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PRENATAL CARE

Jaime Aglugub 17 June 2011

PRENATAL CARE
Pre-conceptional care Prompt diagnosis of pregnancy Initial Prenatal Evaluation Subsequent Visits

Presumptive. Probable. Positive Signs.

DIAGNOSIS of PREGNANCY

PRESUMPTIVE SIGNS
Amenorrhea Nausea and vomiting
Up to 1st trimester

Breast changes
Enlargement and tenderness

Chadwicks sign Quickening


20 weeks AOG

PROBABLE SIGNS
Positive pregnancy test Changes in uterine size and shape Palpation of the fetus Palpation of fetal movement Piscaceks sign Hegars sign Goodells sign

POSITIVE SIGNS
Detection of fetal heart tones
Ultrasound: 5-6 weeks AOG Doppler: 10 weeks AOG Stethoscope: 17-19 weeks AOG

Imaging of the fetus


Ultrasound Radiograph

Birth

Medical History. Physical Examination. Laboratory Tests. Patient Education.

INITIAL PRENATAL EVALUATION

MEDICAL HISTORY
Past Medical Illness Diseases in the Family Psychosocial background
Vices (smoking, alcohol, illicit drug use) Lifestyle (nutrition, exercise)

Obstetric and gynecologic history


Menstrual cycle Gynecologic conditions Previous pregnancies Obstetric score GP (F-P-A-L)
Gravida Para (Full-term, Pre-term, Abortion, Live)

PHYSICAL EXAMINATION
General physical examination Obstetric and gynecologic examination

Speculum exam.

Digital pelvic exam.

ASSESSMENT of GESTATIONAL AGE


Using patients last menstrual period (LMP) Fundal height
18-30 weeks AOG Pubis symphisis to uterine fundus

Ultrasound

Determination of fundal height.

ROUTINE LABORATORY TESTS


Complete blood count (CBC)
Hematocrit and hemoglobin

Urinalysis and urine culture


Protein and sugar levels

Blood typing (ABO and Rh) Rubella status Syphilis screen Pap smear HbsAg testing Antibody screen (at 28 weeks AOG)

PATIENT EDUCATION
Medical/surgical complications Cessation of vices
Smoking, drinking, drug use

Danger signs of pregnancy


Vaginal bleeding Pain/burning sensation on urination

Pelvic and/or abdominal pain


Edema (hands and face) Persistent nausea and vomiting Chills and/or fever

Sudden onset of blurry vision


Severe headaches Regular contractions (<37 weeks AOG) Decreased fetal movement

PATIENT EDUCATION
Nutrition
Nutrient Kilocalories Protein Non-pregnant 2200 55 800 10 8 55 60 180 15 Pregnant 2500 60 800 10 10 65 70 400 17

Fat soluble vitamins A (ug RE) D (ug) E (mg TE) K (ug)


Water soluble vitamins C (mg) Folate (ug) Niacin (mg)

PATIENT EDUCATION
Nutrition
Nutrient Water soluble vitamins Riboflavin (mg) Thiamine (mg) Pyridoxine (mg) Cobalamin (ug) Minerals Calcium (mg) Phosporus (mg) Iodine (ug) Iron (ferrous) (mg) Magnesium (mg) Zinc (mg) Non-pregnant 1.3 1.1 1.6 2.0 1200 1200 150 15 280 12 Pregnant 1.6 1.5 2.2 2.2 1200 1200 175 30 320 15

PATIENT EDUCATION
Nutrition
Pre-pregnancy BMI (kg/m2)
Low (BMI < 19.8)

Normal (BMI 19.8-26) High (BMI > 26-29) Obese (BMI > 29)

Recommended total gain Pounds Kilograms 28-40 12.5-18 25-35 11.5-16 15-25 7-11.5 <15 <7

PATIENT EDUCATION
Other Common Maternal Concerns
Exercise Employment Travel Bowel Habits Sex Nausea and Vomiting Immunization Varicosities Heartburn Medicinal Drug Intake

PATIENT EDUCATION
Schedule of subsequent visits
Depends on whether pregnancy is low-risk or high-risk
Factors for High-Risk Pregnancy Extremes of reproductive age (<17 y.o. and >35 y.o.) With medical complications Poor obstetric and gynecologic history With fetal problems (aging, structure, size) Polyhydramnios or oligohydramnios

PATIENT EDUCATION
Schedule of subsequent visits
Normal Pregnancy Until 28 weeks AOG: Every 4 weeks Until 36 weeks AOG: Every 2 weeks Until delivery: Weekly High-risk Pregnancy Until 32 weeks AOG: Every 2 weeks Until delivery: Every week

Medical History. Physical Examination. Laboratory Tests. Patient Education.

SUBSEQUENT VISITS

MEDICAL HISTORY
Danger signs of pregnancy Nutritional intake Vitamin supplementation

PHYSICAL EXAMINATION
Maternal Health
Blood pressure Weight increase Pelvic examination

PHYSICAL EXAMINATION
Fetal Health
Leopolds maneuvers
Presentation Lie Engagement

Fetal heart rate and rhythm Estimated fetal size and weight Fundic height Fetal movement

SPECIAL LABORATORY TESTS


Recommended for repeat (28-32 weeks AOG)
Hematocrit (or hemoglobin) determination Syphilis serology

Optional tests that should be offered


Screening tests for genetic diseases HIV screening

Required later in pregnancy


Oral glucose tolerance test (OGTT) (24-28 weeks AOG) Rectovaginal culture of Group B Streptococcus (35-37 weeks AOG)

SPECIAL DIAGNOSTICS
Electronic fetal surveillance
Non-stress test (NST) Contraction stress test (CST)

Ultrasound examination
Fetal biometry
Crown-rump length, femur length Biparietal diameter, head circumference

Congenital anomaly scan Biophysical profile (BPP)


5 variables: fetal tone, movement, breathing, amniotic fluid levels and NST

SUMMARY
Prenatal care encompasses maternal and fetal health from pre-conception to delivery. History, physical examination, diagnostics and patient education form the tetrad of every prenatal care visit.

Prenatal Care.

THANK YOU!

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