PRENATAL

CARE PASAY CITY GENERAL HOSPITAL

(DEPARTMENT OF OB-GYNE)
AUGUST 2019

prepared by:
ARABANI – ARANAS - BELISARIO
TOPICS:
DIAGNOSIS IN PREGNANCY

INITIAL PRENATAL EVALUATION

SUBSEQUENT PRENATAL VISITS

NUTRITIONAL COUNSELING
COMMON CONCERNS
 DIAGNOSIS IN PREGNANCY
PRESUMPTIVE EVIDENCE
Symptoms • HIGHLY SUGGESTIVE but
1. Morning Sickness NOT ABSOLUTE
2. Fatigue • Atleast 10 DAYS

3. Frequency in urination
Signs
4. Quickening
5. Amenorrhea
LOWER REPRODUCTIVE 6. Beading cervical mucus
TRACT CHANGES 7. Chadwick’s Sign
8. Breast changes
Bluish discoloration that
appears on the cervix;
9. Skin changes
NOT CONCLUSIVE!FERN LIKE
pattern of mucus
Source: Williams Obstetrics, 24th Edition
 8. Breast changes
9. Skin changes

LATER PREGNANCY:
 grows in
 size,
Increase cutaneous blood flow
 darkening of areola
 Stretch marks
& nipple
 Hyperpigmentation
 enlarging
 ofLinea Nigra
Montgomery
 Melasma gravidarum or chloasma
or mask of pregnancy
LESS OBVIOUS in
 Angioma
MULTIPARAS
*** whose breasts may contain
small amount of colostrum
especially if previous child was
breastfed
 PROBABLE EVIDENCE

1. Enlargement of Abdomen Start at 6 WEEKS

AT 12 WEEKS – Fundus is palpable on
bimanual exam; uterus has become an
abdominal organ
2. Hegar’s Sign 6-8 weeks;softening of UTERINE
ISTHMUS
3. Goodell’s Sign 6-8 weeks; softening of the CERVIX

4. Braxton Hicks contraction 28 weeks; painless, not regular

5. Physical Outlining of Fetus

6. Ballotement 2nd TRIMESTER

7. Detection of beta hCG 6 days after fertilization; 8-9 days post

implantation
PREGNANCY TEST – positive at 12.5
mIU (VERY SENSITIVE)
 POSITIVE SIGNS

1. Fetal Heart Tone NORMAL RATE:

120-160 bpm
AUSCULTATION: As early as 16
weeks
Doppler utz: 10 weeks
TV-UTZ: 5 weeks
2. Perception of Fetal
Movement by the Examiner
3. Sonographic Recognition TV-UTZ : gestational sac by 4-5
weeks
EARLY UTZ: done before 12
weeks AOG
PERCEPTION OF
FETAL MOVEMENT
 Felton 16th -20th
week AOG
 MULTIGRAVIDS: 16th
to 18th weeks AOG
 PRIMIGRAVIDS: 18th
to 20th weeks AOG
SONOGRAPHIC RECOGNITION OF PREGNANCY
 TRANSVAGINAL ULTRASOUND
• 4-5 WEEKS: Gestational Sac
• INTRADECIDUAL SIGN: anechoic center surrounded by
echogenic rim
• DOUBLE DECIDUAL SIGN: two concentric echogenic
rings surrounding the gestational sac
• MIDDLE OF 5TH WEEKS: visualization of the yolk sac
• AFTER 6 WEEKS: embryo is seen as a linear structure
adjacent to yolk sac, cardiac motion is also note
• 12TH WEEK: crown rump length is predictive of
gestational age within 4 days
TOPICS:
DIAGNOSIS IN PREGNANCY

INITIAL PRENATAL EVALUATION

SUBSEQUENT PRENATAL VISITS

NUTRITIONAL COUNSELING
COMMON CONCERNS
 INITIAL PRENATAL EVALUATION

Major Goals
1. Define the health status of the mother and fetus.
2. Estimate the gestational age.
3. Initiate plan for continuing obstetrical care.
 10 DANGER SIGNS OF
PREGNANCY
1. Headache
2. Blurring of Vision
SIGNS OF
3. Prolonged vomiting PRE-ECLAMPSIA
4. Epigastric/ RUQ pain
5. Non-dependent edema
6. Fever SIGNS OF INFECTION
7.Dysuria LIKE UTI which may
cause PROM
8. Watery Vaginal Discharge
9. Bloody vaginal discharge SIGNS OF
THREATENED
10.Decreased fetal movement
PREGNANCY
COMPONENTS OF PRENATAL CARE

History
OBSTETRICS HISTORY
 GP (TPAL)
 Manner of delivery (if CS –
indication)
 BW, place of birth, complications
 Family planning
History
MENSTRUAL HISTORY
 Menarche
 Interval
 Duration
 Amount
 Symptoms
OBSTETRICS COMPUTATIONS
1) DETERMINE AOG/ Age of Gestation

-LMP or UTZ
-AOG is from conception to birth
-AOG is the summation of all days from 1st day of LMP divided
by 7.

EX: LMP: January 5, 2019 DATE OF CONSULT: August 13, 2019

JAN 31-5=26 JUN 30
FEB 28 JUL 31
MAR 31 AUG 13
APR 30 TOTAL: 220 DAYS
MAY 31 220/7=31.4 or 31wks 4days
2) EDC/Estimated Date of Confinement

-Spontaneous onset of labor is expected to occur.

-uses Naegel’s Rule

Jan-March: 1st day LMP + 9mos + 7days

Apr-December: 1st day LMP – 3mos + 7days + 1yr

EXAMPLE – January to March
LMP : January 05, 2019
+9 +7 +0
EDC : Oct 12 2019
EXAMPLE – April to December

LMP : May 18, 2019

-3 +7 +1
EDC :Feb 25 2020
3)Fundic Height/McDonald’s Rule
 20-35 wks AOG
 Has a direct correlation to the fundic height in cm.
 LANDMARKS: from the bony part of the superior border of the symphysis pubis to the tip
to the fundus

12 wks (3mos) just above the symphysis pubis

16 wks(4mos) halfway between the symphysis and umbilicus
20 wks(5mos) umbilicus
32 wks (8mos)midway between umbilicus and xiphoid
36 wks(8mos)b costal margin
ANTEPARTUM FETAL
SURVEILLANCE
 GOALS: To prevent fetal death and unnecessary interventions

 WHEN TO BEGIN TESTING:

Neonatal survival
Severity of maternal disease
Severe complications at 26-28 wks AOG (DM, HPN, Pre-eclampsia)

 TYPES:
Fetal movement counting
Electronic Fetal Monitor (Non-stress test and Contraction stress test)
Biophysical Profile
Doppler Velocimetry
FETAL MOVEMENT COUNTING
 Count how many times the baby moves starting at the
2nd half of pregnancy

 Maximum fetal movement: 28-32wks

 Highest incidence of movement: late evening (11pm-2am)

 Normal daily fetal movement count: good outcome (10kicks

in 2 hrs)
ELECTRONIC FETAL MONITORING
 1 probe is for fetal rate, another probe for uterine contractions
 BASELINES: FHR, FHR Variability, Acceleration, Deceleration
 Acceleration: INC FHR of at least 15 beats lasting for at least 15 secs

A) NON-STRESS TEST
A. Patient in recumbent, left lateral position, lying down and properly oxygenated
B. Assess FHR in response to fetal movement
C. Results: REACTIVE: >/= 2FHR accelerations that peak at least 15bpm above the baseline

NON-REACTIVE: does not meet the reactive criteria over a period of 40 min
(no movement, no acceleration)
ELECTRONIC FETAL MONITORING
B) CONTRACTION STRESS TEST
Asses fetal reserve by measuring the FHR response to stress in the form of uterine contractions.
Stressors: Oxytocin or nipple stimulation
Principle:
Stress (uterine contraction)INC. blood flow to the intervillous space DEC. oxygenation d/t DEC.
blood flow to the baby. Uterine contractions worsen fetal oxygenation FHR deceleration

Results: NEGATIVE: No late or variable deceleration

POSITIVE: Late decelerations ff 50% or more of contractions even if frequency is <3
in 10 minutes.
Non-reassuring test
SUSPICIOUS: Intermittent late decelerations
HYPERSTIMULATION: FHR decelerations more frequently than every 2 minutes or
lasting >90sec
UNSATISFACTORY: <3 uterine contractions in 10 minutes
BIOPHYSICAL PROFILE SCORING
 Prenatal ultrasound evaluation
 Predicts presence or absence of fetal asphyxia & fetal death
 Done after 32nd wk (2nd to 3rd Tri) for women at risk of pregnancy

PARAMETERS
ROUTINE BPS: “BATA”
-Fetal BREATHING, ACTIVITY, TONE, AMNIOTIC FLUID VOLUME
-2 points each, 8/8 score
COMPLETE BPS:
-“BATA” + NST
-10/10
MODIFIED BPS:
-NST and AFI. If either is ABNORMAL, do a COMPLETE BPS or CST
BIOPHYSICAL PROFILE SCORING
PARAMETERS:
BIOPHYSICAL PROFILE SCORING
INTERPRETATION:
AMNIOTIC FLUID INDEX

AFI is measured by dividing the uterus into four imaginary quadrants.

The linea nigra is used to divide the uterus into right and left halves.
The umbilicus serves as the dividing point for the upper and lower halves.
The transducer is kept parallel to the patient’s longitudinal axis and perpendicular to the floor.
The deepest, unobstructed, vertical pocket of fluid is measured in each quadrant in centimeters
The four pocket measurements are then added to calculate the AFI.
Normal AFI values range from 5 to 25 cm
AMNIOTIC FLUID INDEX
 Normal: 5-24cm. It normally increases at..
 10wks: 30 mL
 16wks: 300 mL
 Midterm: 800 mL

OLIGOHYDRAMNIOS: AFI </=5CM OR a single deepest pocket of amniotic fluid </=2cm

Borderline Oligohydramnios: 5-8cm
Problem: Renal pathology (renal urination)

POLYHYDRAMNIOS: AFI>24 cm OR a single deepest pocket of amniotic fluid at least 8 cm that

results in amniotic fluid volme of >2000mL
Problem: GIT Pathology (fetal swallowing)
DOPPLER VELOCIMETRY

 To measure the blood flow using the umbilical artery that represents the
maternal circulation.

 ELEVATED UMBILICAL ARTERY DOPPLER VELOCITY: Placental injury

 Do continuous monitoring of fetal growth, AVF, and fetal well-being

 ABSENT END-DIASTOLIC VELOCITY: Uteroplacental injury.

History
PERSONAL AND SOCIAL
 Menarche
 Interval
 Duration
 Amount
 Symptoms
 Psychosocial Screening:
Lack of transportation, child care, family support
 Unstable housing
 Nutritional problems
 Depression
 Domestic violence
 Poverty
 Substance Abuse
 Smoking
 CIGARETTE SMOKING
 Adverse outcomes:
 Placenta previa
 Abruptio Placenta
 PROM
 Prematurity
 Small for Gestational Age
 Fetal Death
 Fetal Digital Anomalies
 5 A’S OF SMOKING CESSATION

ASK: ask about smoking at FIRST and SUBSEQUENT

prenatal visit
ADVICE: with clear, strong statements that explain the
RISK of continued smoking
ASSESS: patient’s WILLINGNESS to attempt cessation
ASSIST: SELF-HELP smoking cessation materials
ARRANGE: to TRACT smoking abstinence PROGRESS at
subsequent visit
 ALCOHOL
-Ethyl alcohol or ethanol is a potent teratogen
 Growth restriction
 Fetal abnormalities
 Nervous system dysfunction
 ILLICIT DRUG USE
 Fetal distress
 Low birth weight
 Preterm birth
 Drug withdrawal after birth
INTIMATE PARTNER VIOLENCE
refers to a pattern of assaultive and
coersive behaviors

 Preterm delivery
 Fetal growth restriction
 Perinatal death
 CLINICAL EVALUATION
 Physical Examination
 Complete PE
 BP
 Maternal Wt
 Fundic Ht
 FHR
 Pelvic Examination
 Speculum Exam
Chadwick Sign, Nabothian Cyst, Paps Smear
LEOPOLD’s MANEUVER
LM1 – FUNDAL GRIP LM2 – UMBILICAL GRIP LM3 – PAWLIK’s GRIP LM4 – PELVIC GRIP
PAP SMEAR
 Bimanual Exam
 Cervix
 Consistency
 Length
 Gestational Age Assessment

 Small orange: 6th week

 Large orange: 8 weeks
 Grapefruit: 12 weeks
 Crown-rump-length: most accurate tool for
gestational age
 Laboratory Test
 CBC
 Blood Type & Rh status
 Antibody Screen
 HIV test
 Hep B, Syphilis and Rubella Serology
 Pap Smear
 Urine Culture
Others:
 Glucose challenge test
 Fetal aneuploidy screening
TOPICS:
DIAGNOSIS IN PREGNANCY

INITIAL PRENATAL EVALUATION

SUBSEQUENT PRENATAL VISITS

NUTRITIONAL COUNSELING
COMMON CONCERNS
SUBSEQUENT PRENATAL
VISITS
 Intervals of Prenatal
Visits
1 - 28 weeks AOG : 4 weeks interval
28 - 36 weeks AOG : 2 weeks interval
36 – 42 weeks AOG : 1 week interval
 Prenatal Surveillance
Fetal heart rate Headache,
Fetal growth Altered vision,
Fetal activity Abdominal pain
Amniotic fluid Nausea and
volume Vomiting
Maternal blood Vaginal bleeding
pressure Vaginal fluid
Maternal weight leakage
Fetal Heart Sound

- 10 weeks doppler
ultrasound
-110 - 160 beats per minute
Fundal Height
20 - 34 weeks
Funic soufflé - sharp, whistling sound
that is synchronous with the fetal pulse.

Uterine souffle - soft, blowing sound that

is synchronous with the maternal pulse.
SONOGRAPHY

 Provides invaluable
information regarding
fetal anatomy, growth,
and well-being.
 Subsequent Laboratory Tests
Hgb : 28 to 32 weeks
Hct : 28 to 32 weeks
Serology for Syphilis : 28 to 32 weeks
Risk for HIV : before 36 weeks.
High risk for hepatitis B virus : time of
hospitalization for delivery.
 D (h) negative and are unsensitized : 28 - 29
TOPICS:
DIAGNOSIS IN PREGNANCY

INITIAL PRENATAL EVALUATION

SUBSEQUENT PRENATAL VISITS

NUTRITIONAL COUNSELING
COMMON CONCERNS
NUTRITIONAL
COUNSELING
 Maintaining good nutrition and healthy diet during
pregnancy is critical for the health of the mother and
unborn child.

Nutrition education and counseling is widely used

to improve the nutritional status of women during
pregnancy
SEVERE UNDERNUTRITION

 Meaningful studies of nutrition in human pregnancy are

exceedingly difficult to design because experimental dietary
deficiency is not ethical.

 Evidence of impaired brain development has been obtained

in some animal fetuses whose mothers had been subjected
to intense dietary deprivation.

 Progeny deprived in mid to late pregnancy were lighter, shorter,

and thinner at birth, and they had a higher incidences of sub
sequent hypertension, reactive airway disease, dyslipidemia,
diminished glucose tolerance, and coronary artery disease.
 Weight Retention after
Pregnancy
 Not all the weight gained during pregnancy is lost during and
immediately after delivery.
 Average weight gain was 28.6 Ib or 12.9 kg, most maternal weight
loss was at delivery approximately 12 lb or 5.4 kg
 In the ensuing 2 weeks, approximately 9 Ib or 4 kg. An additional
5.5 lb or 2.5 kg was lost between 2 weeks and 6 months
postpartum.

 The more weight that was gained during pregnancy, the more
that was lost postpartum.
Dietary Reference Intake –
Recommended Intake
Calories
Pregnancy requires an additional 80,000 kcal, mostly
during the last 20 weeks, to meet this demand, a caloric
increase of 100 to 300 kcal/day is recommended during
pregnancy
Calories are necessary for energy. Whenever caloric
intake is inadequate, protein is metabolized rather than
being spared for its vital role in fetal growth and
development.
Protein

 Protein requirements rise to meet the demands for growth and remodeling of
the fetus, placenta, uterus, and breasts, and for increased maternal blood
volume.
 During the second half of pregnancy, approximately 1 000 g of protein are
deposited, amounting to 5 to 6 g/day. To accomplish this, protein intake that
approximates 1 g/kg/d is recommended.
 Preferably, most protein is supplied from animal sources, such as meat, milk,
eggs, cheese, poultry, and fish. These furnish amino acids in optimal
combinations
Minerals

 Iron
 Iodine
 Calcium
 Zinc
 Magnesium
 Trace minerals
 Potassium
 Fluoride
Vitamins

 Folic Acid
 Vitamin A
 Vitamin B12
 Vitamin B6
 Vitamin C
 Vitamin D
TOPICS:
DIAGNOSIS IN PREGNANCY

INITIAL PRENATAL EVALUATION

SUBSEQUENT PRENATAL VISITS

NUTRITIONAL COUNSELING
COMMON CONCERNS
COMMON CONCERNS ON
PRENATAL CARE
 EXERCISE
• Significant cardiovascular or pulmonary disease
• Significant risk for preterm labor: cerclage, multifetal
gestation, significant bleeding, threatened preterm labor,
prematurely ruptured membranes
• Obstetrical complications: preeclampsia, placenta previa,
anemia, poorly controlled diabetes or epilepsy, morbid
obesity, fetal growth restriction
 • preeclampsia,
• cardiovascular • placenta previa,
• pulmonary disease • anemia,
• cerclage • poorly controlled diabetes
• multifetal gestation • epilepsy
• significant bleeding • morbid obesity,
• threatened preterm labor • fetal growth restriction
• Prematurely ruptured
membranes
EXERCISE

 walking
 running
 swimming
 stationary cycling
 low-impact aerobics
Employment

Preterm birth
 Fetal-growth restriction
 Gestational hypertension
 Seafood Consumption

340 g
 6-12 ounces
 AVOID

shark
swordfish
king mackerel
tile fish
 Lead Screening

 Miscarriage

 Low birthweight
 Neurodevelopmental impairments
 Gestational Hypertension
 Automobile and
Air Travel
• American Academy
of Pediatrics and
ACOG - pregnant
women can safely
fly up to 36
weeks AOG in the
absence of any
complications.
• Periodic lower
extremity movement
and at least
hourly ambulation
help lower the
venous
thromboembolism
threat.
COITUS
 Miscarriage
 Placenta previa
 Preterm labor threatens
Dental Care
IMMUNIZATIONS
LIVE ATTENUATED VIRUS
VACCINE

Measles Yellow Fever

Mumps Varicella
Rubella Smallpox
OPV
OTHER VACCINES
• Influenza
• Rabies
• HPV
• Hepatitis B
• Hepatitis A
INACTIVATED BACTERIAL
VACCINES

Pneumococcus
Meningococcus
Typhoid
Anthrax
Toxoids

Tdap
Specific Immune Globulins

Hepatitis B
Rabies
Tetanus
Varicella
Caffeine

 500gor five cups of

cofee/day
 200mg daily
Nausea and Heartburn
Heartburn

PLAN FOR THE PATIENT

 Avoiding bending over or lying flat.
 More frequent and smaller meals.
 Antacids
Aluminum hydroxide
Magnesium trisilicate
Magnesium hydroxide
Nausea

Mild - vitamin B6 with

doxylamine
some phenothiazine or H2-
receptor blocking antiemetics.
Pica

• Pagophagia
• Amylophagia
• Geophagia
Ptyalism
Headache
Backache

 Squatting rather than bending when reaching

down
 Use back-support pillow when sitting
 Avoid high-heeled shoes.
 Analgesics
 Heat
 Rest
Varicosities

Femoral venous pressures - 8 mm Hg in

early to 24 mm Hg at term.

PLAN
 Periodic rest with leg elevation and
elastic stockings.
Varicosities

Hemorrhoids
Fatigue
Sleep

Daytime naps
 Mild sedatives at
bedtime
THANK YOU