3. ANTENATAL CARE /EXAMINATION
IT’
S A SYSTEMIC (Examination and advice) of a women
during pregnancy
Assessment’
MEANS is ‘
to evaluate’i.e. here we gather the
information of client status and it identifies the
specific needs of a client by which better care can be
given to the client and her developing fetus.That
means,it is the systematic supervision(examination &
advice)of a woman during pregnancy.So,it is the
foundation stone for antenatal care.
4. Objective
• To screen the ‘
high risk’cases
• To prevent or to detect and treat at the earilest any
complications.
• To ensure continued medical surveillence and prophylaxis.
• To educate mother about the physiology of pregnancy and
labour by demonstration,charts and diagrams so that fear is
removed and psychology is improved.
• To discuss with the couple about the place,time and mode of
delivery and care of newborn.
• To motivate the couple about to the need of family planning.
• To give appropiate advice to couple seeking MTP.
5. GENERAL PRINCIPLES
• Always explain to the patient the need and the nature of
the proposed examination. Obtain a verbal consent once
she has been told what the examination would entail.
• The examiner (male or female) should be accompanied
by another female
• Examination performed in a private side-room,
respecting patient's privacy at all times.
• Patient should be covered at all times and relevant parts
of her anatomy only exposed.
• Make sure the room is well lit and comfortably warm.
6. • Ensure the patient has emptied her bladder
before examining her abdomen.
• Patient should lie in the supine position with a
pillow under the head and arms by her side.
• She is slightly rolled to the left side to prevent
compression of the inferior vena cava by the
enlarged uterus (inferior venacaval syndrome or
supine hypotensive syndrome).
• Ask for any tender area before palpating the
abdomen.
9. History Taking Vital Statistics
• Name: …
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• Date of first examination: …
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• Address:…
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• Age:…
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• Gravida:Parity…
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• Duration of marriage: …
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• Religion:
• Occupation: …
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• Period of Gestation: …
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• Chief Complaints: …
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.(sleep,appetite,bowel habit,urination)
• History Of present illness:…
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• History of present pregnancy: …
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First trimester –
Hyperemesis
gravidarum second trimester-pyelitis, third trimester-anemia,pre-
eclampsia and APH also note the no. of antenatal checkups,any
exposure to medication or radiation
10. • Obstetrics History..No. of children,health
status of the baby,immunization, if any
miscarriage
• Menstrual history: …
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..age of menarche,
LMP,Duration,EDD,Amount of blood flow
• Past medical history: …
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• Past surgical history:
• Family History Personal History
11. General and Physical Examination:
• •
Build:Obese/Average/Thin
• Nutrition:Good/Average/Poor
• Height:Short stature is likely to be associated
with small pelvis.
• Weight:The total weight gain during the course
of singleton pregnancy for a healthy women
averges 11 kg(24 Ib)
• Pallor:The sites to be noted are lower
conjunctiva,dorsum of tongue and nail beds.
12. • Jaundice:The sites to be noted are
conjunctiva,tongue,skin.
• Tongue,teeth,gums and tonsils:
• Neck:Neck veins,thyroid gland or lymph nodes
should be inspected.
• Breast Examination:It should be inspected for
pregnancy changes
14. Obstetrical Examination :
ABDOMINAL EXAMINATION
Inspection
• Describe the abdominal distension (pyriform).
• Previous operative(Caesarean)scars
• Striae gravidarum or stretch marks
• Linea nigra- a dark vertical line appearing on the
abdomen from the pubis to above the umbilicus
during pregnancy due to increase melanocyte-
stimulating hormone made by the placenta.
• Visible foetal movements.
15. Palpation
• Fundal height (Symphysis-fundal height)
• Foetal poles
• Foetal lie
• Presentation- cephalic(head),breech,etc
• Attitude
• Level of engagement of presenting part
• State of uterine wall/ myometrium
• Liquor volume
• Estimate foetal weight
• Foetal movements
16. Auscultation
• Auscultation of the foetal heart:
• Auscultated with a foetal stethoscope( Pinard's
foetal stethoscope) or with a doptone machine.
• Best place to listen is over the foetal back,
closer to the cephalic pole.
• The normal foetal heart rate is btw 110 to 160
beats per minute
19. Abdominal Examination:
• Palpated using four Leopold's manoeuvres
• The fundal grip(foetal poles):
• Both hands placed over the fundus and the contents
of the fundus determined.
• A hard smooth, round pole indicates a fetal head.
• A softer triangular pole continuous with the fetal
body is the fetal buttocks(breech)
20. Lateral grip Symphysis-fundal height(Size and
gestational age of the uterus)
• More objective, distance from the symphysis
pubis to the uterine fundus (top of the uterus)
• size of the uterus directly related to the size of
the fetus.
21. Technique
• Palpate down from xiphi-sternum to determine the
highest part of the uterus(fundus),may not always be
in the midline.
• -Mark this point with a pen after obtaining her
permission.
• -A tape measure turned upsidedown(blinded to avoid
bias) is then placed from the mid-point on the
uppermost border of the symphysis pubis over the
curve of the uterus to the marked highest point of the
uterus.
• -The tape is then turned and actual measurement in
cm is recorded, preferably in graphic form
22.
23. Pawlik grip(3rd Leopold) –
• The thumb and middle fingers of the right hand
are placed wide apart over the suprapubic area
to determine the presenting part.
• -Presenting part of fetus is the lowest most part
of the fetus at the inlet of the pelvis(the lower
fetal pole as opposed to the fetal pole in the
fundus).
• -Cephalic or breech presentation distinguished
from each other
25. • -If cephalic prominence on the same side as
fetal back, fetal head is extended (abnormal
position).
• -If examiners hands reach the fetal head
equally on both sides, fetal head is deflexed
('Military position, indicating mal-position
26. Vaginal Examination:
• It should be done by using the left
fingers(thumb & index),the character of
vaginal discharge,cervix
consistency,cystocele,uterine
prolapse,rectocele is to be elicited.
• Can be done for taking vaginal swabs for
investigations
30. Investigations
• Blood examination (for ABO,Rh,VDRL ) and
screening for blood glucose in selected cases
• Serological test for Rubella , hepatitis B virus,
• Maternal alpha feto protein-at 16-18 weeks is
done to detect neural tube defect down
syndrome and other chromosomal abnormality
• Urine examination
• For examining protein, sugar,pus cells
37. Biophysical Profile Biophysical Profile:
• It is the screening test for utero-placental
insufficiency.
• The fetal biophysical activities are
initiated,modulated and regulated through fetal
nervous system.
• The fetal CNS is very much sensitive to diminished
oxygenation.
38.
39. Non Stress Test(NST)
• It is the continuous electronic monitoring of the fetal heart
rate along with recording of fetal movements
(cardiotocography) is undertaken.
• FHR acceleration with fetal movements,which when
present,indicates a healthy fetus.
• It is used as screening test.
• The test is valuable to identify the fetal wellness rather than
illness.
• Test should be started after 30 weeks and frequency should
be twice weekly
• •
Reactive(Reassuring): When two or more acceleration of
more than 15 beats per minute above the base line and
longer than 15 sec in duration are present in a 20 min
observation.
• •
Non-Reactive(Non-Reassuring):Absence of any fetal
reactivity.
40. Fetal movement count(DFMC)
• •
The patient counts the fetal movements every morning,noon and
evening.
• •
Three counts each of one hour duration are recommended.
• •
If the no. of kicks are less than 10 in 12 hrs. or 3 in each hour it
indicates fetal compromise.
• •
Increased fetal movements associated with maternal
hypoglycemia.
• •
Decreased FM cause obesity,smoking,hypoxia, anterior
placenta,hydramnios,narcotic drugs.
41. Ultrasound
Indications
• •
Diagnosis of pregnancy.
• •
Assessment of gestational age.
• •
Diagnosis of multiple pregnancy.
• •
Assessment of IUGR or BPP.
• •
Uterine size either > dates or < dates.
• •
Asessment of liquor volume.
• •
Diagnosis of any abnormality e.g. placenta
praevia etc.
46. Disease Prophylactic drug
Anemia prophylaxic
Nausea and vomiting
Gestational diabetes
Hyperthyroid
Hypothyroid
Thromboembolism
HIV
30-60mg of elemental iron
Folic 0.4 mg (800 ug)
First-line management –Pyridoxine,
Doxylamine •Alternatives –
Phenothiazines, Metoclopramide (risk of
sedation and extrapyramidal effects) –
Ondansetron –Corticosteroids (for
hyperemesis gravidarum)
First-line treatment –Insulin •
Alternatives –Glyburide and metformin •
Intravenous drip insulin should be used
during labor
•Propylthiouracil –first trimester •
Methimazole –second and third
trimesters •Contraindication –Iodine131 –
risk of thyroid damage in fetus
•Thyroid replacement therapy –
Levothyroxine (0.1 mg/day)
Warfarin (between 6 and 12 wk) –
Unfractionated heparin –Injectable direct
thrombin inhibitors
Lopinavir-ritonavir –Recommended in
pregnant women
•Prevention of mother-to-child
transmission –Zidovudine with single
dose of nevirapine