Antenatal care : Guidelines, reviews, statements, recommendations, standards

Obstetrics Simplified - Diaa M. EI-Mowafi

Antenatal Care

---

Objectives

• Prevention, early detection and treatment of pregnancy related complications as pre-eclampsia, eclampsia and haemorrhage.
• Prevention, early detection and treatment of medical disorders as anaemia and diabetes.
• Detection of malpresentations, malpositions and disproportion that may influence the decision of labour.
• Instruct the pregnant woman about hygiene, diet and warning symptoms.
• Laboratory studies of parameters may affect the foetus as blood group, Rh typing, toxoplasmosis and syphilis.

Frequency of antenatal visits

• Every month during the first 6 months.
• Every 2 weeks during the 7th and 8th months.
• Every week during the last month.
• More frequent visits are indicated in high risk pregnancy.

The first visit

• History.
• Examination: general, abdominal and local.
• Laboratory investigations:
  • Blood grouping.
  • Rh typing.
  • Haemoglobin.
  • Toxoplasma and / or VDRL if needed.
  • Urine analysis particularly for albumin and sugar.

Return visits

• History: ask the patient about any complaint.
• Examination:
  • Blood pressure.
  • Weight.
  • Oedema.
  • Abdominal examination.
• Investigation: urine for albumin and sugar.

INSTRUCTIONS TO THE PREGNANT WOMAN

Diet

The daily requirements are:

• Calories: 2500 Kcal.
• Proteins: 60 gm.
• Carbohydrates: 200- 400 gm.
• Lipids: should be restricted.
• Vitamins:
  • Vitamin A: 5000 IU.
  • Vitamin B1 (Thiamine): 1mg.
  • Vitamin B2 (Riboflavin): 1.5 mg.
  • Nicotinic acid: 15mg.
  • Ascorbic acid (vit. C): 50mg.
  • Vitamin D: 400 IU.
  • Folic acid: 0.5 mg.
• Minerals:
  • Iron: 15 mg.
  • Calcium: 1000 mg.

So the suggested daily diet should include:

• One litre of milk or its derivatives,
• 1-2 eggs,
• fresh vegetables and fruits.
• 2 pieces of red meat replaced once weekly by sea fish and once by calf ’s liver.
• Cereals and bread are recommended also.

Coffee and tea: should be restricted.

Smoking: should be avoided as it may cause intrauterine growth retardation or premature labour.

Rest and sleep: 2 hours in the midday and 8 hours at night.

Exercises: violent exercises as diving and water sports should be avoided. House work short of fatigue and walking are encouraged.

Clothing

• Lighter and looser clothes of non synthetic materials are more comfortable due to increased BMR and sweating.
• Clothes which hang from the shoulders are more comfortable than that requiring waste bands.
• Breast support is required.
• Avoid tight elastic hosiery or its bands.

Shoes: High - heeled shoes should be discouraged as they increase lumbar lordosis, back strain and risk of falling.

Bathing: Shower bathing is preferable than tube or sea bathing for fear of ascending infection. Vaginal douching should be avoided.

Teeth: Regular cleansing. Consult the dentist when needed.

Breasts: to reduce the incidence of retracted and/ or cracked nipples postpartum, the patient is instructed to massage them with a mixture of glycerine and alcohol during the last 6 weeks of pregnancy.

Bowels: Constipation is avoided by increasing vegetables, fluids and milk intake and mild exercise. Liquid paraffin should not be used for long period as it interferes with absorption of fat- soluble vitamins (A and D).

Coitus: Whenever abortion or preterm labour is a threat, coitus should be avoided. Otherwise, it is allowed with less frequency and violence. Some obstetricians advise abstinence in the last 4 weeks of pregnancy for fear of ascending infection.

Travelling: long and tiring journeys should be avoided particularly if the woman is prone to abortion or preterm labour. Flying is not contraindicated but not the long ones and near term.

Medications: not to be taken without obstetrician advice due to risk of teratogenicity

Exposure to infections: is to be avoided particularly those of documented teratogenicity e.g. rubella, cytomegalovirus, herpes hominis and varicella zoster viruses.

Exposure to irradiation: is to be avoided whether diagnostic or therapeutic.

The warning symptoms: which indicate immediate contact to the obstetrician are:

• vaginal bleeding,
• gush of fluid per vagina,
• abdominal pain,
• persistent headache,
• blurring of vision,
• oedema of lower limbs or face,
• persistent vomiting.

Immunisation

Nature of Vaccine	Name	Allowance
Live virus vaccines	Measles Mumps Rubella Poliomyelitis Yellow fever	Contraindicated. Contraindicated. Contraindicated. In risk of exposure only. Travel to endemic areas.
Inactivated virus vaccines	Influenza Rabies	Serious underlying disease. Same as non-pregnant.
Inactivated bacterial vaccines	Cholera Typhoid fever Plague Meningococcal meningitis	For international travels. Travel to endemic areas. Selective for exposed persons. Same as non-pregnant.
Toxoid	Tetanus Diphtheria	Same as non-pregnant.
Immune globulins	Rabies Tetanus Varicella Measles Hepatitis A Hepatitis B	Post-exposure prophylaxis. Post-exposure prophylaxis: give along with hepatitis B vaccine initially, then vaccine alone at 1 and 6 months.