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Obstetric Care

BASIC ANTENATAL CARE

Antenatal care presents preventive medicine opportunities par excellence and is the ideal time to develop an optimal therapeutic relationship with the expectant mother.

Preconception care

  • General nutritional or lifestyle advice

  • Discourage smoking, alcohol, drugs

  • Check rubella immune status

  • Consider genetic issues—family and personal issues

  • Folic acid—at least 1 mth prior to conception 0.5 mg (o)/d, those at risk of neural tube defect 5 mg (o)/d; continue in first 3 mths of pregnancy

The initial visit

  • Careful history, physical examination

  • Establish date of confinement

  • Investigations (Table O2)

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Table O2 Recommended standard antenatal investigations

First visit

Subsequent visits

  • FBE and ferritin

  • Blood grouping and rhesus typing antibody screen

  • Rubella antibody status

  • Cervical screening if due

  • HBV and HCV serology

  • Syphilis serology (TPHA)

  • HIV serology (after counselling)

  • Urine dipstick, micro culture and sensitivity

Consider/discuss:

  • Vitamin D

  • HbA1C (if indicated)

  • Varicella serology

  • Haemoglobin electrophoresis

  • Non-invasive prenatal testing (NIPT) from 10 wks

  • Combined first trimester screening 11–13 wks

  • Fetal anomaly scan 18–20 wks

  • Oral glucose tolerance test 26–29 wks (also at 14–20 weeks if high risk for gestational diabetes)

  • FBE 36 wks

  • Genital swab (group B haemolytic Streptococcus) 36 wks

  • Rhesus antibodies (Rh-negative mother)—28 and 34 weeks

Visits during pregnancy Average is 12 but some recommend as few as 6 or 8.

  • Initial in first trimester: 8–10 wks

  • Up to 28 wks: every 4–6 wks

  • Up to 36 wks: every 2–4 wks

  • 36 wks–delivery: wkly

For each visit record:

  • weight gain

  • blood pressure

  • uterine size/fundal height

  • fetal heart (usually audible with stethoscope at 25 wks and definitely by 28 wks)

  • fetal movements (if present)—patients to record date of first

  • presentation and position of fetus (third trimester)

  • presence of any oedema

  • urinalysis (if hypertensive or signs of pre-eclampsia)

Combined first trimester screening test

(to identify risk for Down syndrome and other fetal abnormalities)

  • serology tests (9–13 wks, 11 is ideal)

    • – free β-HCG

    • – PAPP-A

  • nuchal translucency ultrasound (12–13 wks)

Non-invasive prenatal testing (NIPT) The free fetal DNA test (for aneuploid of chromosomes 13, 18 and 21 and sex chromosomes if requested), done on a maternal blood sample from 10 wks. If the result is high risk, amniocentesis or chorionic villus sampling is required for confirmation.

MANAGEMENT OF SPECIFIC ISSUES

Nausea and vomiting in pregnancy

  • Majority of cases disappear by end of first trimester

  • Explanation and reassurance

  • Simple measures:

    • – small frequent meals, incl. ginger daily

    • – fizzy soft drinks, esp. ginger drinks

    • – ensure adequate hydration, incl. sucking ice chips

    • – avoid stimuli such as cooking smells

    • – rest where possible (fatigue may worsen symptoms)

    • – be careful cleaning teeth

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