Antenatal Care

The Obstetric History 

 

1. Past Obstetrical History.

 

Record of previous pregnancies and labour

 

Was labour premature or postmature, spontaneous or induced, history of instrumental deliveries, previous obstetric complications and previous babies?

 

2. History of the Present Pregnancy

 Ask the last normal menstrual period and then calculate the gestational age of the pregnancy and expected date of delivery.

 

2. Examination of the Pregnant Woman at First Visit

 

Objective:

 

·           To diagnose pregnancy

 

·           To identify high risk pregnancy

 

·           To give advice for pregnant mother

 

 

General Appearance

 

As she walks in, observe any deformity, stunted growth, limp etc. does she look well or pale and tired?

Clinical Observation

 Height; - 150 cm or less needs special care.

 

 

Weight:-The average weight gain during pregnancy is about12-14 kg in the first trimester a woman should gain o.4 kg per month and in the second and third trimester she should gain 0.4 kg per week. It is Concedred as excessive if it is more than 3 kg a month during the second and third trimester; it is lessthan normal if it is less than 1 kg per month during the second and third trimester. Women who are under weigth coming in to pregnancy should gain more weigth than the average (0.5 kg per month or week rather than 0.4 kg). And may gains lessthan average (0.3 kg). Sudden increase in weight that suggests fliud retention or a loss of weight tht suggests illness should be carefully evaluated at prenatal visits.

 

 

Blood pressure: - Checked and recorded at each visit,

 

 

Physical Examination:-

 Appearance: - The hair of a healthy woman is shining andglossy, her eyes bright and clear,

Face: - Oedema, sign of anaemia

 

Neck - Swollen glands

 

Breast Examination

 

Asses the size, any Lumps in the breast

 

Nipples are they inverted or flat?

 

Teach the mother self - examination of the Breast

 

 

Heart and lungs are examined as usual to exclude diseases.

  

Abdominal Examination

 

AIMS

 

·              To observe signs of pregnancy

 

·              To assess fetal size and growth

 

·              To assess fetal health

 

·              To diagnose the location of fetal parts.

 

·              To detect any deviation from normal.

 

 

Steps for Abdominal Examination

  

1.              Inspection

 

2.              Palpation

 

3.              Auscultation

 

 

Inspection (5s)

 

a)     Shape:-

 

·                 Note contour -is it round, oval, irregular or pendulous?

 

·                 Longtudinal, ovoid in primigravida

 

·                 Rround in multipara.

 

·                 Broad in transuerse lie.

 

b) Size:- Should correspond with the supposed period ofgestation

 

c) Skin: - The dark line of pigmentation which is lineanigra isseen any rash?

 

d) Strae gravidarum

 

e) Scar - Any operation scar(c/s)

 

On Palpation:

 

1. Fundal height and fundal palpation (1^st Leopoled Maneuver)

 

1.1 Fundal Height

 

At about 12 to 14 weeks of pregnancy, the uterus is palpated above the symphysis pubis as a firm globular sphere; it reaches the umbilicus at 20 to 22 weeks, the xyphoid process at 36 weeks, and then often returns to about 4 cm below the xyphiod due to “lightening” at 40 weeks.

 

Method: Measure distance of fundus with points on abdomenand assessing the fundal height in finger breadth below the xiphisternum or measure by centimeter.

 

1.2 Fundal Palpation

 

Purpose- To know lie and presentation.

 

Method: - Use 2 hands using palms of hands palpate oneither side of the fundus. Fingers held close together, palpate the upper pole of then uterus and feel that as it is hard or soft or irregular.

Figure:12 Fundal palpation

2. Lateral Palpation: (2^nd Leopled maneuver)

Purpose-To know lie and position

 

Method: - always facing the mother, fix the hand on thecenter of the abdomen, fix the right hand and palpate with left hand and vise versa. Note the regularity; the regular side is the back.

Figure ; 13 Lateral palpation

 

3. Deep pelvic Palpation: (3^rd Leopoled Maneuver)

Purpose -To Know Presentation & Attitude

 

Method: - Feel presenting part, is it hard or soft whilepalpatingfor the presenting part feel for eminences on back side.

 

Figure 14: Deep pelvic palpation

 

4. Pawlick's Grip: (4^th  Leopard Maneuver)

 The lower pole of the uterus is grasped with the right hand the midwife facing the women's head, feel the occiput and sinciput, note which is lower.

Figure 15. Pwlick’s grip 

 

Auscultation: Check Fetal heart, rate and rhythm, count forone minute if regular.

Method: Use Pinards stethoscope

 

·     hand should not touch it while listening,

 

·     ear must be in close from contact with stethoscope,

 

 

Pelivic assessement

 

·                 By x-ray of the pelvis

 

·                 Clinical (assessing sign of contracted pelvis)

 

·                 Head fitting

 

Head fitting

 

The head is the best pelvimeter

 

METHOD 1: Head fitting, sitting patient, Method

 Let her lie on a couch, place hand on the Symphysis pubes and get the woman to sit up by her own effort. The effort should force the head in to the pelvis.

 

METHOD 2 : Left hand grip method Grasp the fetal head withleft hand and push it down wards and backwards if a sense of give is felt the head has entered and there is no over and no cephalo pelvic disproportion.

 

Genito-Urinary System

 

·                 Frequency of micturation

 

·                 Check for abnormal discharge

 

Circulatory System

 

Varicosities: - Varicose veins may occur in the legs, anus(hemorrhoids) and vulva. Vulval varicosities are rare and very painful.

 

The Vulva

  

·                 Vulval warts

 

·                 Purulent irritating discharge

 

The Lower Limbs

 

Examine for bones alignment and deformities.

 

Check pitting oedema in the lower limbs by applying fingertip pressure for 10 seconds over the tibial bone.

 

3. Laboratory test

 

Urine:-For Protein and glucose

 

Blood Tests:-V.D.R.L.

 

·                 Rhesus and blood grouping.

 

·                 Hemoglobin

 

 

4. Points to Be Advised On

 

·                 The advantages of antenatal check up

 

·                 The use of tetanus toxoid vaccine.

 

·                 The danger of lifting heavy loads (exercise).

 

·                 Rest at least 10 hrs at night and 2 in the afternoon, clothing shuold be confortable

 

·                 Breast care

 

·                 Diet - Rich in Iron and protein

 

Report the following

 

 

·        Vaginal bleeding

 

·        Reduced fetal movements

 

·        Frontal or reccuring headaches

 

·        Sudden swelling

 

·        Rupture of the membranes

 

·        Premature onset of contractions etc.

 

Booking for Confinement

 Women should attend: - Monthly upto 28 weeks

 

·     Every 2 weeks up to 36 weeks

 

·     Weekly 36 weeks there after.

 

N.B. High risk mothers eg. multiple pregnancy, suspected disproportion etc. should attend weekly.

 

At subsequent Visits:-

 

·           Blood pressure, weight (edema)

 

·           Abdominal examination (all steps of abdominal examination)

 

·           Hematocrit test should be repeated at 28 and 36 weeks of

 

·           gestation Health Education

 

·           Listening and managing any complaint