These visits should begin early.

Women who are planning to conceive should also visit the pre-pregnancy (Pre- Conception) clinic.

Prenatal visits should be regular:

0-28 Weeks: Every 4 weeks

28-36 Weeks: Every 2 weeks.

after 36 weeks: weekly ,till delivery

B Medications:

Do not take any medications unless prescribed by your doctor/health care provider.

C Diet:

i) Eat a balanced diet with proteins , carbohydrates and vegetables.

ii) Take prenatal vitamins with iron and folic acid . Vitamin A should be avoided as retinol/ retinoic acid can cause human birth defects (Teratogen).

iii) Pregnant women should not diet to loose weight. They should expect to gain about 20-40 lb.

iv) Eat fresh foods and vegetables.

v) Avoid eating raw meat or fish. Fish suspected of having high levels of mercury should also be avoided.

vi) Reduction in caffeine intake (reduce to 1 cup of coffee, 1 cup of tea or 1 cup of caffeinated cola daily).

D) Birth Classes:

Pregnant women and their partners should be encouraged to join birth classes.

E) Rest and Activity:

Adequate rest must be taken every day.

Sternous physical activities/exercise should be avoided by pregnant women.

However mild to moderate exercises are recommended.

Heart rate should be kept to below 140 beats/ minute during exercise.

F) X-Rays and other Noxious Exposures:

Avoid all X-rays unless approved by your physician.

Always inform your physician, dentist and other health care provider that you are pregnant or you are planning to conceive.

Chemical and radiation hazards should be avoided (especially  for industrial workers)

Avoid excessive heat, like spending long time in hot water tubs.

Handling of cat feces shoud be avoided.

Gloves should be worn during gardening.

G) Alcohol:

Alcohol should be avoided in pregnancy as there is no safe limit for the level of alcohol intake. The baby can suffer from fetal alcohol syndrome which can result in permanent damage to the central nervous system of the baby.

Fetal alcohol syndrome is probably due to the direct toxic effect of ethanol and its metabolites such as acetaldehyde.

On examination of the baby ,the characteristic findings are low set ears, shortened palpebral fissures, hypoplasia of the mid face, a smooth philtrum ,thin upper lip, microcephaly, mental retardation and attention deficit disorder. Other abnormalities include skeletal and cardiac abnormalities.

Fetal alcohol syndrome will be covered extensively in another post.

H) Cigarette Smoking:

This topic will be covered extensively in a subsequent post. However a summary will be presented here.

Cigarette smoking results in fetal exposure to carbon monoxide and nicotine.

Premature delivery occurs more commonly among cigarette smokers (20% more frequently among smokers).

The birth weight of the fetuses of smoking mothers are on average 200g less than the fetal birth weight among non-smokers.

There is also a much higher risk of abruptio placentae, premature rupture of membranes and placenta previa (low lying placenta) among smoking mothers.

Passive smoking is equally dangerous to pregnant women and their fetuses as it is to any other human beings (and perhaps animals and pets).

Cigarette Smoking and pregnancy will be covered extensively in another post.

I) Illict Drugs and Pregnancy

Cocaine and amphetamines are common drugs that are taken by many women of child bearing age. It is difficult to manage and even anticipate due to the fact that most of them even deny the use of illict drugs.

Amphetamines and cocaine have powerful vasoconstrictive effects that can lead to numerous complications in pregnancy such as preterm delivery, placental abruption, sudden infant death syndrome (SIDS) ,intrauterine growth restriction, premature rupture of membranes and neurobehavoural deficits.

Opoids (eg Opium) can cause prematurity ,fetal death and intrauterine growth retardation.

Illict Drugs and pregnancy will be covered extensively in another post.

References:

Page 764 to 765 Chapter 18 Obstetrics CMDT 2006 -Current Medical Diagnosis and Treatment. Edited by Lawrence M. Tierney, Jr. ,Stephen J. McPhee, Maxine A. Papadakis 45th edition Lange Publications.Mc Graw Hill

]]> http://www.askdrshihaan.org/pregnancy/2008/11/advice-to-pregnant-women/feed/ 0 http://www.askdrshihaan.org/pregnancy/2008/11/tests-and-proceduresinvestigations-in-pregnancy-week-by-week/ http://www.askdrshihaan.org/pregnancy/2008/11/tests-and-proceduresinvestigations-in-pregnancy-week-by-week/#comments Sun, 23 Nov 2008 11:05:14 +0000 Dr Shihaan http://www.askdrshihaan.org/pregnancy/?p=189 In each visit

i) Weight

ii) Blood Pressure

iii) Fundal height

iv) Fetal heart rate

v) Urine for protein and glucose

Review any other problems/concerns the patient may have related to pregnancy or general well being, including nutrition.

6-12 Weeks

i) Confirmation of the uterine size and growth by pelvic examination.

ii) Doppler scan for fetal heart rate and tone, which is usually audible by doppler at 10-12 weeks of gestation.

iii) Transvaginal Chorionic Villus Sampling. The ideal time to do a transvaginal chorionic villus sampling (Only if indicated) is 10- 12 weeks.

Transvaginal chorionic villus sampling is used for screening of trisomy 18, 21 and cardiac defects.

The parameters used for screening include nuchal translucency via sonography, hcg and PAPP-A.

12- 18 Weeks

i) Genetic counseling: of women aged 35 years or older at delivery or for those with a family history of congenital anomalies.

Women who have had a previous child with a chromosomal abnormality , metabolic disease or neural tube defect should also be counseled.

ii) Amniocentesis: Can be performed as indicated (Usually after counseling for genetic abnormalities-see above) and requested by the patient.

12- 24 Weeks

i) Fetal ultrasound scan: The best time for a dating fetal ultrasound scan (To confirm the correct age of the fetus) is 18-20 weeksof gestation.

Ultrasound scan done around this time is also useful to evaluate fetal anatomy.

16-20 Weeks

i) Maternal serum alpha-fetoprotein test: This should be offered to all women to screen for neural tube defects. In some states of the USA this test is compulsory.

The serum alpha-fetoprotein measurement can be combined with the measurement of hcg and estriol (Called the triple screening test for fetal Down’s syndrome) or inhibin A (Quad screen test for Down’s) for the detection of fetal Down’s syndrome.

20-24 Weeks

i) Cervical length measurement by ultrasound: This is very important in women with a previous history of preterm labour .It should be measured from 18 weeks in women with a history of preterm labour (>2.5 cm is normal).

24 Weeks to Delivery

i) Perform ultrasound scan as indicated for fetal size and growth-usually evaluated when fundal height is 3cm less than or greater than expected for gestational age.

In diagnosed cases of multiple pregnancy ultrasound scanning should be performed every 4 weeks.

26- 28 Weeks:

i) Screening for gestational diabetes by a 50g glucose load (Glucola) followed by a 1-hour post-Glucola blood glucose determination.

If values of the 1-hour test ate abnormal, it should be followed up by 3-hour glucose tolerance test.

28 Weeks:

Repeat antibody testing for Rh-negative patients if the initial antibody screen is negative.

Please note that the result is not necessary before Rh (D) immune globulin is administered.

28-32 Weeks:

Repeat the complete blood count to evaluate for anemia of pregnancy.

28 Weeks to Delivery:

Determination of the fetal position and presentation. The patient should be questioned at each visit for the symptoms and signs of preterm labour or rupture of membranes.

Maternal perception of fetal movements should be assessed at each visit.

Other investigations such as CTG can be performed if indicated.

36 Weeks to Delivery:

i) Repeat syphilis test, HIV test, cervical cultures for N gonorrhoea and Chlamydia trachomatis in at-risk patients.

ii) Discuss with the patient the signs and symptoms of the onset of labour, pain management during labour and the management of labour and delivery.

iii) Fetal lung maturity tests for all elective cesarean sections.

iv) The CDC (Atlanta) has recommended universal prenatal culture based screening for group B streptococcal colonization in pregnancy.

a single standard culture of the vagina and anorectum should be collected at 35 to 37 weeks of gestation.

Prophylaxis should be given only if the cultures are positive.

In patients who have not done the screening, the risk factors for ascending infection are intrapartum temperatures greater than 38 degrees celsius or membrane rupture greater than 18 hours.

Recommended prophylaxis :

penicillin G, 5 million units intravenously as a loading dose followed by 2.5 million units intravenously every 4 hours until delivery.

Alternatively 2g of Cefazolin intravenously followed by 1g intravenously every 8 hours until delivery.

41 Weeks and Beyond:

Examination of the cervix to determine the probability of successful induction of labour. If the cervix is favourable (> or =50% effaced, cervix> or = 2cm,vertex at -1 station, soft cervix and midposition) ,induction of labour can be undertaken.

If unfavourable antepartum fetal testing is begun while preparing for a cesarean section delivery

Feel free to disclose confidential issues such as previous abortions, stillbirths, contraceptives etc.

A detailed history and a comprehensive examination will be done by the medical doctor or midwife.

The booking history briefly comprises of the following:

a) History of the Current Pregnancy:

It is important that a careful menstrual history be taken from a pregnant woman.

Are her menstrual cycles regular or irregular? If it is regular, what is the length of the normal cycle? The date of her last known menstrual period (LMP) should be ascertained. It should be stressed that we are always talking about the 1st day of the last menstrual period.

If the duration of the menstrual period or the quantity of the blood loss has been abnormal , effort should be made to identify the last normal period.It is also important to find out weather her last menstrual period was similar to a normal period. Sometimes women can mistaken a decidual bleeding for a normal menstruation.

Decidual bleeding or implantation bleeding is slight bleeding that takes place during implantation, which is actually 2-3 weeks after the LMP.

Calculation of the EDD (Expected Date of Delivery):

On average the pregnancy lasts for 40 weeks from the date of the last menstrual period.

The expected date of delivery(EDD) can easily be found by adding 9 months and 7 days to the last menstrual period( LMP).

b) History of Past Deliverie (Past Obstetric History)

This is an extremely important  aspect of the history taking during the booking visit. A summary should be made of all previous pregnancies (including stillbirths and abortions).

Pregnancies should be noted in chronological order from the first to the last.

The details of the pregnancy such as the year , place of confinement, antenatal history, duration of pregnancy, weather labour was induced or spontaneous, duration of labour, method of delivery, problems during delivery and in the puerperium. Other important details include the weight, sex, condition at birth and subsequent health and the method of feeding of the baby should be recorded.

The antenatal period is defined as the period between conception of the fetus and delivery.

What is antenatal Care?

Antenatal care is defined as specialized health care that should be received by all women who are pregnant. Antenatal care is generally provided in the form of clinics that are manned by doctors, midwives, nurses and other health care workers such as nutritionists etc.

Usually the mother suspects that she is pregnant when her regular menstrual flow fails to occur at the expected time. This leads to the anxious mother to confirm the presence of pregnancy shortly after a missed period.Some women wait for a longer time before confirming their pregnancy.

The utilization of antenatal care is now routine in most developed countries, unfortunately it is not so in most developing countries.

Factors that contribute to the lack/ under- utilization of antenatal care facilities in developing countries are:

i) Illiteracy

ii)Bad roads

iii)Poverty

iv)Limited medical institutions.

However there is a strong co-relation between the level of education of the woman and the degree of utilization of antenatal care. The more educated a woman is the greater the chances of utilization of antenatal care.

Is it necessary that a pregnant woman must be seen by a doctor during pregnancy or delivery?

No it is not necessary that all women should see a doctor during antenatal care or during delivery. Midwives can manage well on their own, including the delivery. Pregnancies managed by midwives even reduces interventions. They call in the doctor only when necessary.

What is Shared Antenatal Care?

In shared antenatal care a team provides the antenatal care, instead of a single doctor, or a midwife. The team which provides the antenatal care to a pregnant lady involves mainly the obstetrician, family practitioner and the midwife.

The most important reason why we should have shared antenatal care is to decongest the hospitals  and therefore allow hospital doctors to spend more time with women who have obstetric problems. This approach is also very convenient to the mother as she can continue her antenatal care at a local clinic closer to her house.For shared antenatal care to be effective there should be no communication barrier. The “Antenatal Card” or “Co-Operation card” is the main method of communication. This can be supplemented by letters, telephone calls,e-mails etc.

Aims/Objectives of Antenatal Care:

The main objective of antenatal care is to ensure a healthy mother and infant at the end of the pregnancy.

1) Health Education: The antenatal care can provide the right opportunity for health education. These health talks can cover topics such as physiological changes during pregnancy, nutrition, hygiene, care of the teeth, coitus, immunization, relaxation,travel and exercise after during pregnancy and after delivery. One can also use this opportunity to dispel any myths and fears about pregnancy.

2) Monitoring of fetal well being.

3) Screening to detect fetal abnormalities.

4) Detection and treatment of complications of pregnancy.

5) Detection of possible problems in labour ,before the labour commences.

How many times do I need to make antenatal visits during a pregnancy?

The total number of antenatal visits to be made by a pregnant lady varies. It depends on the risk factors (  Like previous history of stillbirth etc), the woman might have.

If the visits are made less frequently, it might be difficult to identify complications. If visits are made too frequently, it might increase the number of interventions.

For a pregnant lady with no risk factors, the following visits are recommended:

i) The booking (First visit) around 12 to 14 weeks of pregnancy, ideally in a hospital antenatal clinic.

ii) Every 4 weeks up to 28 weeks of pregnancy.

iii) Every 2 weeks up to 36 weeks

iv) At 36 weeks the woman should be assessed again in the hospital clinic by the obstetrician.

v) Until 40 weeks, she can be seen at again her local clinic, every week.

vi) At 40 weeks the woman should be seen again by the obstetrician in the hospital antenatal clinic.

What is the booking visit?

This is the first antenatal visit, and it should be comprehensive. Ideally a thorough history and examination should be done on every pregnant woman in the first visit. This is to identify any risk factors if present. It is also expected that if a translator is necessary for the history taking, he/she should not be a relative (Confidential issues).

The history, examination and the relevant investigations to be carried out during the booking visit, will be covered in another article.

References

i) Textbook of Obstetrics and Gynaecology for the Medical Student- Volume II -By Akin Agbola and Numerous contributors.

ii) Oxford Handbook of Clinical Specialties

iii) Essential Antenatal Care- A Guide for the Trainee