Antenatal Care

Last updated 26.09.12

   

Timing

Visits

 

Definition

-  Care provided to a pregnant women prior to labour

 

Features

-  Book in at hospital around 14/40

-  Usually requires referral letter to Maternity Ward

-  Objectives

-  Maintaining & improving health & general wellbeing, emphasising importance of a healthy diet, exercise & avoiding smoking, alcohol & illicit drugs

-  Educate regarding pregnancy & labour

-  Screen & manage maternal & fetal problems

-  Refer as appropriate

-  Models of Antenatal Care

-  Shared Care

-  Coperative arrangement between Obstetrician (GP or specialist) or hospital based Obs unit & midwife, GP, RFDS or AMS

-  Team Care

-  Coperative arrangement between Hospital midwives & specialist Obstetricians

-  Private Care

-  Private Obstetrician (GP or specialist) & private hospital midwives

-  OR Private Obstetrician (GP or specialist) with private hospital midwife & Hospital midwives

 

Timing Top

Antenatal Visits

 

Frequency of Visits

-  Varies according to parity, social circumstances, co-morbidities & complications of pregnancy

-  Pre-pregnancy

-  1st Antenatal appointment prior to 12/40

-  Traditional Model

-  Every 4 weeks from conception to 28/40

-  Every 2 weeks 28-36/40

-  Every week 36 wks to labour

-  Post partum F/U at 6/52 +/- 4/52

-  Primips with uncomplicated pregnancy 10 visits = adequate

-  Multips with uncomplicated pregnancy 7 visits = adequate

 

1st Antenatal Visit

-  Confirm pregnancy

-  Plan antenatal care

-  History

-  Age

-  Gravida & Parity

-  Menstrual Hx

-  S/S in current pregnancy

-  Obstetric Hx

-  Calculate dates: LMP or US

-  Gynae Hx

-  PMH

-  Epilepsy

-  Renal disease

-  Thyroid disease in pregnancy

-  DM in pregnancy

-  HTN in pregnancy

-  Assess VTE risk

-  PKU..

-  HIV: untreated = contraindicated to vaginal delivery

-  HSV: active lesions at time of labour = contraindicated to vaginal delivery

-  Family Hx: genetic disorders

-  Social Hx

-  Smoking, EtOH, Drugs

-  Support, partner, home

-  Meds, allergies

-  +/- Influenza vaccination

-  Examination

-  +/- Edinburgh Postnatal Depression Scale (EPDS) & Antenatal Risk Questionnaire (ANRQ): Depression, risk of PND

-  Weight, height: BMI

-  Obesity in Pregnancy

-  >30 consider specialist R/V

-  >35 consider anaesthetics R/V

-  Low BMI associated with low birth weight & IUGR

-  Low maternal weight gain in pregnancy associated with low birth weight, IUGR & preterm delivery

-  Excessive weight gain in pregnancy associated with macrosomia & DM (in later life)

-  Thyroid Exam

-  Breast Exam

-  Abdominal Exam

-  Prev Caesarean: VBAC vs repeat LUSCS

-  Gravid uterus: fundal height..

-  Masses

-  Pain/tenderness

-  Pelvic Exam

-  +/- Pap smear

-  +/- VE

-  Vitals

-  BP: hypertension in pregnancy

-  Urinalysis

-  Nitrites, Leukocytes: UTI, Asymptomatic bacteruria

-  Proteinuria: Pre-eclampsia

-  Glucose: DM, GDM

-  Antenatal Ix

 

Ongoing Visits

-  History

-  Fetal movements: RFM, FDIU

-  Contractions: Braxton Hicks, threatened preterm labour, labour

-  PV bleeding/discharge: APH, threatened M/C, ruptured membranes

-  Discussion re post partum contraception

-  Examination

-  Fundal height

-  At every visit after 12/40

-  SGA/IUGR, LGA, ruptured membranes

-  Lie, presentation, engagement: breech, cephalic, transverse

-  Fetal heart from around 16-20/40

-  BP

-  At every visit

-  PIH, Pre-eclampsia

-  Investigations

-  +/- Urine Dipstick: Pre-eclampsia, GDM, UTI

-  +/- F/U on antenatal investigations as appropriate

 

 

Referral Top

Indications for Referral from GP Obstetrician to Specialist Obstetrician

 

-  Preterm delivery <35/40

-  PPROM <34/40

-  Cervical incompetence

-  Multiple pregnancy (twins..)

-  Placenta praevia

-  Placental abruption

-  Blood group antibodies

-  Isoimmunisation

-  Platelet Iso-immunisation (NAIT)

-  Trophoblastic disease

-  Fetal abnormality

-  Eclampsia

-  IUGR <3rd centile

-  Perinatal death

-  Oligohydramnios

-  Polyhydramnios

-  APH

-  Maternal cardiac disease

-  Maternal pulmonary hypertension

-  Maternal Hx of VTE (DVT, PE)

-  Maternal Prolactinoma

-  Pre-exisiting DM: Type 1 or Type 2

-  Oesophageal varicosies

-  Marfans syndrome

-  Coagulopathy (thrombocytopaenia, Von Willebrands..)

-  Thrombophillia

-  Infection with Rubella, Varicella, CMV, Parvovirus, HIV, Hep A/B/C/D/E, Syphilus, TB, Listeriosis, Toxoplasmosis, Malaria

-  Stroke, TIA, AV malformation

-  Epilepsy

-  MS, Myasthenia, cord lesions, muscular dystrophy

-  EtOH or drug dependance

-  Psychiatric condition on medication or unstable

-  Glomerulonephritis, pyelonephritis, renal failure or renal abnormality

-  Connective tissue disease (SLE, RA, PAN, scleroderma..)

 

 

 

 

References

 

RANZCOG: C-Obs 30, Suitability Criteria for Models of Care & Indications for Referral within & between Models of Care, March 2009