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 isthmusthe 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:

Prenatalcare 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.
Symptomsincluding 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 1517 weeks to screen for Downs
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 1820 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 mothers 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 As model, is recommended in
clinical practice to help pregnant women quit
smoking (Fiore2008,Melvin2000,ACOG2010).
The 5 As 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, its 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/precon
ceptioncare/conditioninfo/Pages/before-
pregnancy.aspx

American College of Obstetricians and

Gynecologists (ACOG).

23rd Edition Williams Obstetrics