Basic Antenatal Care

Front 1

address possible sensations during pregnancy

Back 1

heartburn, backache, leg cramps, various fears and
anxieties

Front 2

Preconception care

Back 2

- geenral health

- screening

- genetic counselling

Front 3

General Helath advice

Back 3

optimal nutrition and
diet, weight control, regular exercise and discouragement
of smoking, alcohol and drugs.

Front 4

Foods to avoid

Back 4

Listeria infection is a
problem if contracted, with fetal mortality being
30–50%. Protection is afforded by good personal and
food hygiene. For those who ask, advise avoidance of
unpasteurised dairy products, soft cheeses, cold meats,
raw seafoods, chilled ready-to-eat foods and takeaway
foods

Front 5

Folic acid

Back 5

Folic acid (0.5 mg tablets) is now generally
recommended to commence at least 1 month prior to
conception, continuing to 12 weeks postconception. For
women at risk, the dose is 5 mg/day for at least 1 month
and preferably 3 months preconception.

Front 6

Examination

Back 6

blood pressure, cardiac status, urinalysis
and cervical smear.

Front 7

Rubella serology

Back 7

Rubella serology should be estimated and, if required,
immunisation 3 months prior to conception should
be initiated. Test for seroconversion 3 months later.
Vaccination should be avoided in early pregnancy.

Front 8

VAricella

Back 8

Ask about a history of varicella and, if necessary,
consider serology and vaccination

Front 9

Vaccinationd to consider

Back 9

• Boostrix (diphtheria, tetanus, pertussis)
• MMR (measles, mumps, rubella)
• Varicella
• Infl uenza (to protect against infection
in the second and third
trimester)

Front 10

summary: advice to patients

Back 10

• Stop smoking.
• Stop alcohol and other social drugs.
• Reduce or stop caffeine intake.
• Review current medications with your GP.
• Follow a healthy diet.
• Avoid being overweight.
• Take folic acid for 3 months before conception.
• Have a good exercise routine.
• Ensure rubella immunity.
• Have a regular breast check and Pap smear.
• Eat freshly cooked and prepared food.
• Consider genetic and family history.
• Consider health insurance cover.

Front 11

The inital visit

Back 11

book them into an antenaal outpatient department

- must make a estimated due date US helps

Front 12

History

Back 12

• Confi rm the pregnancy by the menstrual history and
by urine or serum human chorionic gonadotrophin
(HCG), if necessary.
• Previous obstetric history:
— gestation, length of labour, mode of delivery,
birthweight of each baby
— consider previous problems: fetal or neonatal
abnormalities or deaths; pre-term or growthretarded
infants
— abortions: determine if there has been any
termination of pregnancies or fi rst or second
trimester spontaneous abortions
• Medical history:
— check for past evidence of diabetes, tuberculosis,
anaemia, rubella, rheumatic fever, heart or kidney
disease, jaundice, depression, transfusions and
rhesus status
• Family history:
— features to consider are multiple pregnancies,
hypertension and diabetes
— if any of these pertain to fi rst-degree relatives,
consider a glucose screening or tolerance test
• Psychosocial history:
— this is very important and includes an assessment
of the emotional attitude
• Drug history:
— includes intake of nicotine, alcohol, aspirin, illicit
drugs, OTC drugs and prescribed drugs

Front 13

vaginal bleeding

Back 13

if Rh negative, send blood
sample for Rh antibodies—if absent, give one
ampoule anti-D gammaglobulin within 72 hours of
fi rst bleed

Front 14

if maternal age >37 years

Back 14

consider fi rst trimester
combined screening test and feasibility of
amniocentesis or chorionic villus sampling or other
relevant tests (Down syndrome)

Front 15

Examination

Back 15

• general fi tness, colour (?anaemia)
• basic parameters: height, weight, blood pressure,
pulse, urinalysis (protein and glucose). A woman is
hypertensive if the systolic BP ≥140 mmHg and/or
diastolic BP is ≥90 mmHg3
• head and neck: teeth, gums, thyroid
• chest: including breasts/nipples
• abdomen: palpate for uterine size and listen to fetal
heart (if indicated)
Perform the four classic techniques of palpation
(applies to later visits):
1 Fundal palpation
2 Lateral abdominal palpation
3 Pawlik palpation
4 Deep pelvic palpation
• legs: note oedema or varicose veins

Speculum examination: perform a Pap smear and
swab (if indicated by abnormal vaginal discharge).
Pelvic examination (optional): confi rm uterus size
and period of gestation by bimanual palpation

Front 16

Antenatal screening

Back 16

Debate continues
about screening for syphilis, group B Streptococcus in
late pregnancy, thyroid function, hepatitis B and C and
ultrasound.

Front 17

1st trimester combined screening test

Back 17

• Serology tests (9–13 weeks, 10 is ideal):
— Free β-HCG
— PAPP-A
• Nuchal translucency ultrasound (12–13 weeks)

Front 18

Estimating due date

Back 18

from the first day of the last menstrual period

subtract 3 from the month and add 7 to the days

Front 19

Visits during pregnancy

Back 19

average number is 12, being reviewed to 6

A common routine schedule
• Initial in fi rst trimester: 8–10 weeks
• Up to 28 weeks: every 4–6 weeks
• Up to 36 weeks: every 2 weeks
• 36 weeks–delivery: weekly

A systematic review of seven RCTs found no
difference in the detection of pre-eclampsia, urinary tract infection, low birthweight or maternal mortality when a schedule of reduced antenatal visits was compared with the traditional routine.

Front 20

Things to record for each visit

Back 20

• weight gain
• blood pressure
• urinalysis (protein and sugar)—see Table 101.2
• uterine size/fundal height
• fetal heart (usually audible with stethoscope at
25 weeks and defi nitely by 28 weeks): detected by
Sonicaid (or similar) from 18–20 weeks3
• fetal movements (if present)
• presentation and position of fetus (third trimester)
• presence of any oedema

Front 21

Record day of fi rst fetal movements (i.e. ‘quickening’)
(ask patient to write down the dates):

Back 21

• primigravida: 17–20 weeks (primigravida first birth-multi is 2nd or more)
• multigravida: 16–18 weeks

Front 22

Fundal Height

Back 22

The uterus is a pelvic organ until the
twelfth week of pregnancy. After this time it can be
palpated abdominally. At about 20–22 weeks it has
reached the level of the umbilicus and reaches the
xiphisternum between 36 and 40 weeks. Palpation of
the fundal height is affected by obesity and tenseness
of the abdominal wall.

Front 23

Routine Ix

Back 23

Front 24

Causes of proteinuria in pregnancy

Back 24

Urinary tract infection
Contamination from vaginal discharge
Pre-eclampsia toxaemia
Underlying chronic kidney disease

Front 25

Nutrition Advice

Back 25

1 Eat most:
• fruit and vegetables (at least 4 serves)
• cereals and bread (4–6 serves)
2 Eat moderately:
• dairy products—3 cups (600 mL) of milk or
equivalent in yoghurt or cheese

• lean meat, poultry or fish—1 or 2 serves (at least 2 serves of red meat per week)
3 Eat least:
• sugar and refi ned carbohydrates (e.g. sweets, cakes,
biscuits, soft drinks)
• polyunsaturated margarine, butter, oil and cream

Front 26

Weight gain in prgnancy

Back 26

12kg

Front 27

Drugs in pregnancy

Back 27

avoid all even ideally caffeine

avoid passive smoking

smoking cessation programs are effective in imporveing irth outcomes

but can have 1 cup of coffee or 2 teas

Front 28

Breastfeeding

Back 28

encourgared

Front 29

Activities durign pregnangcy

Back 29

Mothers should be reassured that pregnancy is a
normal event in the life cycle and that normal activities
should be continued. Housework and other activities
should be performed to just short of getting tired

Front 30

Sex in pregnancy

Back 30

Coitus should be encouraged during pregnancy but
with appropriate care, especially in the 4 weeks before
delivery. Restriction would only seem necessary if there
has been an adverse obstetric history and there are major
complications in the current pregnancy.

Positions: posterior entry and the female in superior positions are suitable

Front 31

Travel

Back 31

avoid standing in trains

avoid air travel after 28 weeks and its not permitted after 36 weeks

Front 32

Fetal movement chart

Back 32

If daily fetal movements exceed 10 and the regular
pattern has not changed signifi cantly, then usually the
fetus is at no risk. However, if the movements drop to
fewer than 10 per day, the patient should be referred
to hospital for fetal monitoring

Front 33

Possible exposure to rubella

Back 33

When contact with a possible case of rubella occurs
during pregnancy it is essential to establish the immune
status of the patient. If she is already immune no further
action is necessary. If her immune status is unknown,
perform a rubella IgG titre and IgM and repeat the IgG
and IgM titres in 2–3 weeks.

Front 34

Vaginal bleeding in early pregnancy

Back 34

common 10% of all pregnancies

BUT 15% do miscarry

- gotta make sure its not an ectopic and or a threatened misccarriage

Front 35

Vaginal bleeding < 6 weeks

Back 35

• <6 weeks: Do serial quantitative HCG levels, which should double every 2 days (ultrasound usually unhelpful). If rise is too slow it means a non-viable pregnancy (?in tube or uterus). If HCG >1500 IU/L transvaginal ultrasound is used to show gestational sac.

Front 36

Vaginal bleeding 6-8 weeks

Back 36

Ultrasound will defi ne an intra-uterine
pregnancy by excluding an ectopic.

Front 37

Vaginal bleeding >8 weeks

Back 37

Normal ultrasound reassuring since miscarriage rate is only 3%.

Front 38

Vaginal bleeding 18-24 weeks

Back 38

A small bleed between 18–24 weeks indicates
cervical ‘weakness’ and warrants a speculum or vaginal examination plus fetal assessment

Front 39

Morning sickness

Back 39

occurs in >50%

almost always disappears by end of 1st trimester

mild cases reassure and avoid drugs

Front 40

Morning sickness NON-PHARM

Back 40

— small, frequent meals
— a fi zzy soft drink, especially ginger drinks, may help
— avoid stimuli such as cooking smells
— take care with teeth cleaning
— avoid oral iron

Front 41

Medication for morning sickness

Back 41

— pyridoxine 50–100 mg bd
— if still ineffective add metoclopramide 10 mg tds

Front 42

Hyperemesis gravidarum

Back 42

This is severe vomiting in pregnancy, which may result
in severe fl uid and electrolyte depletion.
Associations
• Normal complication
• Hydatidiform mole
• Multiple pregnancy
• Urinary infection

Front 43

Mx of Hyperemesis

Back 43

• Test urine—MCU (micro-culture of urine); ketones: if
+ve, admit to hospital
• Ultrasound examination
• Test electrolytes, urea, LFTs
• Bed rest
• Nil orally
• Fluid and electrolyte replacement
• Pyridoxine 50–100 mg daily IV/oral
• Metoclopramide 10 mg IV → 10 mg (o) tds (if
necessary)
• Return to oral intake

Front 44

Heartburn

Back 44

Non-pharmacological treatment such as frequent small meals, avoidance of bending over and elevation of the head of the bed are the mainstays of treatment.
Smoking, alcohol and caffeine (coffee, chocolate, tea) intake should be avoided. Regular use of antacids is effective (e.g. alginate/antacid liquid—Gaviscon, Mylanta Plus—10–20 mL) before meals and at bedtime.
H2-receptor antagonists may be necessary.

Front 45

Cramps

Back 45

Pregnant women are more prone to cramp. If it develops
they should be advised simply to place a pillow at the foot
of the bed so that plantar fl exion of the feet is avoided
during sleep. Prolonged plantar fl exion is the basis of
the cramps. Quinine, including tonic water, should be
avoided. There is no evidence that calcium supplements
help cramps during pregnancy.

Front 46

Varicose veins

Back 46

These can be troublesome as well as embarrassing. Wearing special supportive pantyhose (not elastic bandages) is the most comfortable and practical way to cope, in addition to adequate rest

Front 47

Haemorrhoids

Back 47

Haemorrhoids in the later stages of pregnancy can
be very troublesome. Emphasising the importance of
a high-fi bre diet to ensure regular bowel habit is the
best management. Painful haemorrhoids may be eased
by the application of packs soaked in warm saline or
perhaps haemorrhoidal ointments containing local
anaesthetic.

Front 48

Dental Hygiene

Back 48

Dental problems can worsen during pregnancy so
special care of teeth and gums, including a visit to the
dentist, is appropriate. Continuation of cleaning with
a softer brush is recommended.

Front 49

Back Pain

Back 49

Advice about lifting, sitting and resting
using a fi rm mattress, and avoiding high-heeled
shoes, will help

• First trimester: use normal physical therapy and advise exercises

• Second trimester: use supine side lying rotation and sitting techniques only; advise exercises.
• Third trimester: avoid physical therapy (if possible); encourage exercises.

Front 50

Guidelines to back pain Tx in pregnancy

Back 50

Guidelines for treatment
• Keep mobilisation and manipulation to a minimum.
• Use stretching and mobilisation in preference to
manipulation.
• Safeguard the SIJs in the last trimester.
• Encourage active exercises as much as possible.
• Avoid medications wherever possible.
• Give trigger point injections (5–8 mL 1% lignocaine)
around the SIJs if necessary.

Front 51

Exercise guidlines in pregnancy

Back 51

Advise the patient that walking is an excellent exercise.
For additional exercise activity:
• exercise at a mild to moderate level only
• avoid overheating and dehydration
• allow for a long warm-up before exercise and a long
cool-down
• choose low-impact or water exercise
• stop if there are adverse symptoms (e.g. any pain,
bleeding, faintness, undue distress)
• avoid scuba diving and sky diving

Front 52

Carpal tunnel syndrome

Back 52

Splinting of the hand and forearm at night might be
benefi cial. If desperate, an injection of corticosteroid
into the carpal tunnel can be very effective (check drug
category for risk relative to dates). Sometimes operative
division of the volar carpal ligament is necessary. Most
problems subside following delivery.

Front 53

Hypotension

Back 53

This is due to increased peripheral circulation and
venous pooling. If bleeding is eliminated, advise to
avoid standing suddenly and hot baths. It may cause
syncope. Fainting may occur when the woman lies
on her back in the latter half of pregnancy (supine
hypotension).

Front 54

Pruritus

Back 54

Generalised itching (pruritus gravidarum) is usually
associated with cholestasis due to oestrogen sensitivity
in the third trimester. Order LFTs and, if not serious,
reassure and prescribe a soothing skin preparation (e.g.
aqueous cream ± glycerol).

Front 55

Obesity

Back 55

Obesity is associated with increased obstetric morbidity,
including diffi cult labour and potential anaesthetic risks.
Encourage weight loss diet with the aid of a dietitian

Front 56

Breathlessness of pregnancy

Back 56

physiological breathlessness of pregnancy
in a woman with unexplained dyspnoea. It starts in
the second trimester, is constant and aggravated by
exercise and emotional stress. No special treatment is
needed or helpful. The breathlessness usually settles
6–8 weeks after delivery.

Front 57

Supplements in pregnancy

Back 57

iron, folic acid, B12, iodine, vit D

Front 58

Iron

Back 58

Iron is not routinely recommended for pregnant women
who are healthy, following an optimal diet and have a
normal blood test. Those at risk (e.g. with poor nutrition,
vegan diet) will require supplementation.

Front 59

Folic acid

Back 59

Folic acid is advised for all women contemplating
pregnancy, starting at least 1 month prior to conception
and continuing until 12 weeks after conception. Dose:
0.5 mg (o) daily.12 In those at risk (e.g. previous neural
tube defect and history of epilepsy), the dose is 5 mg
per day.15

Front 60

Vitamin B12

Back 60

Vitamin B12 is essential for the developing fetus and if
defi ciency is known or suspected (e.g. vegetarian/vegan
diet), test and give injections of B12 if defi cient.

Front 61

Iodine

Back 61

It is recommended, for pregnant and lactating women
and those planning a pregnancy, to increase iodine
intake by 100–200 mcg by using iodised salt for cooking
and a multivitamin that includes iodine.

Front 62

Vitamin D

Back 62

There may be a case for routine testing but it is advisable
to test women who are dark-skinned, veiled and at risk.16
If defi cient, aim to keep vitamin D levels >70 nmol/L
with cholecalciferol 1000–2000 IU daily.

Front 63

Advice on when to seek medical help

Back 63

• If contractions, unusual pain or bleeding occur before term
• If the baby is less active than usual
• If the membranes rupture (with fl uid loss)
• The onset of regular contractions 5–10 minutes apart