Antenatal care and pregnancy surveillance Flashcards
In the UK/ high-income countries, what number of appointments do women in their first pregnancy, and women in their subsequent pregnancies, usually have with healthcare professionals?
- First: 10
- Second: 7
What determines whether a patient receives antenatal care from midwives or with other members of the MDT including obstetricians?
if no risk factors or obstetric problems may all be from midwives; if risk factors, health problems, obstetric problems or poor obstetric history → some antenatal care from obstetrician etc.
What is the first appointment that women have with healthcare professionals during pregnancy and when does this occur?
‘Booking’ appointment with midwife by 10 weeks’ gestation
What are the aims of the first, ‘booking’ appointment with the midwife?
- idetnfiy risks
- screen for abnormalities or illness
- develop rapport and encourage future attendance by ensuring positive experience
- key health promotion messages
- gain initial observations of mother - to compare with later deterioration
How can likely gestation of the pregnancy be established at the booking appointment before 10 weeks’ gestation?
establishment of first day of last menstrual period, and abdominal examination
What are 4 groups of risk factors to be identified at first appointment in pregnancy (booking appointment) that increase risk of obstetric problems or complications for mother or fetus?
- Personal history and current health
- Family history
- Obstetric history - previous pregnancies
- Current pregnancy
What are 7 risk factors for obstetric complications under the category of personal history and current health?
- History of subfertility and fertility treatment
- Medical conditions including diabetes, thyroid problems, epilepsy, asthma, heart disease, hypertension, renal disease, cancer
- Surgical history - gynaecological procedures, treatment to the cervix, breast surgery, abdominal surgery
- Raised BMI or very low BMI
- Mental health - bipolar disorder, postpartum psychosis, schizophrenia, depression, postnatal depression, anxiety disorders, eating disorders
- Lifestyle - smoking, non-prescription and prescription drug use
- Social difficulties - domestic abuse, financial difficulties, previous child-protection concerns
What are 3 family history risk factors for obstetric complications to be established at the first appointment in pregnancy?
- Pregnancy related: first-degree relative with congenital abnormality or genetic abnormality, pre-eclampsia, venous thrombosis
- Medical conditions - diabetes, heart disease, inherited conditions e.g. sickle cell anaemia, cystic fibrosis
- Mental health - first degree relative with postpartum psychosis, schizophrenia, bipolar disorder, severe postnatal depression or depression
What are 7 risk factors in the obstetric history for obstetric complications that should be noted at the first, booking appointment of pregnancy?
- Miscarriage at >14weeks, stillbirth or neonatal death
- Recurrent miscarriage (3 consecutive first-trimester losses)
- Premature birth or small for gestational age infant
- Pregnancy-related hypertension, gestational diabetes, rhesus isoimmunisation, antepartum haemorrhage
- Induction of labour - indication
- Operative birth (C-section or instrumental delivery), shoulder dystocia, breech birth
- Postpartum haemorrhage, retained placenta, OASI (obstetric anal sphincter injury)
What are 4 current pregnancy factors which are risk factors for obstetric complications that should be picked up at the first, booking appointment?
- Hyperemesis
- Vaginal bleeding
- Abdominal pain
- Findings from pregnancy ultrasound
What is the recurrence risk of postpartum psychosis if there is a personal history?
1 in 2-4 (background risk of 1 in 500)
What management of family history of blood disorders will be required?
relevant counselling and screening
What are 3 examples of pre-existing maternal medical conditions that will require multifisciplinary care planning and monitoring throughout pregnancy?
- Diabetes
- Thyroid conditions
- Epilepsy
What could require discussion of choices relating to delivery?
previous caesarean section
What type of management of obstetric complications risks may be needed? 3 types
- management of lifestyle risks: referral for smoking cessation support, dietetic support to promote healthy eating
- mental health risks e.g. bipolar disorder: liaison with mental health services to
- social difficulties: liaison with local social care/ voluntary sector organisations
What are 6 aspects of the general physical examination performed at the first antenatal appointment?
- BMI
- blood pressure
- heart rate
- auscultation of heart and lungs - in area with high incidence of heart and respiratory conditions
- abdominal examination to determine uterine size/abnormal masses/ scars
- urinalysis - protein and glucose (UTI, hyperglucaemia)
What are 6 aspects of further screening in addition to the general physical exam at the first antenatal appointment?
- FBC - anaemia and thrombocytopenia
- Blood group: ABO and rhesus status of mother, any red cell antibodies
- Haemoglobin electrophoresis - screen for thalassaemia and sickle cell anaemia
- Hepatitis B status
- Syphilis
- HIV
What are 5 symptoms/ forms of discomfort many women may experience during early stages of pregnancy that might cause worry?
- Nausea and vomiting (morning sickness)
- Lower abdominal discomfort
- Frequency of micturition
- Vaginal ‘spotting’ (small amounts of bleeding per vagina)
- Breast tingling or discomfort
In addition to identifying obstetric risks, the physical examination and initial screening tests, what else is important to discuss with a woman at the first antenatal appointment?
discussion about options for screening for chromosomal and structural fetal abnormalities
What should you explain to a woman about screening for Down syndrome/ screening generally at the first antenatal appointment? 3 aspects
- nuchal translucency testing between 11 and 14 weeks
- routinely offered fetal anomaly scan between 18 and 22 weeks
- advise initial screening won’t provide conclusive answer about abnormality but presents a risk factor so can make further decisions about testing - chorionic villus sampling or amniocentesis
How can you explore a woman’s readiness to make positive health behaviour e.g. stopping smoking, drinking alcohol, using drugs during pregnancy, eating healthily and being more physically active at the first antenatal appointment?
Motivational interviewing or brief intervention approaches
Provide clear info about impact of particular behaviours on maternal and fetal health, while remaining non-judgemental in approach
What are 6 potential effects of smoking in pregnancy?
- Miscarriage
- Premature birth
- Small for gestational age babies
- Stillbirth
- Sudden unexpected death in infancy (SUDI)
- Increased hospital admissions in first year of baby’s life
What group of problems is drinking alcohol during pregnancy related to?
spectrum of potential problems called Fetal Alcohol Spectrum Disorder (FASD)
What proportion of babies are believed to be born with effects from alcohol?
1 in 100
What type of lifelong problems can FASD have on an affected person?
Learning and bahvioural difficluties
What are 3 broad areas to cover with pregnant women at the first antenatal appointment regarding lifestyle?
- Alcohol, smoking, drugs
- Diet
- Physical activity and exercise
How can women be helped to achieve a balanced diet in pregnancy?
vitamin and mineral supplements
Which 2 particular vitamin supplements are recommended in all pregnant women in the UK and why?
- Folic acid 400mcg for the first 12 weeks to reduce risk of neural tube defects
- 5mcg daily vitamin D
Which type of vitamin supplements should pregnant women be warned to avoid and why?
vitamin A supplements - teratogenic
What is the advice about physical activity in pregnancy?
Same as for all adults in UK: 5 periods of moderate physical activity for 30 min each week e.g. walking, swimming, gardening, yoga
What are the benefits of physical activity in pregnancy?
helpful in maintaining and improving physical and mental health in pregnancy and may help to relieve some of the discomforts of pregnancy
What point in pregnancy is considered the second trimester?
12-20 weeks
What are the 4 key parts of antenatal care in the second trimester (12-20 weeks)?
- Follow up of results from initial blood tests
- Fetal anomaly screening at 18-22 weeks
- Instigating any treatment or further surveillance indicated by these results
- At each appointment in 2nd trimester: 4 key measurements recorded (maternal blood pressure, urinalysis, ask about pain or vaginal loss, ascultation of fetal heart from 18 weeks)
What 4 physical tests must be performed at each antenatal appointment throughout the second trimester?
- Maternal blood pressure measurement
- Maternal urinalysis
- Ask about any pain or vaginal loss
- Auscultation of fetal heart from 18 weeks
What should you ask at every antenatal appointment during the second trimester?
(any pain or vaginal loss)
woman’s wellbeing, both physical and emotional - helps identify which symptoms are of concern and require further investigation by asking about impact on woman’s life
What are 12 common problems/ ‘minor disorders’ of pregnancy?
- Nausea and vomiting
- Heartburn
- Haemorrhoids
- Constipation
- Pelvic girdle pain, sciatica, back pain
- Anaemia
- Carpal tunnel syndrome
- Bleeding gums - gingivitis/ gum disease
- Fatigue
- Itching
- Rashes
- Vaginal discharge
What should you monitor if a woman reports nausea and vomiting during pregnancy?
investigate severity through history taking
if more than occasional, monitor weight, dehydration (urinalysis), consider hospitalisation
When should you consider hospitalisation in a pregnant woman with nausea and vomiting?
if weight loss, dehydration
What should you exclude as a cause of nausea and vomiting in pregnancy?
urinary infection
What is the typical advice/ management for nausea and vomiting in pregnancy?
Eat little and often
Antiemetics can be safely prescribed
What are 4 aspects of management of heartburn in pregnancy?
- Antacids
- Monitor diet to identify which foods worsen or improve symptoms
- Eat little and often
- If persistent and not relieved with common treatments, consider H2 antagonists
What is the management of haemorrhoids in pregnancy?
over the counter treatments; avoid constipation through remaining well-hydrated and eating plenty of fruit and vegetables
What is the management of constipation in pregnancy?
OTC treatments; avoid constipation - good hydration, eat fruit and veg, increase dietary fibre
What is the management for pelvic girdle pain/ sciatica/ back pain in pregnancy? 3 aspects
- avoid over-abduction of hips
- refer for physiotherapy - prescribed exercises to relieve pain, improve mobility and strengthen muscles
- walking aids in more severe cases
What is the usual management of anaemia in pregnancy?
usually iron deficiency - prescribe iron supplement, improve intake of iron rich foods and monitor improvement
What are 4 aspects of the management of carpal tunnel syndrome in pregnancy?
- Monitor severity
- Exclude pre-eclampsia
- Refer for physiotherapy
- Wrist splints may be helpful
Why is gingivitis/ gum disease and bleeding more common in pregnancy?
hormonal changes
What is the management of bleeding gums in pregnancy?
careful oral hygiene and dental check up
At what point in pregnancy is fatigue most common?
first trimester
What should you screen for with fatigue in pregnancy and what is the management?
anaemia
encourage physical activity to improve sleep quality
What causes itching in pregnancy?
hormonal changes and stretching of the skin
What can severe itching in pregnancy sometimes indicate and when should you be particularly alert for this?
obstetric cholestasis - after 30 weeks
How can you confirm cholestasis in cases of severe itching in pregnancy?
biochemical testing
What are 2 key types of rashes in pregnancy?
- Polymorphic eruption of pregnancy (1:240 pregnancies)
- Pemphigoid gestationis (1: 10 000 pregnancies)
How does polymorphic eruption of pregnancy present?
abdominal urticaria and vesicles (with no bullae), rarely in umbilical area, sometimes extends to proximal limbs
How do you manage polymorphic eruption of pregnancy?
antihistamines and topical steroids
How does pemphigoid gestationis present in pregnancy?
pruritic erythematous papules, plaques and wheals spreading from periumbilical area to the breasts, thighs and palms
What is pemphigoid gestationis associated with?
fetal compromise
What is the treatment for pemphigoid gestationis?
antihistamines, topical steroids and systemic steroids
What is a common finding with vaginal discharge in pregnancy?
heavier discharge normal during pregnancy
When should vaginal discharge in pregnancy be investigated further and how?
if malodorous or accompanied by itching - vaginal swab for culture
What is a very important social and environmental factor to enquire about during a woman’s pregnancy and how must this be done?
- domestic violence or abuse
- ensure on at least one occasion during pregnancy, time alone with woman to enquire about home situation
What is a link between domestic violence and pregnancy?
research suggests it can begin or escalate in pregnancy
What are 5 social issues to consider for a woman during pregnancy?
- Domestic abuse
- Substance misuse
- Involvement with judicial system
- Homelessness
- Poverty
If any social issues arise during pregnancy how might this be managed?
talk to woman about need to make referral for social support through social services and/or voluntary sector organisation
Familiarise self with local safeguarding and child-protection procedures
At what point in pregnancy is the third trimester?
20 weeks to term
What are 5 things to assess for in the third trimester of pregnancy, in addition to the 4 key things during the second trimester too (BP, urinalysis, pain/vaginal loss, fetal heart auscultation)?
- Abdominal examination
- Presentation
- Evaluation of fetal growth
- Enquiry about fetal movements
- Polyhydramnios or oligohydramnios - assess with palpation and measurement
What does abdominal examination involve in the third trimester of pregnancy?
- inspection, palpation and auscultation of fetal heart using Pinard stethoscope or hand-held Doppler device
- If fetal heart can’t be heard, ultrasound can be done to assess fetal well-being
How should you try to auscultate the fetal heart during antenatal appointments in the third trimester?
Pinard stethoscope or hand-held doppler device
if doesn’t work, ultrasound
What is meant by presentation and how can this be determined at antenatal checks in the third trimester?
= part of the fetus overlying the pelvic brim (e.g. cephalic, breech, shoulder)
examination and palpation of uterus will idetnfy this
What 3 things about the fetus should be assessed with examination and palpation fo the uterus in the third trimester?
presentation, position, descent
What is meant by position (as opposed to presentation) in pregnancy?
while presentation is the lowermost part of the fetus presented to the pelvic brim, position refers to location of the point of direction with reference to the four quadrants of the maternal outlet
How can evaluation of fetal growth be performed in the third trimester?
at each appointment from 24 weeks onwards, healthcare professional should measure from pubic symphysis to fundus of uterus and plot measurement (symphysio-fundal height, FSH) on size chart.
(prior to that: ultrasound measures; 10-14 weeks CRL, 15-20 head circumference)
From which point should fetal growth be measured using SFH?
from 24 weeks onwards
What should you do if SFH is outside normal range or becomes static?
ultrasound examination should be offered
What is the usual trend in fetal movements during pregnancy?
tend to increase in frequency and strength until 32 weeks, then remain relatively stable until birth
What is an important thing to do to keep track of fetal movements?
encourage woman to become familiar with individual apttern of baby’s movements
advise that it’s a sign of baby’s wellbeing
What should you advise women to do if they become aware of any reduction in the baby’s normal pattern of movements?
lie down for an hour to rest and focus on baby’s movements - if continue to be reduced, seek advice from HCP