Prenatal care By

Connie Sussan Austen.

What is pre-natal care. Prenatal care is defined as the care given to a woman during her stages of pregnancy, to monitor the mother and her fetus. Largely social reformers and nurses introduced and organized prenatal care in the United States.

Whitridge Williams reviewed 10,000 consecutive deliveries at Johns Hopkins Hospital and concluded that 40 percent of 705 perinatal deaths could have been prevented by prenatal care. In 1954, Nicholas J. Eastman credited organized prenatal care with having “done more to save mothers’ lives in our time than any other single factor” (Speert, 1980).

Historically, the first focus of prenatal care was to improve maternal safety. The accepted plan of visits, consisting of monthly visits in early pregnancy, becoming more frequent in the mid trimester, then weekly in the last month, was an attempt to detect the most common serious illness of women in pregnancy – pre-eclampsia.

Epidemiologic studies support the benefit of this approach, as they appear to demonstrate lower maternal and perinatal mortality for women who receive prenatal care (Greenberg, 1983).

Prenatal care is a comprehensive program which consist from: (1) Preconceptional care.

(2) Prompt diagnosis of pregnancy.

(3) Initial prenatal evaluation.

Preconcepttional care: Because health during pregnancy depends on health before pregnancy, preconceptional care should logically be an integral prelude to prenatal care.

Comprehensive preconceptional care program has the potential to assist women by reducing risks, promoting healthy lifestyles, and improving readiness for pregnancny.

Prompt diagnosis of pregnancy:

The diagnosis of pregnancy usually begins when a woman presents with symptoms, and possibly a positive home urine pregnancy test result.

Clinical findings and symptoms may indicate an early pregnancy:

The abrupt cessation of menstruation in a healthy reproductive-aged woman who previously has experienced spontaneous, cyclical, predictable menses is highly suggestive of pregnancy. Amenorrhea is not a reliable indication of pregnancy until 10 days or more after expected

menses onset. When a second menstrual period is missed, the probability of pregnancy is much greater. Uterine bleeding somewhat suggestive of menstruation occurs occasionally after conception.

Nausea and vomiting. Nausea occurs in 80% of nulliparous and 60% of multiparous women. For many pregnant women this is the first sign of pregnancy with the symptoms occurring even before the first period is missed.

The nausea and vomiting usually disappears by 16 weeks gestation and lessens in severity after about 12 weeks.

Change in cervical mucus: Dried cervical mucus examined microscopically has characteristic patterns dependent on the stage of the ovarian cycle and the presence or absence of pregnancy. Mucus crystallization necessary for the production of the fern pattern is dependent on an increased sodium chloride concentration. Cervical mucus is relatively rich in sodium chloride when estrogen, but not progesterone, is being produced. Thus, from approximately the 7th to the 18th day of the cycle, a fern like pattern is seen.

Anatomical changes in the breasts that ac- company pregnancy are characteristic during a first pregnancy

Change in uterus size: During the first few weeks of pregnancy, the increase in uterine size is limited principally to the antero-posterior diameter. By 12 weeks, the body of the uterus is almost globular with an average diameter of 8 cm. At 6 to 8 weeks menstrual age, a firm cervix is felt which contrasts with the now softer fundus and compressible interposed softened isthmus—the Hegar sign. The softening at the isthmus may be so marked that the cervix and the body of the uterus seem to be separate organs.

Pregnancy test.

Measument of HCG:

Detection of hCG in maternal blood and urine provides the basis for endocrine tests of pregnancy.

Human chorionic gonadotropin (hCG) is a glycoprotein hormone that contains two carbohydrate side chains: alpha (a) and beta (b). The a subunit is identical to that of follicle stimulating hormone (FSH), luteinizing hormone (LH) and thyrotrophin (TSH). The b subunit is immunologically specific. HCG is secreted by the trophoblast cells of the fertilized ovum and later by

the definitive placenta.

Trophoblast cells produce hCG in amounts that increase exponentially following implantation. With a sensitive test, the hormone can be detected in maternal plasma or urine by 8 to 9 days after ovulation.

False-positive hCG test results are rare (Braunstein, 2002). A few women have circulating serum factors that may interact with the hCG antibody.

Home pregnancy test:

This is a test done at home where the woman urinates on a pregnancy kit strip. Two main sorts are available: a double band of blue or a central spot of pink indicates a positive test while a single band of blue or absence of a pink spot indicates a negative pregnancy test.

Bastian and colleagues (1998) evaluated studies of home pregnancy test kits and found that testing done by volunteers achieved a mean 91-percent sensitivity. Importantly, actual patients obtained only 75-percent sensitivity and a high false-negative result rate.

Initial prenatal evaluation:

Prenatal care should be initiated as soon as there is a reasonable likelihood of pregnancy.

The major goals are to:

Define the health status of the mother and fetus.

Estimate the gestational age.

Initiate a plan for continuing obstetrical care.

The three basic components of prenatal care are:

(1) Early and continuing risk assessment. To reduce the risk of pregnancy complications.

Following a healthy, safe diet; getting regular exercise as advised by a health care provider; and avoiding exposure to potentially harmful substances such as lead and radiation can help reduce the risk for problems during pregnancy and ensure the infant's health and development. Controlling existing conditions, such as high blood pressure and diabetes, is important to avoid serious complications in pregnancy such as preeclampsia.

Reduce the infant's risk for complications. Tobacco smoke and alcohol use during pregnancy have been shown to increase the risk for Sudden Infant Death Syndrome, alcohol use also increases the risk for fetal alcohol spectrum disorders, which can cause a variety of problems such as abnormal facial features, having a small head, poor coordination, poor memory, intellectual disability, and problems with the heart, kidneys, or bones. According to one recent study supported by the NIH, these and other long-term problems can occur even with low levels of prenatal alcohol exposure.

(2) Health promotion.

Health promotion consists of providing Information on proposed care, enhancing general knowledge of pregnancy and parenting, and promoting and supporting healthful behaviors.

(3) Medical and psychosocial interventions and

follow-up. Help ensure the medications women take are safe. Certain medications, including some acne treatments and dietary and herbal supplements, are not safe to take during pregnancy. For example The acne medicine isotretinoin (such as Amnesteem and Claravis). This medicine is very likely to cause birth defects also some antibiotics, such as doxycycline and tetracycline.

Prenatal check up. During pregnancy, regular checkups are very important. Typically, routine checkups occur:

• Once each month for weeks four through 28 • Twice a month for weeks 28 through 36 • Weekly for weeks 36 to birth This consistent care can help keep the mother and baby healthy, spot problems if they occur, and prevent problems during delivery. Women with high-risk pregnancies need to see their doctors more often. The Frist Prenatal Visit:

Provides the opportunity to:

• Obtain general medical history and reproductive history.

Review outcome of previous pregnancies and assess pregnancy risk. Obtain previous records if any abnormal outcome.

Perform genetic history, screening for inherited illness and malformations.

Such reproductive histories as preterm birth, low birth weight, preeclampsia, stillbirth, congenital anomalies, and gestational diabetes are important to obtain because of the substantial risk for recurrence.

Women with prior cesarean delivery should be asked about the circumstances of the delivery, and discussion about options for the mode of delivery for the current pregnancy should be initiated.

• Conduct physical examination.

Clinicians should be familiar with physical findings associated with normal pregnancy, such as systolic murmurs, exaggerated splitting, and S3 during cardiac auscultation, or spider angiomas, palmar erythema, linea nigra, and striae gravidarum on inspection of the skin. During the breast examination, clinicians should initiate discussion about breastfeeding.

A pelvic examination should be performed and Pap smear status documented or obtained, to rule out infections like chlamydia, syphilis Gonorrhea and Bacteria Vaginitis.

Follow up visits:

At each return visit, steps are taken to determine the well-being of mother and fetus. Certain information is considered especially important for example assessment of gestational age and accurate measurement of blood pressure.

Evaluation typically includes:

Fetal

• Heart rate(s)

The fetal heart can first be heard in most women between 16 and 19 weeks when carefully auscultated with a standard nonamplified stethoscope. By 21 weeks, audible fetal heart sounds were present in 95 percent, and by 22 weeks they were heard in all. The fetal heart rate now ranges from 110 to 160 bpm.

• Size.

To monitor the growth of the baby.

• Amount of amnionic fluid

The amount of amniotic fluid increases until the beginning of the third trimester. At the peak of 34 to 36 weeks, may carry about a quart of amniotic fluid. After that, it gradually decreases until birth.

Low levels of amniotic fluid can make complications during labor more likely. The main concern is that the fluid level will get so low that the baby's movements or contractions will compress the umbilical cord.

• Fetal movements

Fetal movement should be felt 6-10times in two hours.

Maternal

• Blood pressure.

High blood pressure during pregnancy is defined as a reading of 140/90 or higher, even if just one of the numbers is elevated. Severe chronic hypertension is 160/110 or higher.

• Weight.

Monitoring of weight gain can is believed to prevent gestational hypertension and fetal macrosomia. There is irrefutable evidence that maternal weight gain during pregnancy influences birthweight.

• Symptoms—including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, and dysuria

• Height in centimeters of uterine fundus from pubic symphysis .

Between 20 and 34 weeks, the height of the uterine fundus measured in centimeters correlates closely with gestational age in weeks. The fundal height should be measured as the distance over the abdominal wall from the top of the symphysis pubis to the top of the fundus.

• Vaginal examination late in pregnancy to monitor the,

Clinical estimation of the pelvic capacity and its general configuration. Also check for Consistency, effacement, and dilatation of the cervix this is mostly done from 37-40wks.

Pregnancy interventions and continuous test.

• Frist trimester screen

A screening test done at 11 to 14 weeks to detect higher risk of:

Chromosomal disorders, including Down syndrome and trisomy 18. It also can reveal multiple births.

• Provide indicated genetic carrier testing, e.g. Tay-

Sachs Disease, Sickle cell disease, hemoglobinopathies.

Screen for STDs, including HIV, and counsel about prevention strategies. HIV is a virus the attacks the CD4 cells in the body and can lead to AIDS. Is a mother is infected with HIV and not taking her anti-retroviral there is high chance of passing it to the baby, it can be passed through genital fluid and breast milk in this case. This medications are mostly prescribed at the second trimester. After birth for 6weeks the baby will still be given medications for preventive measures.

• Test urine for protein and glucose at each visit to rule out diabetes, kidney damage and Pre-eclampsia.

Ketone in the urine is due to decrease in amount of carbohydrate so the body starts breaking down fat

to store as energy.

• Test for triple marker (alpha fetoprotein, BHCG, estriol) at 15–17 weeks to screen for Down’s syndrome and neural tube defects.

• Perform mid-trimester genetic amniocentesis for women over age 35 and others at increased risk.

This test can diagnosis certain birth defects, including:

Down syndrome: is the most frequent genetic cause for mild to moderate mental retardation and related medical problems. It is caused by a chromosomal abnormality. For an unknown reason, a change in cell growth results in 47 instead of the usual 46 chromosomes. This extra chromosome changes the orderly development of the body and brain.

Cystic fibrosis: one of the most common serious genetic (inherited) diseases. One out of every 400 couples is at risk for having children with CF. CF causes the body to make abnormal secretions leading to mucous build-up. CF mucous build-up can impair organs such as the pancreas, the intestine and the lungs

Spinal bifida: is the most common of all birth

defects. Its name means clef spine, or a failure of a fetal spine to close the right way when it is developing before birth. It occurs very early in pregnancy, roughly three to four weeks after conception, before most women know that they are pregnant. Any woman can have an affected pregnancy. Most women who bear a child with Spinal bifida have no family history of it.

This test is performed at 14 to 20 weeks. It may be suggested for couples at higher risk for genetic disorders. It also provides DNA for paternity testing.

• Perform ultrasound exam at 18–20 weeks to screen for other anomalies.

Reasons for ultrasound :

Check for multiple fetus. In this situation, ultrasonography is invaluable in determining the number of fetuses, the chorionicity, fetal presentations, evidence of growth retardation and fetal anomaly, the presence of placenta previa, and any suggestion of twin-to-twin transfusion.

Diagnosis and confirmation of early pregnancy.

The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus.

Asses possible risk of miscarriage, ectopic

pregnancy

Placental localization. Ultrasonography has become

indispensible in the localization of the site of the placenta and determining its lower edges, thus making a diagnosis or an exclusion of placenta previa. Other placental abnormalities in conditions such as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be assessed.

Fetal malformation eg club foot, spinal bifida, cleft palate.

Determine is an intrauterine growth retardation condition is present ( caused by decrease in oxygen to the fetus and mal-nutrition by the mother).

Doppler ultrasound during pregnancy is to check fetal umbilical blood flow, placental blood flow and blood flow in the heart and brain. Its done at each visit to monitor the fetal heart beat . Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm) and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk of miscarriage.

• Rescreen for gonorrhea, chlamydia, syphilis, and group B streptococcus in mid-third trimester.

Gonorrhea and Chlamydia are STD that can lead to pelvic inflammatory disease if not treated .

Group B streptococcus is a type of bacteria that live in the vagina and rectum, but it could be passed to the baby during birth, which can lead to death. GBS is tested between 35 or 37 weeks, if its high in the flora of the vagina antibiotics are given to treat it.

• Instruct about the course of normal pregnancy, warning signs, e.g., decreased fetal movement, rupture of membranes, bleeding, uterine contractions.

• Ensure control of blood sugar for women with diabetes mellitus.

Perform glucose load test (50 gram glu, one hour blood sugar ) at 24-28wks to screen for gestational

Diabetes.

• Determine blood type and screen for blood type antibody (Rh, Kell, other blood group sensitization).

Rh negative women where the fetus's father is Rh positive, leading to a Rh positive pregnancy. During birth, the mother may be exposed to the infant's blood, and this causes the development of antibodies, which may affect the health of subsequent Rh+ pregnancies. In mild cases, the fetus may have mild anemia with reticulocytosis. In moderate or severe cases the fetus may have a more marked anemia and erythroblastosis fetalis (hemolytic disease of the newborn). When the disease is very severe it may cause hydrops fetalis or stillbirth. Rh disease is generally preventable by treating the mother during pregnancy or soon after delivery with an intramuscular injection of anti-RhD immunoglobulin (Rho(D) immune globulin). Administration of Rh immune globin to Rh negative mother’s is done at 28wks.

• Determine hemoglobin or hematocrit, diagnose and treat anemia.

Pregnant women need more iron than normal for the increased amount of blood they produce during pregnancy. Symptoms of a deficiency in iron

include feeling tired or faint, experiencing shortness of breath, and becoming pale. Because these symptoms are common for all pregnant women, health care providers check iron levels throughout pregnancy.

The ACOG recommends 27 milligrams of iron daily (found in most prenatal vitamins) to reduce the risk for iron-deficiency anemia. Some women may need extra iron through iron supplements.

• Screen for hemoglobinopathy.

This is done at 26-28 weeks, The sickle cell hemoglobinopathies (HbS S, HbS C, and HbS-Thal) are hemolytic anemias characterized by recurrent painful crises, systemic infection, and infarction of various organ systems. HbS S is the most common, and affects approximately one in 708 African Americans. There is increased risk for fetal death, so care routinely includes ultrasound assessment of fetal growth and prenatal fetal heart rate monitoring.

• Screen for tuberculosis; evaluate positives and treat. ( for example women with HIV have a high risk of contacting TB)

• Encourage weight gain for very slender women. Assess maternal weight and adequacy of nutrition, counsel about diet, obtain additional food sources if needed

• Screen for use of tobacco, alcohol and other drugs Because they can cause preterm birth and sudden infant death syndrome.

A brief, five step intervention program, referred to as the “5 A’s” model, is recommended in clinical practice to help pregnant women quit smoking (Fiore2008,Melvin2000,ACOG2010).

The 5 A’s include the following:

Ask about tobacco use. Advise to quit. Assess willingness to make a quit attempt. Assist in quit attempt. Arrange follow-up.

Note: smoking can cause baby to have decrease in oxygen supply and may lead to early labor, the

Baby may also develop asthma or bronchitis

• Counsel about avoiding environmental exposure to volatile household chemical (e.g., paints, oven cleaners, cleaning Xuid, lead, other heavy metals).

• Counsel about avoiding exposure to sick children who might have transmissible viral illness

• Determine adequacy of living conditions and seek improvement if needed.

• Determine if woman is being abused and arrange help if needed.

• Non stress test .

This test is performed after 28 weeks to monitor baby's health. It can show signs of fetal distress, such as if the baby does not getting enough oxygen.

• Prescribe folic acid

Folic acid is a B vitamin (B9). It helps produce and maintain new cells. This is especially important during times when the cells are dividing and growing rapidly such as infancy and pregnancy.

The United States Public Health Service recommends that all pregnant women and women of childbearing age [15 to 44 years] in the United States who are capable of becoming pregnant should consume [a supplement containing] 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spinal bifida or other neural tube defect (NTDs). Although a related form (called folate) is present in orange juice and leafy, green vegetables (such as kale and spinach), folate is not absorbed as well as folic acid. Most prenatal vitamins contain the recommended 400 micrograms of folic acid as well as other vitamins that pregnant women and their developing fetus need. Folic acid has been added to foods like cereals, breads, pasta, and other

grain-based foods. Studies show that taking folic acid for 3 months before getting pregnant and 3 months after conceiving can reduce the risk of NTDs, such as spinal bifida, by up to 70%. In addition, taking 400 micrograms of folic acid daily reduces the risk for neural tube defects by 70% also. Biophysical profile (BPP)

This test is used in the third trimester to monitor the overall health of the baby and to help decide if the baby should be delivered early.

High-risk pregnancy Pregnancies with a greater chance of complications are called "high-risk." But this doesn't mean there will be problems. The following factors may increase the risk of problems during pregnancy: • Very young age or older than 35 • Overweight or underweight • Problems in previous pregnancy • Health conditions you have before you become

pregnant, such as high blood pressure, diabetes, autoimmune disorders, cancer, and HIV

• Pregnancy with twins or other multiples Health problems also may develop during pregnancies that make it high-risk, such as gestational diabetes or preeclampsia. Women with high-risk pregnancies need prenatal care more often and sometimes from a specially trained doctor. A maternal-fetal medicine specialist is a medical doctor that cares for high-risk pregnancies. In the case of post term pregnancy: Post term Pregnancy is when gestational age has passed above 40-42 weeks.

Ultrasound is conducted weekly for amniotic fluid volume, fetal heart rate is monitored twice a week and in most cases induction is advised.

Importance of Prenatal care.

Monitor baby's movement After 28 weeks, it’s advised to keep track of baby's movement. This will to notice if the fetus is moving less than normal, which could be a sign that your fetus is in distress. Count your baby's movements every day so you know what is normal for you. If the count is less than 10 movements within two hours or if you notice the baby is moving less than normal. If your baby is not moving at all its advised that the mother should go to the nearest hospital.

Helps to reduce risk of miscarriages . Noticed when a fetal heart beat is missing, an ultrasound is advised to be positive.

Helps to reduce rate of premature birth. Birth before 37weeks is considered preterm. The U.S experienced a 20% increase in premature birth from 1990-2006. Women who have little or no prenatal care or obese women and those who have had preterm labor before are at increased risk. Preterm birth is the leading cause of newborn death and disability.

Babies who survive often have lifetime health complications for example breathing problems due incomplete formation of the lungs, Cerebral palsy and intellectual disabilities.

Helps in monitoring high risk pregnancies.

References . http://ob-ultrasound.net Prenaral care Effectiveness and Implementation Textbook ; Edited by Marie C. McCormickHarvard School of Public Health, Boston, Massachusetts www.hsph.harvard.edu/children and Joanna E. Siegel Arlington Health Foundation, Arlington, Virginia.

https://www.womenshealth.gov/pregnancy/you-are-pregnant/prenatal-care-tests.html

https://www.nichd.nih.gov/health/topics/preconceptioncare/conditioninfo/Pages/before-pregnancy.aspx

American College of Obstetricians and Gynecologists (ACOG).

23rd Edition Williams Obstetrics