Antenatal (prenatal) Care

1. Antenatal (prenatal) Care Prepared by : Ayda khader Feb.2017

2. Introduction • The prenatal period is a preparatory one, both physically in terms of fetal growth and maternal adaptation and psychologically in terms of parenthood. Prenatal is a time of intense learning for the parents and for those close to them, as well as a time for development of family unity. Regular prenatal visits ideally begin soon after the first missed menstrual period, offer opportunities to ensure the health of the expectant mother and her infant.

3. Aims of antenatal care: • To support and encourage a family's psychological adjustment to childbearing. • •To promote an awareness of the sociological aspects of childbearing and rearing and the influences that these may have on the family. • •To monitor the progress of pregnancy. • •To recognize deviation from the normal and provide management or treatment as required. • •To ensure that the woman reaches the end of her pregnancy physically and emotionally prepared for her delivery.

4. To help and support the mother in her choice of infant feeding to promote breast feeding. • •To offer the family advice on parenthood either in a planned program or on an individual basis. • •To build up a trusting relationship between the family and their caregiver

5. The initial visit (booking visit): • The visit should take place as soon as possible after pregnancy had been confirmed. Advice should be given early because the fetal organs are almost completely formed by the 12th week of pregnancy.

6. Objectives for the booking visit: • To assess levels of health by taking a detailed history and to employ screening test appropriate. • To ascertain baseline recordings of weight, height, blood pressure and hemoglobin level in order to assess normality. These findings are used for comparison as the pregnancy progresses. • To identify risk factors by taking accurate details of past and present obstetric and medical history. • To provide an opportunity for the woman and her family to express any concerns they might have regarding this pregnancy or previous obstetric experiences.

7. Nursing care follows the nursing process: Assessment includes detailed health history, physical examination and screening laboratory tests.

8. Health history History Taking • Social history • Environmental factors, includes home, overcrowded. • Financial problem, employment. • Social classes and mortality and morbidity. • General health • Good habits should be reinforced. • Exercise important. • Give up smoking and restrict of alcohol consumption

9. Menstrual history • L.M.P • E.D.D • Menstrual period, duration and amount. • Oral contraceptive last 3months. • Obstetric history • Past obstetric to predict the outcome of the present pregnancy. • Pervious termination of pregnancy, normal, augmentation, induction, forceps, or vacuum, delivery. • Gravid, Para, abortions causes, how many times, D&C. • Grand multigravida, grand multipara. • Complication in previous child bearing, high risk factors.

10. Medical history • Cardiac problem, U.T.I, Diabetes and essential hypertension. • Asthma, epilepsy, infection, psychiatrics and drugs uses. • Family history • Genetics conditions especially in relative • Diabetes and hypertension mother. • Multiple pregnancies.

11. Conditions that require additional antenatal surveillance • Grand multiparty more than four deliveries. • Vaginal bleeding at any time during pregnancy. • Stillbirth or neonatal death, baby small or large gestational age and congenital abnormality. • Rhesus isoimmunisation and blood disorder • Two or more spontaneous abortions, pervious preterm labuor. • Ante-partum hemorrhage. • Previous history of deep vein thrombosis or pulmonary embolism.

12. Chronic illness as hypertension and pregnancy-induced hypertensions • Family history of diabetes or cardiac murmur detected. • Maternal weight over 85kg or less than 45kg and maternal height less than 5feet (150cm).

13. Examination of the Pregnant Woman I. General examination at First Visit • Height:160cm is indication of normal sized pelvis; short women also may indicate CPD. • Weight:Women with a BMI in the obese range are associated with an increased risk for gestational diabetes (GD) and PIH. • BMI for pregnant women reflects mother’s body mass relative to height that calculated by dividing maternal prepregnancy weight (kilograms) by the square of height (meters). • Classification of BMI: Underweight: <18.5; Normal: 18.5 - 24.9; Overweight: 25– 29.9; Obese: 30 or greater

14. Blood pressure: • Baseline reading • Nervous or anxious long waiting can elevate BP. • Position is very important because ofBrachial artery is more in setting.Lower in recumbent position. • 140/90 at booking is indicative of hypertension. • More than 30 mm Hg over systolic and more than 20 mmHg over diastolic consider hypertension (old idea).

15. Urinalysis Must be done at first visit to exclude any abnormality such as: • Ketones due increase metabolism caused by fetal need or vomiting. • Glucose cause increase blood circulation renal threshold or disease. • Protein due to contamination by vaginal leucorrhea or UTI or PIH.

16. Blood tests: “At the initial visit” • •Complete blood count values (CBC) • •Blood type and Rh factor. • •Antibody screen texoplasmosis, Rh, rubella’’ • •Rubella titer (if not Known). • •VDRL (Venereal Disease Research Laboratory) test for syphilis. • •Hb electrophoresis, when indicated (to detect for sickle cell, thalassemia). • •Hepatitis B virus screen.

17. Nursing Examination Eliminationpattern • Initial visit should ask about the normal woman’s dietary habit. • Colour of stool and urine. Vaginal discharge • Vaginal discharge (Leucorrhea= Leukorrhea: A white, odorless, physiological vaginal discharge; increases in pregnancy due to increased mucus secretion by cervical glands in response to the estrogen-induced hypertrophy of the glands).

18. Women should ask about any changes in amount, colour or odour. • Acid pH of the vagina which inhibits growth of bacteria, but allows overgrowth of Candida albicans. Itchy causes soreness, other than creamy-white. If discharge has an offensive odour, infection must be suspected.

19. Edema • This is not likely to be presented in the initial assessment but may occur with pregnancy progress. • Physiological edema results from increase daily activities or hot weather. • Noticed any swelling rings. • Pitting edema in the lower by applying fingertip pressure for 10 second over the tibial bone, a depression will remain when finger is removed. • If edema reaches the knees and affecting the face, it may indicate PIH with other marker.

20. Varicosities • Assess any predisposing factors of DVT. • Leg should be examined at every visit. Easier if the woman stands up for examination. • Also observe for redness areas in the calf that may cause phlebitis. • Area which appears white as if deprived of blood could be caused by DVT. • The women should be asked to report any tenderness that she feels either during the examination or at any time during the pregnancy.

21. Breast examination • Pregnant women should be informed about breast changes during pregnancy. • Asses the size, any lumps in the breast • Teach the mother self- examination of the Breast

22. Abdominal examination • Aims of abdominal examination • To observe sings of proper pregnancy progress (fetal growth consistent with gestational age). • To assess fetal size. • To asses fetal health. • To diagnose the location of fetal parts. • To detect any deviation from normal.

23. Methods Inspection The size of the uterus • A full bladder, distended colon or obesity may give a false impression of fetal size. • Multiple pregnancy or polyhydramnios will enlarge both the length and width of the uterus. The shape the uterus • The shape of the uterus is longer than its a broad when the fetus lies longitudinally. • If the lie of the fetus is transverse, the uterus is low and broad.

24. Multiparous (MP) uterus may lack the snug ovoid shape of the primgravida (PG) uterus. • Often it is possible to see the shape of the fetal back or limbs • In case of occipitoposterior, a saucer- like depression is seen at or below the umbilicus Skin changes • Stretch marks from previous pregnancies appear silvery and recent one appear pink • Linea nigra may be seen, this is normal dark line of pigmentation running longitudinally in the center of the abdomen below and sometimes above umbilicus. • Scars may indicate previous obstetric or abdominal surgery.

25. Palpation • The nurse hand should be clean and worm that the hands are moved smooth over the abdomen in a stroking motion to avoid causing contraction. Determine the height of the fundus • The nurse places her hand with pressing gently just below the xiphisternum and move her hand down the abdomen until feels the curved upper border of the fundus. • Noting the number of fingerbreadths that can be accommodated between the two points. • Alternatively, the distance between the fundus and symphysis pubis determined by tap measurement. • Fundus reaches the umbilicus at 20-22 weeks and xiphisternum at 36 weeks

27. Leopold’s maneuvers It’s a series of specific palpations of the pregnant uterus to determine fetal position and presentation A- Fundal palpation (1st Leopold’s maneuver) • This is to determine the fetal presentation (breech or the head) and also lie (longitudinal or transverse) • The nurse place her both hand in the sides of fundus, fingers held close together and curving around the upper border of the uterus. • Last month of pregnancy lightening occurs and fetus sinks down into lower pole. • Primigravida has a strong abdominal muscle that encourages the fetal head to enter to brim of the pelvis.

28. B- Lateral palpation (2nd Leopold’s maneuver) • Use to locate the fetal back in order to determine the position of fetus(anterior or posterior) • The hands are places on either side of uterus at level of umbilicus. • Gentle pressure use in order to detect which side of the uterus offers the greater resistance. • Head is harder than the buttocks but the head is more rounded. • Walking the finger of both hands over the abdomen from one side to other is an excellent method of locating the back.

29. C- Pelvic palpation (3ed Leopold’s maneuver) • Pelvic palpation can cause contractions of the uterus and may cause discomfort to some women. • Should ask the women to bend her knees slightly in order to relax the abdomen. • The sides of the uterus are grasped between the palms of the hands with finger held close together. • If the head is the presenting, a hard mass round smooth surface will be felt. • Also nurse can estimate how much of the head is palpable in the pelvic brim to determine the engagement.

30. D- Pawlik’s maneuver (4th Leopold’s maneuver) • The nurse grasps the lower pole of the uterus between her fingers and thumb to determine the size, flexion and mobility of the head.

33. Auscultation • Listening of FHS, like heartbeat it is a double sound but more rapid than the adult heart. • Pinard’s fetal stethoscope is used to hear fetal heart directly and determine that its fetal and maternal heart beats at 20 weeks’ gestation • Electronic Doppler also can be used at 10 weeks of gestation

34. Follow- up antenatal visits (Subsequent visits): • •It has been stressed that all the information gathered will enable a decision to be made about the subsequent care offered to the pregnant woman and her family. The plan of care is suited to the needs of the teaching and counseling the client and her family.

35. Schedule: The gravid should be seen once each month until the 32nd week, every 2 weeks until the 36th week, and each week thereafter until delivery. More frequent visits may be required if there are complications.

36. Purpose of continuing antenatal care: 1.To continue observe for maternal health and freedom from infection. 2.To assess fetal well- being. 3.To ascertain that the fetus has adopted a lie and presentation that will allow vaginal delivery. 4.To ensure that the mother and family are confident to decide when labor has commenced and that they have telephone numbers to use if they wish to seek advice. 5.To offer an opportunity to express any fears or worries about pregnancy and labor. 6.To discuss any views about the conduct of labor and formulate a birth plan if required.