Evidence-BasedRoutine Antenatal CareThe Main References
Objectives of Antenatal Care
Early, accurate estimation of gestational age Identification of the patient at riskOngoing evaluation of the health status of both mother and fetus Anticipation of problems and interventionPatient education
What is the adequate no of visit ?
Initial prenatal demographic assessment
NamesMarital status Age Home address Occupation Husband `s name and occupation
Initial prenatal social and demographic assessment
Date of delivery Gestational age at delivery Location of delivery Sex of child Birth weight Mode of delivery Type of anesthesia Length of labor Outcome (miscarriage, stillbirth, ectopic, etc) Details (eg, type of cesarean section scar, forceps, etc) Complications (maternal, fetal, child)
Basic medical history for the pregnant woman and her family
Initial prenatal menstrual history Last normal menstrual period (definite or uncertain?)
Current pregnancy history Medications taken Cigarette use Exposure to radiation Vaginal bleeding Nausea, vomiting, weight loss Infections
Gestational age assessment: LMP and ultrasoundPregnant women should be offered an early ultrasound scan to determine gestational age (in addition to last menstrual period [LMP] for all cases) to detect multiple pregnancies. This will ensure consistency of gestational age assessmentsimprove the performance of mid-trimester serum screening for Downs syndrome reduce the need for induction of labour after 41 weeks. [A]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
13Clinical examination ofpregnant womenMeasurement of weight and body mass indexMaternal weight and height should be measured at the first antenatal appointment, and the womans BMI calculated (weight [kg]/height[m]). [B]Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
14Clinical examination ofpregnant womenPelvic examinationRoutine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended. [B](1)Blood pressure measurementIt is not known how often blood pressure should be measured, but most guidelines recommend measurement at each antenatal visit.[C](2)Evaluation for edemaEdema occurs in 80 percent of pregnant women. It lacks specificity and sensitivity for the diagnosis of preeclampsia[C](3).
1- Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 20082- U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Washington, D.C.: U.S. Department of Health and Human Services, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1996.3- Smith MA. Preeclampsia. Prim Care 1993;20:655-64.
15Screening for haematological conditionsAnaemiaScreening should take place at the first appointment and at 28 weeks when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected.Haemoglobin level less than 11 g/dl at first contact and 10.5 g/dl at 28 weeks should be investigated and iron supplementation considered if indicated.Ramsey M, James D, Steer P, Weiner C, Gornik B. Normal values in pregnancy. 2nd ed. London: WB Saunders; 2000.
Screening for haematological conditionsBlood TypingRh and ABO blood typing should be performed at the first prenatal visit.(1) RhoD immune globulin (Rhogam) is recommended for all nonsensitized Rh-negative women at 28 weeks' gestation (300 mcg) and within 72 hours after delivery of an Rh-positive infant (2,3)Nonsensitized, Rh-negative women also should be offered a dose of RhoD immune globulin after spontaneous or induced abortion, ectopic pregnancy termination, chorionic villus sampling (CVS), amniocentesis, cordocentesis, external cephalic version, abdominal trauma, and second- or third-trimester bleeding (2,3)1-U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. 19962- Clinical management guidelines for obstetrician-gynecologists. American College of Obstetrics and Gynecology. Int J Gynaecol Obstet 1999;66:63-70.3- Fung Kee, et al. Prevention of Rh alloimmunization. J Obstet Gynaecol Can 2003;25:765-73.4- British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for blood grouping and red cell antibody testingduring pregnancy. Transfusion Medicine 1996;6:714.
Screening for fetal anomaliesScreening for structural anomaliesPregnant women should be offered an ultrasound scan to screen for structural anomalies, ideally between 18 to 20 weeks of gestation, by an appropriately trained sonographer and with equipment of an appropriate standard as outlined by the National Screening Committee. [A]
Screening for Downs syndromefrom 11 to 14 weeks nuchal translucency (NT)+NBthe combined test (NT, hCG and PAPP-A) from 14 to 20 weeks the triple test (hCG, AFP and uE3) the quadruple test (hCG, AFP, E3, inhibin A) [B]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
18Screening for infectionsAsymptomatic bacteriuriaPregnant women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth [A]Asymptomatic bacterial vaginosis Pregnant women should not be offered routine screening for bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes.[A]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
19Screening for infectionsCytomegalovirus The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered. [B]Hepatitis B virusSerological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child-transmission [A]Hepatitis C virusPregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence to support its effectiveness and cost-effectiveness.[C]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
20Screening for infectionsHIVPregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection. [A] RubellaRubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies. [B]
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
21Screening for infections SyphilisScreening for syphilis should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and baby. [B]ToxoplasmosisRoutine antenatal serological screening for toxoplasmosis should not be offered. [B]Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection [C]Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
22Screening for infections InfluenzaInfluenza vaccination generally is recommended in women who will be in the second or third trimester of pregnancy during flu season.(1,2) Pregnant women with medical conditions that increase their risk of complications from influenza should be immunized regardless of gestational age. There is no evidence that vaccination in the first trimester of pregnancy is unsafe.(3)
1 Ressel GW. ACIP releases 2003 guidelines on the prevention and control of influenza. Am Fam Physician 2003;68:1426, 1429-30, 1433.2 American College of Obstetricians and Gynecologists. ACOG committee opinion. Immunization during pregnancy. Obstet Gynecol 2003;101:207-12. 3 Goldman RD, Koren G. Influenza vaccination during pregnancy. Can Fam Physician 2002;48:1768-9.
23Screening for gestational diabetes The ACOG recommend that all pregnant women be screened for gestational diabetes at 24 to 28 weeks' gestation, except women who are at low risk (e.g., younger than 25 years, normal prepregnancy weight, no history of abnormal glucose metabolism, poor obstetric outcomes, or first-degree relatives with diabetes)1- American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001. Gestational diabetes. Obstet Gynecol 2001;98:525-38..
24Screening for gestational diabetes Screening protocols : a two-step protocol (i.e., one-hour, 50-g glucose-challenge test followed by a diagnostic three-hour, 100-g glucose-tolerance test) is the main method used in North Americaa two-hour, 75-g glucose-tolerance test is offered in Europe.Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008
25Fetal growth and wellbeingDetermining fetal growthSymphysisfundal height should be measured and recorded at each antenatal appointment from 24 weeks [A].Ultrasound estimation of fetal size for suspected large-for-gestational-age unborn babies should not be undertaken in a low-risk population.Ro