the values plotted on a centile chart,
ideally customized to the woman herself.
• Concerns that fetal growth may be slow, or has stopped
altogether, should be addressed by ultrasound scanning. (growth
scans are not recommended in the absence of specific risk factors)
• Women should not be advised to routinely count fetal movements
in normal pregnancies, however, further fetal assessment is
indicated if the woman perceives a reduction in movements.
• It is still common practice to listen to the fetal heart at each
antenatal visit in the second and third trimester, either with a
Pinnard stethoscope or Doppler ultrasound. This is no longer
supported by NICE if the fetus is active, but it is recognized as
reasonable if the woman requires reassurance.
 Assessment of fetal well being

• Progressive fundal height growth as per expectations

• Fetal well being tests – from 28 weeks onwards if
clinically indicated

Kick count : adequate maternal perception of fetal movement

( at least 10 in 12 hours)
Non stress test
Contraction stress test
Biophysical profile score
Doppler ultrasound of fetal umblical vessels

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NON-STRESS TEST
Reactive NST: at least 2 fetal movements with accelerations of
15 bpm lasting 15 sec or more within 20 minutes indicates fetus
with adequate oxygenation and an intact central nervous system
CONTRACTION STRESS TEST
Initiation of contractions by oxitocin or nipple
rolling
Positive CST results (bad): with persistent late
decelerations is evidence that the fetus will
not be able to withstand the hypoxic stress of
the uterine contractions
Negative CST results(good): No persistent
decelerations noted with at least 3
contractions.
Biophysical profile

• 8-10 normal
• 6 suspecious
• 0, 2, 4 abnormal
Doppler of fetal umbilical vessels
a small amount of diastolic flow implies high resistant
downstream resistant and implies low perfusion.
A measure of the amount of diastolic flow relative to
systolic is provided by many indices like pulsatility index
or resistant index.
Uterine artery Doppler:notch seen in early diastolic
component result from increase vascular resistance and
may be associated with preeclampsia, IUGR and
placental abruption.
 Readings
1. Obstetrics by ten teachers, 19th edition, by
Philip N Baker and Louise C Kenny. Chapter 5
& 6 pp:48-74

2. National Institute for Health and Clinical

Excellence guidance 62, Antenatal care of
uncomplicated pregnancies Issue date: March
2008.
Good Luck