PERINATAL FOLLOW-UPS

Goals

To reduce maternal and perinatal mortality and morbidity rates

To improve the physical and mental health of women and children

Importance

To ensure that the pregnant woman and her fetus are in the best possible health.

To detect early and treat properly complications

Offering education for parenthood

To prepare the woman for labor, lactation and care of her infant

Schedule for Antenatal Visits

The first visit or initial visit should be made as early is pregnancy as possible.

Return Visits: Once every month till 7th month. Once every 2 weeks till the 9th month Once every week during the 9th month,

till labor.

Pattern Of Follow Up Visits

4 weekly appointments from 20 weeks until 32 weeks

Followed by fortnightly visits 32 weeks to 36 weeks and weekly visits.

The minimum number of ‘visits’ recommended by the Royal College of Obstetricians and Gynaecologists is 5, occurring at 12, 20, 28-32, 36 and 40-41 weeks.

BOOKING VISIT: FIRST VISIT

Assessment

History Examination Investigation

Booking History

1. Past Medical History

2. Past Obstetric History

3. Previous Gynaecological History

4. Family History

5. Social History

Booking Examination

Full Physical Examination:

Cardiovascular

Respiratory Systems

Abdominal

Full Pelvic Examination

Full Breast Examination

Examination for most

healthy women :

1. Accurate measurement of blood pressure

2. Abdominal examination to record the size of the uterus

3. Recognition of any abdominal scars indicative of previous surgery

4. Measurement of height and weight for calculation of the BMI.

Women with a low BMI are at greater risk

of fetal growth restriction and obese women

are at greater risk of fetal growth restriction

and obese women are at significantly greater

risk of most obstetric complications, including

gestitational diabetes, pre-eclampsia, need for

emergency caesarean section and anaesthetic

difficulties.

Confirmation of the pregnancy

1. The symptom of the pregnancy ― Breast tenderness― Nausea― Amenorrhea― Urinary Frequency

2. Positive urinary or serum pregnancy test are usually sufficient confirmation of a pregnancy.

3. Dating Pregnancy, confirms the pregnancy and accurately dates it.

Dating Pregnancy

A. Menstrual EDD

B. Ultrasonography

Menstrual History:

A complete menstrual history is important to establish the estimated date of delivery. It includes:

- Last menstrual period (LMP).- Age of menarche.- Regularity and frequency of menstrual cycle.- Contraception method.- Any previous treatment of menstrual - Expected date of delivery (EDD) is calculated by

Naegele’s rule

Dating by ultrasound

Benefits of a dating scan:1. Accurate dating women with irregular

menstrual cycles or poor recollection of LMP.

2. Reduced incidence in induction of labor for ‘prolonged pregnancy’

3. Maximizing the potential for serum screening to detect fetal abnormalities

4. Early detection of multiple pregnancies

5. Detection of otherwise asymptomatic failed intrauterine pregnancy

Advice, Reassurance & Education Reassurance & explanation on

pregnancy symptoms:

1. Nausea

2. Heartburn

3. Constipation

4. Shortness Of Breath

5. Dizziness

6. Swelling

7. Back-ache

8. Abdominal Discomfort

9. Headaches

Information regarding:

1. Smoking

2. Alcohol Consumption

3. Drugs

4. Nutrition & Exercise

Booking Investigation1. Full Blood Count

2. Blood Group & Red Cell Antibodies

― Women found to be rhesus negative will be offered prophylactic anti-D administration at 28 and 34 weeks’ gestation to prevent rhesus iso-immunization and future HDN.

― Other possible iso-immunization events, such as threatened miscarriage after 12 weeks’ gestation, antepartum haemorrhage and delivery of the baby, may require additional anti-D prophylaxis in rhesus-negative women.

3. Rubella ― Women who are found to be rubella non-

immune should be strongly advised to avoid infectious contacts and should undergo rubella immunization after the current pregnancy to protect themselves for the future.

4. Hepatitis B― Vertical transmission to the fetus may occur,

mostly during labour, and horizontal transmission to staff or the newborn infant can follow contact with body fluids.

― A baby born to a hepatitis B carrier should be actively and passively immunized at delivery.

5. Human Immunodeficiency Virus― In known HIV-positive mothers, the use of

antiretroviral agents, elective Caesarean section and avoidance of breastfeeding reduces vertical transmission rates from approximately 30% to less than 5%.

― The Department of Health guidelines now recommend that all pregnant women should be offered an HIV test at booking.

6. Syphilis

7. Urine examination: asymptomatic bacteriuria is more likely to ascend and cause pyelonephritis in pregnancy.

This causes significant maternal morbidity, but also predisposes to pregnancy loss and preterm labour.

All women at booking should wither have a midstream urine sent for culture or be tested with a dipstick which recognizes nitrates, the presence of which sensitivity predicts the presence of significant bacteria.

8. Hemoglobin Studies

― To screen and treat iron deficiency anemia

― To screen thalassaemia and sickle cell disease are usually reserved for women who have an ethnic background and those from the Middle East.

9. Gestational Diabetes

1. Fasting Blood Sugar

― At first visit, if > 95 mg/dl, ask for an early oral glucose tolerance test

10. Tests for high risk groups

Serum TSH

TORCH tests

Glucose tolerance tests

Indirect Coombs test for Rh incompatible couples

Antenatal complications dealt with in

High risk pregnancy units in

collaboration with related departments

Endocrine (diabetes, thyroid, prolactin and other endocrinopathies)

Miscellaneous medical disorders (e.g. secondary hypertension, autoimmune disease)

Haematology (thrombophilias, bleeding disorder)

Substance Misuse

Preterm labour

Multiple gestation

Teenage pregnancy

Content Of Follow Up Visits

General questions regarding maternal well-being.

Enquiry regarding fetal movements (24 weeks).

Measurement of blood pressure (a screen for pregnancy-related hypertensive disorders).

Urinalysis, particularly for protein, blood and glucose: this is used to help detect infection, pre-eclampsia and gestational diabetes.

Oedema is common in pregnancy and is mostly an insensitive marker of pre-eclempsia.

Oedema of the hands and face is somewhat more important as a warning feature of pre-eclampsia.

Weight gain

Abdominal palpation for fundal height:

If repeated symphysis–fundal height measurement are made throughout a pregnancy, the detection of fetal growth problems and abnormalities of liquor volume increased.

Auscultation of the fetal heart:

There is no evidence that this practice is of any benefit in a woman confident in the movements of her baby; however, it provides considerable reassurance and will occasionally detect an otherwise unrecognized intrauterine fetal death.

INSTEAD……….

ULTRASONOGRAPHIC evaluation of fetal growth, anatomy, amniotic fluid volume, placenta, cervix

From 36 weeks, the lie of the fetus (longitudinal, transverse or oblique), its presentation (cephalic or breech) and the degree of engagement of the presenting part should be assessed and recorded.

It is often at this appointment that a decision is made regarding the mode of delivery (i.e. vaginal delivery or planned Caeserean section).

36 – 40 weeks, Non-Stress Test (NST) for high risk pregancies (1x/week)

40 – 42 weeks, Non-Stress Test (NST) (2x /week)

At 41 weeks’ gestation, a discussion regarding the merits of induction of labour for prolonged pregnancy should occur.

An association between prolonged pregnancy and increased perinatal morbidity and mortality means that women are usually advised that delivery of the baby should occur by 42 completed weeks’ gestation.

This will usually mean organizing a date for induction of labour at approximately 12 days past the EDD.