Antenatal Care Flashcards
How do we diagnose a patient to be pregnant?
- Amenorrhea
- Breast tenderness
- Urinary frequency
- Morning sickness due to increased HCG
What confirmatory tests can we do to detect pregnancy?
- Two positive pregnancy tests
Which will measure the urine BHCg level
What is the goal of the first antenatal visit?
- Detailed History
- Examination
- Special Investigations
- Establish duration of pregnancy
- Risk grading
What is the most important questions to ask on history?
- Detailed history about previous pregnancies
- Detailed history about current pregnancy
- History about medical or surgical procedures
- Any medication and allergies(could be teratogenic to the baby)
- Smoking and alcohol consumption
- Family history
- Social hx-marital status, living circumstances
What does gravidity mean?
The number of previous pregnancies plus the current one including miscarriages and ectopic pregnancies
-if the mom has a previous multiple pregnancy it is still regarded as a one
What does parity mean?
The number of previous fetuses that reached viability (6 months, 22 weeks or a weight of 500mg)
- this also includes stillbirths and multiple pregnancies
- so if there were twins then it is known as para 2
What does grand parity mean?
It means that there were 5 or more pregnancies that reached viability
So grava 6, para 5
What causes miscarriages consecutively and successively in the first trimester?
Some genetic abnormality in either the mother of father
What causes miscarriages in the mid-trimester?
Chorioamnionitis, syphillis or cervical incompetence
What does do we need to ask about previous obstetric pregnancy?
- Gravidity and parity
- Ectopic and miscarriages
- The year of delivery and duration of pregnancy
- The method of delivery
- Gender of the baby
- The birth weight of the baby
- Was the baby born alive or dead
What do we need to ask the patient regarding a c/s?
- What the indications of the c/s were
- Type of c/s-vertical or transverse
- All other complications
What pregnancy complications tend to recur in other pregnancies?
- Preterm labour
- Early severe Pre-eclampsia
- Post-partum haemorrhage
- Abruptio placentae
- Perinatal deaths
What is the most important history you need to ascertain about the current history?
- The first day of the last menstrual period
- Any medical problems since pregnancy started(UTI, bleeding )
- Irritating complaints such as nausea and vomiting, heartburn constipation and oedema of the feet
- Whether it is a planned pregnancy
- Contraception after pregnancy
Which drugs are teratogenic in the 1st trimester?
Retinoids for acne
Which drugs are teratogenic at term?
Warfarin
What kind of care do patients with a BMI of >40 require?
Intermediate care
What kind of care do patients with a BMI of >50 get?
High risk care
What are the 4 main things you would have to prepare for if the patient has a high BMI?
- Hypertension and Diabetes
- Shoulder dystocia because of a big baby
- Cephalo-pelvic disproportion
- Intra-uterine growth restriction
What is the approach to an obstetric plan?
- Start with the general appearance of the patient-does the patient look well/unwell
- Do JACCOLD
- Determine the BMI of the patient-regarding their height and weight
- Examine the thyroid (can be slightly enlarged during pregnancy)
- Examine the breasts(any lumps or nipple discharge)
- Resp and cardio exam
- Abdominal exam(any abnormal masses or organomegaly)
- Internal and external genital exam: vaginal speculum exam and papsmear and bimanual examination
When should we be worried about a thyroid on examination?
If the thyroid is enlarged and nodular or has a single lump on it
What kind of murmurs are often normal in pregnant women?
- mid-systolic, grade 2/6
- ejection characteristic and usually in the parasternal areas(either aortic or mitral)
What do we inspect for on the vulva?
Any single or multiple ulcers, purple to discharge or enlarged I GUI also lymph nodes
What do we look for in the speculum examination?
- Vaginal discharge-infection?
2. Ulcer that bleeds easily-cervical carcinoma?
When should we decide to do a papsmear on a patient?
When a patient has a abnormal cervix
Previous abnormal papsmear or if the patient is above the age of 30 years
What is the most accurate way of determining gestational age at 12 weeks?
Bimanual vaginal exam
What is the most accurate way of determining gestation after 18 weeks?
SF
How long do we measure the SF height?
From 18-36 weeks
What would lead to a smaller SF than expected?
- Intra-uterine growth restriction
- Intra-uterine death
- Normal but small baby
- Oligohydroamnios
What would lead to a bigger SF than expected?
- Multiple pregnancies
- Diabetes
- Polyhydroamnios
- Macrosomia
What are the 3 ways to determine estimated day of delivery?
- Dates
- Palpation (bimanual exam <12 weeks, abdominal palpation from 12-17 weeks, SF height from 18-36 weeks)
- Ultrasound before 24 weeks
What is the advantage and disadvantage of ultrasounds?
Advantage: reliable before 24 weeks
Disadvantage: unreliable after 24 weeks
What does the Leopoldo maneuver consist of?
- Fundal grip
- Lateral grip-to determine the fetal back
- Paw like grip
- Pelvic grip
What should we think of if the lower pole is fixed?
That there might be possible engagement of the head
At 34 weeks, how many fifths of the head can we expect to feel?
3/5 of the head as it begins to become engaged
How many fifths of the head can we feel if the head is engaged?
2/5
What stethoscope do we use to hear the foetal heart?
Picard stethoscope
When can we start using the doppler for auscultation?
From 12-14 weeks
What other sounds can we expect when auscultating?
- Uterine souffle-murmur caused by maternal blood flow through placenta
- Funic souffle-fetal blood flow through umbilical cord
How do we approach doing a vaginal examination?
- Inspection of the vulva and vagina-ulcers
- Speculum examination (take papsmear for cytology)
- Bimanual examination
- look at the cervical dilation and effacement
- uterus consistency and size and leimyomas
- pouch of douglas
What special investigations would we do on the patient visits?
- Hb
- HGT
- Mid-stream urine specimen-protein, glucose, leucocytes
- Bloods: syphilis, HIV, Rhesus
- Ultransound
Which patients must be referred for ultrasonography?
- Hypertensive
- Obese
- Patients older >35 years
- Previous c/s
- Rhesus sensitisation
- Antepartum haemorrhage
- Decreased or increased fundal group
When do we typical do ultrasound scans?
At 13 weeks to determine the duration of pregnancy
And at 20-24 weeks to exclude congenital abnormalities
What nutritional supplements do the patients need?
- Iron-200mg tablet per day if the Hb is >11g/dL
- Folic acid to prevent neural tube defects
- I done if iodine deficient
- Pyridoxine if there’s a defect in homocysteine metabolism
When is the first antenatal visit done?
2 weeks after the first, usually to check out the special investigations results
If the patient is HIV positive when should they come fro their second antenatal visit?
A week after to determine their CD4 count and also to start ARV treatment
What groups are patients divided into?
- Low risk group-managed by midwives
- Intermediate group-can be managed by one doctor
- High risk group-need tertiary care
What visit schedule do low risk patients have?
- They have to visit every 6 weeks until 34 weeks
- Then visit every 2 weeks until 38 weeks
- Then at 41 weeks for induction of labour
What is the visit schedule for patients that are intermediate and high risk?
Seen as often as possible
What are the important factors we assess at 28 weeks?
- Ante-partum haemorrhage
- Pre-eclampsia (sudden rise in blood pressure and proteinuria)
- Poor intra-uterine growth and increased intracranial-uterine growth
- Anaemia
- cervical Changes
- Diabetes
- Foetal movements
What needs to be checked at 34 weeks?
- Everything mentioned in 28 weeks
- Fetal lie is NB- if the baby is in breech
- Possible consideration for c/section at 39 weeks
- Examine the breast for discharge or nipple inversion to decide on breastfeeding
- Talk about contraception and possible sterilization
When do we do a external cephalic version?
At 36 weeks
What do we need to focus in the 41st week?
- To admit the patient for the first day of the 2nd week
Why do we not allow pregnancy to go until the 42nd week?
To avoid possible
- intra-uterine death
- Meconium aspiration
- intra-partum foetal distress
