ANTENATAL AND POSTNATAL CARE Flashcards
——— is the healthcare and education given to pregnant women by health-care professionals aimed at ensuring the best health conditions for both mother and baby from conception to onset of labour.
It is a form of preventive, promotive and therapeutic health care. True or false?
DEFINITION
Antenatal Care
True—It is a form of preventive, promotive and therapeutic health care.
AIM is to?
AIM: To have a wanted pregnancy result in a healthy mother delivering a healthy baby, through the monitoring of the progress of the pregnancy in order to support maternal health and normal fetal development.
This is meant to achieve a positive pregnancy experience in the expecting mother.
A positive pregnancy experience is defined as maintaining physical and sociocultural normality, maintaining a healthy pregnancy for mother and baby , having an effective transition to positive labour and birth, and achieving positive motherhood, including maternal self-esteem, competence and autonomy( W.H.O 2016 ).
Objectives for antenatal care
Definition of puerperium
OBJECTIVES
• Assessing the health status of the mother and the fetus through thorough history, examination and investigations, including screening tests.
• Identifying any risk factors that may affect the outcome of the pregnancy.
• Prompt intervention when complications occur.
• Education on healthy life style, avoidance of harmful practices such as intake of alcohol, tobacco, recreational drugs/unprescribed drugs, use of insecticide treated bed nets, danger signs of pregnancy, normal physiological changes in pregnancy, common disorders or complaints, what to expect in labour, birth preparedness, puerperium, informed choice on breastfeeding, immunization, and parenthood.
Thus providing effective
- communication about physiological, biomedical, behavioural and sociocultural issues
- support, including social, cultural, emotional and psychological support, to pregnant women in a respectful way
• Planning the time, place and mode of delivery.
• Contraceptive counseling and service.
• To ensure the safe delivery of a full term healthy baby with minimal stress or injury to mother and baby.
• To help prepare the mother physically, psychologically and socially to breastfeed successfully, experience normal puerperium and to take good care of the baby
** Puerperium:
the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.
IMPORTANCE OF ANTENATAL CARE
Promotion of maternal, fetal and neonatal health.
Reduction of maternal and neonatal morbidity and mortality
Entry point for other health programmes
- infection screening
- screening for other medical conditions such as hypertension, diabetes, sickle cell
- immunization for both mother and baby
- nutrition support for both mother and baby
PRECONCEPTION CARE
This is the specialised form of care for women of reproductive age before they get pregnant, in order to detect, treat or counsel them about any existing medico-social conditions which can adversely affect outcomes for mother and baby. Ideally all prospective mothers should be evaluated before getting pregnant. This is particularly necessary in those with:
1. Chronic medical conditions such as diabetes mellitus, hypertension, heart disease, renal disease, tuberculosis and HIV.
2. Genetic disorders, eg. Sickle cell – for genetic counseling and selection of partners. Family history of diabetes.
3. Recurrent pregnancy loss: to evaluate and treat any treatable cause.
4. Unhealthy life style – smoking, excessive alcohol intake, obesity, poor personal hygiene, drug abuse.
Conduct of preconception care
• Detailed history, examination, investigations
• Appropriate treatment.
• Health education on life style issues, personal hygiene, avoidance of harmful agents to the fetus.
• Counselling on whether to embark on pregnancy or not, for example when there is HIV / AIDS, severe heart disease, end stage diabetes mellitus, severe hypertension with retinopathy, severe renal disease.
THE CONDUCT OF NORMAL ANTENATAL CARE (ANC)
Antenatal care is usually offered by a midwife in a maternity home or hospital. In low-resourced settings, Community Health Nurses also offer antenatal care in CHPS compounds (recommended by WHO). A general practitioner or an Obstetrician may also offer antenatal care. Clients may be seen by different categories of health workers depending on theie risk status. This is called task-shifting or shared antenatal care.
ANTENATAL VISITS (CONTACTS)
The WHO now prefers the word “contact” to “visit”, as the former implies an active connection between a pregnant woman and a health-care provider that is not implicit with the word “visit”. Evidence suggests that more ANC contacts, irrespective of the resource setting, are probably associated with greater maternal satisfaction than less ANC visits. The 2016 WHO ANC model recommends a minimum of eight (8) ANC contacts. The 1st contact ideally must take place in the first trimester (up to 12 weeks of gestation). Two contacts are scheduled for the second trimester (at 20 and 26 weeks) and five contacts scheduled in the third trimester (at 30, 34, 36, 38 and 40 weeks).
Irrespective of this regimen, the total number of antenatal visits will depend on the risk status of the client which should be determined at each visit by repeated history taking, examination and investigations. Clients with certain medical conditions in pregnancy may require more ANC contacts.
The older traditional regimen of ANC visits was 4 weekly till 28 weeks, 2 weekly till 36 weeks, and weekly till delivery. Other regimens offered in the past include Focused ANC which was considered client-centred, friemdly and interactive. In this regimen the same health worker offered all necessary care to the client (history, examination, treatment and health education).
THE FIRST ANTENATAL VISIT (BOOKING VISIT)
The first visit a pregnant woman makes to the health facility is called the booking visit. The purpose of this initial visit is to confirm the pregnancy and identify existing or potential problems that could adversely affect the pregnancy and childbirth. It also offers the opportunity to determine if she will require routine or special care and plan her continuing care (risk assessment). The booking visit must ideally be in the first trimester. Objectives of this initial visit are
• To assess the state of health by taking a detailed history, thorough physical examination, carry out appropriate investigations and screening tests
• To obtain baseline recordings of blood pressure, urinalysis, blood values, uterine growth and fetal development to be used as a standard for comparison as the pregnancy progresses
• To identify risk factors
• To provide an opportunity for the woman and her family to express and discuss any concerns they might have about the current pregnancy and previous pregnancy complications, labour and delivery or puerperium
• To offer education and counselling pertaining to pregnancy in order to maintain the health of the mother and the healthy development of the fetus
• To build the foundation for a trusting relationship in which the woman and her care-giver are partners in care
Details of care at the first visit involve: • Demography
• Full history
• Physical examination including pelvic examination if indicated.
[NOTE: History taking and examination of the pregnant woman have been covered in Chapter 5]
• Investigations
• Pregnancy test, Ultrasound
• Haematology and blood film for malarial parasites
• Sickling, grouping and Rh factor, G6PD
• Diabetes screen (See Chapter 35)
• Infection screen – VDRL / RPR, HBsAg, HIV (opt out approach)
• Urine analysis.
• Stool examination.
• Others where indicated eg. LFT, RFT, funduscopy.
Identify any risk factors and manage / advise accordingly.
Routine ANC drugs: Iron (30-60 mg elemental iron), Folic acid (400ug), Multivite/B
Complex, oral calcium when necessary
Tetanol immunization (see schedule below)
Education and counselling on:
i. Common disorders of pregnancy
ii. Danger symptoms and signs in pregnancy
iii. Healthy diet. A healthy diet contains adequate energy, protein, vitamins and minerals, obtained through the consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts, whole grains and fruit.
iv. Lifestylemodification:clothesandshoes,moderateexercises,sexualconcerns, personal hygiene, use of insecticide treated nets (ITN)
v. Family planning and contraceptives
vi. Need to come for subsequent visits
vii. Need to take all prescribed medications
Note that policies for screening for gestational diabetes vary from country to country and from centre to centre. However screening only those with risk factors may miss a significant proportion of GDM cases. It is better to screen all clients at booking, and repeated at 24-28 weeks when the metabolic changes in pregnancy are likely to unmask any GDM. Since urinalysis is done at each visit, those who test positive for urine sugar should be screened for diabetes. Asymptomatic bacteriuria must be treated with a full course of antibiotics.
Common disorders of pregnancy 🤰
Common disorders of pregnancy
• Nausea and vomiting, ptyalism
• Breast changes
• Backache and ligament pain (postural
and hormonal)
• Headache (stress, fatigue, emotional)
• Constipation, heartburns
• Increased vaginal discharge
• Oedema of lower extremeties.
• Acroparaesthesia
• Dyspnoea at 34 – 38 weeks
• Physiological skin changes (chloasma, ache, striae
gravidam, linea nigra)
• Emotional instability
Danger symptoms / signs of pregnancy
PELVIC
• Bleeding
• Fluid loss
• Offensive discharge
ABDOMINAL
• Epigastric pain
• Uterine cramps
• Decreased fetal movement
CEREBRAL
• Dizziness
• Blurred vision
• Visual disturbances
• Severe headaches
URINARY
• Dysuria
• Oliguria
OTHERS
• Fever
• Chills
• Jaundice
• Facial swellings
Tetanol immunization schedule (for the non-immunized client)
Dose—When to give—Duration of Protection
1st Dose— At booking (irrespective of gestation)— No protection
2nd Dose—At least Four weeks after 1st dose—1-3 years
3rd Dose—At least Six Months after 2nd dose—At least 5 years
4th Dose—At least one Year after 3rd dose—At least 10 years
5th Dose—At least one Year after 4th dose—Life-long
NOTE 📝— If there is enough evidence that the client has completed the schedule as above, there is no need for a repeat or booster, as she is protected for life.
RISK ASSESSMENT
Increased risk of adverse pregnancy outcome is associated with:
RISK ASSESSMENT
Increased risk of adverse pregnancy outcome is associated with:
• Extremes of age: < 18 yrs, > 35 yrs
• Grandmultiparity, nulliparity History of infertility
• Low socioeconomic status
• Single motherhood
• Smoking, alcohol
• Previous pregnancy loss
or neonatal loss, preterm
delivery,cervical cerclage
• Previous C/S or uterine
surgery
• Previous or current SGA,
LGA, anomalous fetus
• Previous or current hypertension, diabetes, other medical condition.
• Multiple pregnancy, polyhydramnios.
• Bleeding in current or
previous pregnancy.
• Family history of medical
condition affecting
pregnancy.
• Maternal obesity.
• Short stature (≤ 1.5m)
• Reduced fetal movement
• Maternal anaemia
• Poor weight gain
• Reduced liquor volume
• Malpresentation
• Uterine abnormalities,
including fibroids.
• Rh negative status
• Any previous obstetric
problem
These cases are designated high risk and require care in specialist centres where a more detailed evaluation and monitoring can be given. After risk assessment, low risk cases may be attended to at lower centres and by skilled midwives or General Practitioners/ Family Physicians and referred to specialist centres if any risk arises (shared care).
SUBSEQUENT ANTENATAL CONTACTS
At each subsequent visit, review the previous notes. Take history, perform physical examination, Do urine dipstick for protein and sugar and request for any indicated investigation. Re-determine client’s risk status.
Ensure that:
• Client perceives fetal movements
• Weight gain is appropriate
• Symphysio-fundal height is compatible with gestational age
• Fetal heart tones are present and normal
• Danger signs, if present, are appropriately evaluated and managed
• Health education is given
• Emphasize on delivery by skilled trained healthcare personnel The following are done at the specified times.
• Fetal anomaly scan at 18-22 weeks gestation.
• Tetanol injections are given as detailed in the schedule above
• Sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment for malaria (IPT): at 16wks or quickening, and repeated monthly till onset of labour, as direct observed treatment [DOT). Rule out G6PD deficiency before giving SP
• Repeat Hb / PCV at 28 and 36 weeks
• Repeat infection screen (Hep B and HIV) at 36 weeks. If HIV positive, start client on HAART
Approximate level of the uterine fundus to various gestational ages is shown below
⬇️ Refer to book page 76
Book page 76
