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The Childbearing Family

Antenatal Assessment

Antenatal Assessment
What is Antenatal Assessment? Why do an Antenatal Assessment? What is Maternal Mortality? What is Maternal Morbidity? What is Perinatal Mortality? What is Neonatal Mortality? What is Infant Mortality?

Antenatal Assessment
To achieve the goals of antenatal care, the following is necessary; Early, accurate estimation of gestational age Identification of the patient at risk for complications Ongoing evaluation of the health status of both mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication

Antenatal Assessment
Maternal Mortality DEFINITION: The quotient between the

number of maternal deaths in a given year and the number of live births in that same year, expressed per 100,000 live births, for a given country, territory, or geographic area, as reported by the national health authority.

Antenatal Assessment
Maternal death is defined as the death of a
woman while pregnant or within the 42 days after termination of that pregnancy, regardless of the length and site of the pregnancy, due to any cause related to or aggravated by the pregnancy itself or its care, but not due to accidental or incidental causes.

Rate in T&T 70.4per 100,000 per year

Antenatal Assessment
The Major causes of death during
pregnancy are; Ectopic pregnancy Hypertension Haemorrhage Embolism Anaesthesia -related complications

Antenatal Assessment
Infant Mortality The # of infant deaths in the first year of

life after live birth per 1000, compared with the number of live births in one year from a specific geographic area. In Trinidad and Tobago -28.9 per 1000

Antenatal Assessment
Neonatal Mortality The # of deaths during the first 28 days of life per

1000, live births per year. Neonatal deaths were caused by respiratory distress syndrome (57.8%), birth asphyxia (22.2%) and sepsis (13.5%) . Another study of early onset Group B streptococcal (GBS) infection in neonates at the Mount Hope Women's Hospital over the period 199697 found that the incidence of early onset neonatal GBS sepsis was five to six times higher than that reported in the USA and UK In Trinidad and Tobago -23/1000 (2000)

Antenatal Assessment
Peri-Natal Mortality The # of stillbirths and deaths (from a viable

birth)in the firs week of life per 1000, live births and foetal deaths(after 28 weeks) Stillbirths resulted from the hypertensive disorders of pregnancy, abruptio placentae, diabetes mellitus, intrapartum foetal distress and lethal congenital anomalies In Trinidad and Tobago 27.7 per 1000 per year

Antenatal Assessment
4MILLION babies die in the 1st. Four
weeks of life. 3Million in early neonatal period. 3.3Million are stillborn. 1.3 preventable. 90% in the developing world

Antenatal Assessment
In Trinidad ad Tobago; Over 50% of pregnant women attend free prenatal

clinics that are provided in the health centers in Trinidad and Tobago At each visit a midwife conducts an examination. At least twice during the pregnancy, a medical officer conducts an examination. This system facilitates the referral of women with complications (about 19% of clients) to specialist clinics at six hospitals.

Antenatal Assessment
The established protocol for prenatal care
at the health centers includes testing for anaemia and VDRL , screening for diabetes, and tetanus immunization. Iron and folic acid supplements are recommended to pregnant women but are not generally available free at the health centers

Antenatal Assessment
Tetanus is a life-threatening bacterial disease that is
caused by the toxin of a bacterium called Clostridium tetani. Tetanus bacteria enter the body through an open wound. It could well be a tiny prick or scratch on the skin, although Tetanus infection is more common when there is a deep puncture wound such as a bite, cut, burn or an ulcer. Tetanus affects a persons nervous system and can be fatal if left untreated. It is preventable through immunization.

Antenatal Assessment
The Tetanus Toxoid (TT) vaccine is given
during pregnancy to prevent tetanus to the mother as well as baby. Antibodies formed in the mothers body, after the vaccination, are passed on to the baby and protects for a few months after birth. It also helps prevent premature delivery.

Antenatal Assessment
In the first pregnancy, the recommendation is at least
two doses of the TT vaccine. The first vaccination is given in the first trimester soon after a pregnancy test is confirmed and after the first antenatal appointment. The second dose of the TT vaccine is given at least four to eight weeks after the first. Some experts recommend that the second dose of the vaccine should be given four weeks prior to the expected date of delivery. The WHO also recommends that a third vaccine be given six months after the second one to provide protection for at least five years.

Antenatal Assessment
If this is a second pregnancy and it has
been less than two years since the last pregnancy and the patient had received both TT vaccines, then only a booster dose is recommended. In many countries such as the US, the Td or tetanus-diphtheria vaccine is recommended for pregnant women.

Antenatal Assessment
About 90% of all deliveries take place in government
institutions, which have facilities for cesarean sections, blood transfusions, and acute neonatal care. The other 10 % take place in private hospitals and nursing homes (most of which have facilities for cesarean sections), with minimal numbers taking place in homes and "other places." Almost 90% of all deliveries are supervised by midwives, the other 10% by doctors or "other persons." Only about 10% of mothers use postnatal services at health centers.

Antenatal Assessment
The infant mortality rate is estimated at 29
infant deaths per thousand live births, while the probability of dying before ones fifth birthday, the under-5 mortality rate (U5MR) is estimated to be around 35 per one thousand live births. These estimates have been calculated by averaging mortality estimates obtained from women 25-29 years and 30-34 years, and refer to mid 2004.

Antenatal Assessment
Low Birth Weight Weight at birth is a good indicator, not only of a

mothers health and nutritional status but also the newborns chances for survival, growth , long-term health and psychosocial development.

Low birth weight (less than 2,500 grams) carries


a range of grave health risks for children.

Antenatal Assessment
Babies who were undernourished in the womb
face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease They are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life.

Antenatal Assessment
Children born underweight also tend to have; - A lower IQ - Cognitive disabilities, affecting their performance in school and their job opportunities as adults.

Antenatal Assessment
Early screening therefore is a major
contributor to better outcomes of pregnancy. Screening and a thorough history are usually the most important activities of the first Ante-natal visit. Pre-conceptive screening would be the option of choice if possible

Antenatal Assessment
Think about the setting for the first
interview. Quiet Focused Privacy Health history

Antenatal Assessment
First Trimester Early confirmation gives most reliable assessment of

gestational age. Confirm Estimated Date of Delivery(E.D.D) Ask for the first day of the last menstrual period! Naegeles rule Add seven days Subtract three months ,Adjust the year if needed . There is a 2wk margin of error either side of this date

Antenatal Assessment

What can affect the estimation of this date? Does not remember L.M.P Has irregular periods Was taking the contraceptive pill Had a lighter than normal period Just had a baby and has not had a period as yet. Is still having periods

Antenatal assessment

Take a complete health history; Social family-partner-housing-work-finances Psychosocial feelings-coping skills-self esteembody image Medical- history of any illness or disease, present or past Surgical- surgeries or procedures that may have impact Obstetrical previous pregnancies-results, Parity, Gravida

Antenatal assessment
Menstrual history first day of last
menstrual period Family history -diseases-heredity-genetic This gives a baseline to work with and a basis for referral if necessary

Antenatal assessment
Physical Examination Head to toe exam including , breasts for signs of
activity . Will give a general assessment of well being and signs and symptoms of pregnancy Weight /height Vital signs baseline Heart, lungs. Urinalysis abnormalities, albumin, blood, sugar, leucocytes Blood tests

Antenatal Assessment

Abdominal Palpation The abdominal examination consists of: 1 -Preparation for this 2 -Inspection 3 Fundal palpation, 4 -Lateral palpation 5 -Pelvic palpation 6 -Auscultation 7 -Documentation and decision making

Antenatal Assessment
Laboratory TestsHb - Group- Rh factor
Platelets- HIV-VDRL(Venereal Disease Research Laboratory) Sickle- WBC Rubella Ultrasound may be done this helps to date the pregnancy if needed. Heart rate/movement depending on stage of pregnancy Advice can be given on nutrition minor problems-exercise-rest-social referral-follow up appointments and supplements

Antenatal Assessment
Preparation It is important to carry out the usual

essential care skills such as: Introduce yourself to the woman Consult the antenatal notes Determine the level of risk and the maternity care needs of the woman Respect hygiene measures and the privacy of the woman

Antenatal Assessment
The womans abdomen is inspected for its
shape. This can indicate size and lie of the fetus, the amount of amniotic fluid and sometimes fetal movement may be noticed. Obvious scars will be seen and this information may be significant.

Antenatal Assessment
Fundal Height The fundal height is measured to estimate

whether this is in keeping with the expected date of birth. This can be done using landmarks i.e. xiphisternum, the symphysis pubis ,the umbilicus where the fundal height can be measured in relation to these, and the period of gestation is calculated.

Antenatal Assessment
Using the flat interior of the tips of the
middle fingers of both hands the fundus is palpated to identify the fetal pole (cephalic or breech). If no pole is located the lie is not longitudinal.

Antenatal Assessment
Fundal palpation is carried out to find out
the lie and presentation of the fetus. Things which influence the fundal height are: maternal parity, size, full bladder, the lie and the number of fetuses. To determine what is found in the fundus a hand is placed on the abdomen below the xiphisternum and gently moved downwards until the fundus is felt.

Antenatal Assessment
Alternatively a measuring tape is used to
estimate the # of centimetres, which will approximate the # of weeks gestation. If the estimate is larger or smaller then the expected date, one must look for a cause.

Antenatal Assessment
Lateral palpation assesses the main body of the
uterus to confirm the lie and identify the fetal position. The fetal back is usually firmer and more regular in form than the other side of the fetus i.e. the abdomen and the limbs. One hand is placed on one side of the uterus to apply pressure, whilst the other attempts, using the flats of the fingertips, to identify what is found in the opposite side.

Antenatal Assessment
The same manoeuvres are then carried out on
the other side of the uterus, that is the right hand held firmly on the mothers left side of the uterus and the flats of the insides of the fingertips identify the shape and form of the right side of the uterus. Lateral palpation also provides insight into the size of the fetus, the tone of the uterus, amniotic fluid volume and also whether fetal movements are present.

Antenatal Assessment
Pelvic palpation is used to identify the
presentation, that is the part of the fetus lying in the lower pole of the uterus, over the pelvic brim. It can be determined whether: the fetus is flexed or extended the presenting part is engaged or not the presenting part is mobile (ballotable), or engaging

Antenatal Assessment
To carry out pelvic palpation both hands are
used. One hand is placed on either side of the presentation and pressure is applied. The presentation can be felt. It may help if the woman takes a deep breath and blows out. Engagement of the presentation is assessed according to the passage of the widest diameter of the presenting part through the pelvic brim.

Antenatal Assessment
Auscultation
Locating the fetal presentation and lie will be helpful to show where to place the stethoscope to listen to the fetal heart. The approximate points of fetal heart sounds are shown on the image below. right occipito- posterior right

Antenatal Assessment
The fetal heart is assessed for its presence, its
rate and its regularity. The normal heart rate is between 120 & 160 beats per minute. This is easy to distinguish from the maternal heart rate, which must also be assessed to determine that the fetal heart is actually being listened to. Following the procedure the findings are discussed with the mother and documentation and follow up carried out as appropriate

Antenatal Assessment

Antenatal Assessment
Records Records of the abdominal examination should
include the following features: The fundal height, The lie, Presentation and degree of engagement, The position (if identified), The fetal heart rate and whether fetal movements are felt.

Antenatal Assessment
Abdominal examination during pregnancy Abdominal examination provides the woman

with information that pregnancy is progressing well. She can be reassured regarding fetal growth and fetal well being. Other examinations and tests are used in conjunction with the abdominal examination, for example ultrasonic scan.

Antenatal Assessment
The Pelvic Examination; Reveals important information regarding both internal

and external health of the reproductive system External Look for any abnormalities ;e.g. varicosities and oedema, previous episiotomy Internal Goodells sign (softening of the cervix) Hegars sign (softening of the lower uterine segment ) Chadwicks sign (bluish tinge of the vaginal and cervical mucosa)

Antenatal Assessment

Speculum exam Inspect the cervix and shape of os Look for signs of discharge , ulceration or inflammation. Bi- manual exam (two-handed) Assess uterine size Assess other pelvic organs Recto-vaginal exam Some doctors will do this exam to assess the strength of the posterior vaginal wall

Antenatal Assessment

An explanation is given to the patient Equipment set up. Private setting Positioned lithotomy (not in stirrups) Speculum exam Bi-manual exam Recto-vaginal exam Assessment of pelvic size (usually done approx. 36th week.

Antenatal Assessment
Second Trimester Visits are usually scheduled as;
Monthly until the 28th wk. Then 2wkly till 36th wk. and weekly thereafter until delivery Every visit the following checks are doneWeight Vital signs Urinalysis Foetal assessment , fundal height ,foetal heart rate, Oedema-varicosities ,vaginal infection, foetal movement , possible blood tests

Antenatal Assessment
Discussion of other topics: Any problems Nutrition Childbirth classes different ways of

preparing Type of delivery-what type of delivery, birthing choices Method of feeding

Antenatal Assessment

Third Trimester Routine checks again Cephalo-pelvic assessment(clinical)- if any doubt x-ray pelvimetry. Advice on labour and delivery- choices Nutrition and feeding Foetal Assessment clinical assessment of growth-uterine size foetal heart movementultrasound

Antenatal Assessment
Cephalo-pelvic Assessment Cephalo-pelvic disproportion exists when

the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. Foetus size, position ,abnormality Mother pelvic shape, size ,measurement, inlet and outlet.

Antenatal Assessment
Foetal assessment of wellness Kick counting Non Stress Test (NST) Biophysical Assessment Ultrasound/MRI Foetoscopy Others

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