Antenatal care

Pre conception counselling

Smoking

Alcohol

Drugs

Diet

Exercise

Folic acid

Pre conception counseling

Family history

Personal history

Past obstetric history

Folic acid

Rubella status

First visit

LMP EDD

POH

MH

PMH

Drugs

Allergies

First visit

Smoking

Alcohol

FH

Advise

Exemption card

Referral

Low risk pregnancies 12-14/52 hosp visit

Routine blood testsBlood group + rhesus factorFbc + haemoglobinopathies if indicatedRandon blood sugarTreponemal antibodyHep bHiv pappa

Low risk pregnancies

Hosp visit 12-14/52

History

Nuchal transluceny scan

Low risk pregnancy

15 weeks

Serum AFP and downs screening

If booking scan not done before 14 weeks

Low risk pregnancy

23 weeks – anomally scan 26 weeks – midwife/gp 28 weeks – fbc + antibodies 30 weeks – midwife/gp 34/36/38/40 weeks – midwife/gp 41 weeks - hosp

Exercise

Non – contact sport only after 16/52

Intensity decreased by 25%

HR under 140/min

Core temp < 38

Strenuous exercise limited to 15-20 mins

Antenatal visits

Weight gain 12-15kg in total BP dias. >90 or increase > 20 from first visit is

significant Urinalysis watch for protein glucose uti Fetal movements Uterine size Fetal lie presentation

Common discomforts

Pelvic pains – ligamental stretch

Urinary frequency - ? Uti

Ankle swelling – ivc compression

Varicosities – support stockings

Heartburn – posture antacids

Constipation – fluids, fibre, fybogel

Common discomforts

Low back pain – posture and relaxin

Dental decay – see dentist

Skin changes – chloasma

Itch – iron def, cholestasis antihistamines

Stretach marks - moisturisers

First trimester

Ectopic preg

Sharp pain

Irregular vaginal bleeding

Abdo tenderness

Dizziness or fainting

Ectopic pregnancy

Diagnosis

Pos preg test

Serial hcg levels they increase more slowly

Progesterone level lower than normal

Ultra sound scan vaginally/abdominally

Ectopic pregnancy risk factors

PID Previous tubal preg or tubal surgery Endometriosis IUD Multiple induced abortions Drugs that stimulate ovulation

Ectopic pregnancy treatment

Tube not ruptured

Methotrexate

Salpinostomy flushng the tube out

Laparoscopic removal

Ectopic pregnancy treatment

Tube ruptured

Laparoscopic removal of embryo and tube

Miscarriage

Symptoms

Pv bleeding

Colicky pain

Refer to EPAU

hyperemesis

1 in 300 preg

Weeks 8-20

Cause unknown – high oestrogen & hcg

More commom multiple preg obesity first babies

Treatment

Exclude other causes Drink small amounts frequently Diet high in cho and proteins Admit for iv fluids if severe, dehydrated or

electrolyte imbalance Drugs -

Anaemia

Symptoms

Fatigue weakness

Pallor

Dizziness or fainting

SOB

palpitations

Anaemia

Treatment

Diet

Pregaday

Does not alter outcome in most cases

Infection in pregnancy

Chicken pox – only 2% of infections age > 20yrs 3% risk of fetal damage in first 20/52

If mum’s rash develops 1/52 before delivery or to 4/52 after

baby can get sever infection needs protection

No risk between 20/52 and term

If no history of cp check varicella antibodies

If non immune needs VZ Ig no later than 10 days from exposure

Infections in pregmnancy

Rubella – 2-10/52 90% chance of featal damage Toxoplasma gondii 89% adults not immune If fetus infected 10% chance of fetal damage Avoid kittens particularly litter trays Eat well cooked meat Wash vegetables Listeria – soft cheeses, pate. Cookchill foods

Pre eclampsia

Raised BP

Proteinura

XS swelling

Pre eclampsia

3-4% pregnancies

!% very severe

50,000 deaths world wide

Pre eclampsia Risk factors

Young mothers teenagersOlder mothers > 35 yrsFamily historyFirst pregnancyNew fatherDiabeteshypertension

Pre eclampsia

Serious adverse effectsFitsStrokePulmonary oedemaKidney failureLiver damageD I C

Pre eclampsia Warning signs

Raised bpProteinuriaXs swellingHeadcaheFlashing lightsVomiting Upper abdo pain

Pre eclampsia

TreatmentLower bpMagnesium sulphateDeliver babyAspirinMetabolic syndrome

Gestational diabetes

Plenty of insulin, but insulin malfunctioning Macrosomia > 4500g Problems with labour and delivery Newborn has low blood sugar Increased risk stillbirth Proper management prevents increased risk

ofcomplications

Risk factors

Incidence 1%-3% pregnancies Family history Obesity Maternal age > 30 yrs Previous large baby Prior icidence of gestational diabetes Ethnic group – south asians, mexican american

Treatment

Control blood sugar

Exercise

Diet

Blood glucose monitoring

A few will need insulin

Intra uterine growth retardation

Birth weigth < 2500g

Causes

Smoking

Poor nutrition

Placental factors

Maternal ill health

Risk factors

Smoking Drug and alcohol use Severe malnutrition Maternal high bp, or pre eclampsia Infections – cmv, rubella, toxoplasma Chronic maternal disease – diabetes,

rheumatological

Diagnosis

Fundal height – 18-34/52 height = distance in cm

Ultra sound – ratio of head circumference to abdo

Treatment

Stop smoking

Good nutrition

Bed rest on left side

Fetal movement chart

Serial ultrasound scans

Volume of amniotic fluid

Hydatidiform mole

Incidence 1 in 2000 preg

Increased risk with age

Abnormalities in sperm chromosome

Abnormalities of egg

Hydatidiform mole

Signs

Uterus larger than date

Vaginal bleeding

Diagnosis

Ultrasound

Hcg higher than normal

Hydatidiform mole

Treatment

Suction curettage

Monitor hcg for several months due to risk of choriocarcinoma

Postpone preg for a year

APH

Placenta abruptio

1% of all deliveries

Vaginal bleeding in 3rd trimestre

Constant back or abdo pain

Contractions tenderness or rigidity of uterus

Risk factors

Smoking Pergnancy induced hypertension Alcohol or drug use Increased maternal age >40 yrs Premature rupture of membranes Injury to mother

Diagnosis

No clear test

May or may not show on ultrasound

Exclusion of other causes of bleeding – placenta

praevia

Treatment

Evaluate maternal well being

Monitor

Evaluate fetal well being

If severe bleeding or fetal distress cesarean

Placenta previa

4-8% placentas low lying Only 10% remain low Marginal – placenta near edge of os Partial – placenta covers cervical opening Total – placent completely covers os All need cesarean

Placenta previa

SignsPainless bright red vaginal bleeding

Risk factorsSmokingFirst preg after lscsPrevious placenta previaAdvanced maternal age

Placenta previa

Diagnosis

Ultrasound

Treatment

lscs

Post term pregnancy

> 42/52 Risks

Reduced amniotic fluid increased risk of cord compression

Meconium in liquor inhlaed by baby causing pneumonia

Too large baby > 4500g

Management

Monitor babyToo large baby

Decreased amniotic fluid

Deliver if cervix ripe try oxytocinon

If cervix not ripe try prostaglandin gel

Otherwise lscs

Pre term labour

Labour before end of 36th week preg

Low birth weight < 2500g

8-12% of all pregnancies

Signs and symptoms

Regular uterine contractions for more than 1 hr

Backache

Intestinal cramping with or without diarrhoea

Spotting or blood tinged discharge

Thin cervix, dilation beyond 1 cm, contractions

Risk factors

Smoking alcohol drugs Previous pre term delivery 3 or more 1st trimestre miscarriages Cervical incompetence Placenta previa Serious maternal infection Low maternal weight < 45 kg

Postnatal care

Maternal Lochia xs bleeding = pph admit Breasts – engorgement lasts 2-3 days mild temp

fell fluey Nipple pain- camomile creams daktarin if

candidal Mastitis – empty breast flucloxacillin

Postnatal care

Blood pressure

Fundal height

Perineum

Symptoms of depression

Contraceptive advice

Postnatal care

FetalMethod of delivery

Length of gestation

Weight

Feeding

concerns

Postnatal care

Fetal examinationFontanelles Eyes- cataractSclera – jaundiceHsLungsAbdo - masses

Postnatal care

Fetal exam

Genitalia

Hips

Femoral pulses

Spine

Birth marks

6 week exam Maternal

Feeding DepressionLochiaContracptionBpAbdo examSmear if due

6 week exam

FetalAccording to chs schedule