Antenatal Care PDF

Continuity of carer. Better postnatal and perinatal mental health care. A fairer payment system for different types of care. Safer care, with multiprofessional working and training and measurement of performance using routinely collected data Overview of antenatal care The aims of antenatal ca...

Continuity of carer. Better postnatal and perinatal mental health care. A fairer payment system for different types of care. Safer care, with multiprofessional working and training and measurement of performance using routinely collected data Overview of antenatal care The aims of antenatal care are: To optimize pregnancy outcomes for women and babies. To prevent, detect and manage those factors that adversely affect the health of mother and baby. To provide advice, reassurance, education and support for the woman and her family. To deal with the ‘minor ailments’ of pregnancy. To provide general health screening. Antenatal care aims to make the woman the focus. Women should be treated with kindness and dignity at all times, and due respect given to personal, cultural and religious beliefs. Services should be readily accessible and there should be continuity of care. There is a need for high-quality, culturally appropriate, verbal and written information on which women can base their choices, through a truly informed decision-making process, which is led by them. In the UK and many countries worldwide, maternity care for an individual woman is provided by a community-based team of midwives and family practitioners (such as GPs), a hospital consultant team or a combination of the two. Some women have complex pregnancies and in these instances a hospital- based obstetric team leads their antenatal care and they are said to have consultant care. Many more women have pregnancies where there are no overtly complicating factors and these women usually have community-based care and are said to be under midwifery care. A further group have risk factors identified at booking, for example previous caesarean section, which mandate clinical input by obstetricians but where the majority of routine care can still be provided by the community team. This is referred to as shared care. Advice, reassurance and education Pregnancy is a time of great uncertainty and stress and this is compounded by the many physical changes experienced by the woman during her pregnancy. Common symptoms include nausea, heartburn, constipation, shortness of breath, dizziness, swelling, backache, abdominal discomfort and headaches. Generally, these reflect physiological adaptations to pregnancy but may become extremely debilitating for the pregnant woman. Occasionally they will represent the first presentation of a more serious problem. Information regarding smoking, alcohol consumption and the use of drugs (both legal and illegal) during pregnancy is extremely important. In some populations almost one-third of women smoke during pregnancy, despite its association with fetal growth restriction, preterm labour, placental abruption and intrauterine fetal death. A major role of antenatal care is to help women limit these harmful behaviours during pregnancy, for example by inclusion in smoking cessation programmes. Alcohol or illegal substance misuse may require more specialized skills from support services including perinatal mental health teams. The information given should be of high quality and evidence based. It should be provided in a manner appropriate to the woman and in different formats (e.g. written information) where appropriate and possible. Parentcraft education is the term often used to describe formal group discussion of issues relating to pregnancy, labour and delivery and care of the newborn. These sessions offer an opportunity for couples to meet others in the same situation and help to establish a network of social contacts that may be useful after the delivery. They may include a tour of the maternity department, the aim of which is to lessen anxiety and increase the sense of maternal control surrounding delivery. First trimester When a woman becomes pregnant one of the first interactions with the health services is known as the booking visit. At this point, or shortly afterwards, a midwife will take a detailed history, examine the woman and perform a series of routine investigations (with the woman’s consent) in order that appropriate care can be offered. If risk factors are identified that may potentially impact on the pregnancy outcome, the midwife will access specialized services on behalf of the woman. This may mean referral to a hospital consultant obstetric clinic or other specialist services as appropriate. Medical or psychosocial issues raised at the booking visit may need to be explored in some depth. Body mass index and weight assessment Height and weight should be measured at the booking visit, body mass index (BMI) calculated and assessed and women counselled accordingly. If the BMI is more than 35 kg/m2, it is recommended that the woman is reviewed by an obstetric consultant or other healthcare professional who can provide appropriate advice on the increased pregnancy risks (Table 2.1) and interventions to minimize excessive gestational weight gain. The Institute of Medicine have guidelines on recommended weight increase in pregnancy. For normal weight women (BMI 18.5–24.9 kg/m2) the recommended total weight gain in pregnancy is 11–16 kg (25–35 lb); for overweight women (BMI 25–29.9 kg/m2) 7–11 kg (15–25 lb); and for obese (≥30 kg/m2) women 5–9 kg (11–20 lb). Women with raised BMI should be counselled regarding appropriate weight in pregnancy and counselled regarding the risks. In general, the risks increase as BMI rises. General pregnancy dietary advice The Royal College of Obstetricians and Gynaecologists (RCOG) provides the following dietary advice for optimal weight control in pregnancy: Do not eat for two; maintain your normal portion size and try and avoid snacks. Eat fibre-rich foods such as oats, beans, lentils, grains, seeds, fruit and vegetables as well as whole grain bread, brown rice and pasta. Base your meals on starchy foods such as potatoes, bread, rice and pasta, choosing whole grain where possible. Restrict intake of fried food, drinks and confectionary high in added sugars, and other foods high in fat and sugar. Eat at least five portions of a variety of fruit and vegetables each day. Dieting in pregnancy is not recommended but controlling weight gain in pregnancy is advocated. It may be difficult for pregnant women to make these changes to their diets for the first time in their adult life, and further work is needed to determine how to enable pregnant women to follow this guidance. General exercise advice Aerobic and strength conditioning exercise in pregnancy is considered safe and beneficial. It may help recovery following delivery, reduce back and pelvic pain during pregnancy and contribute to overall wellness. The aim of exercise during pregnancy is to stay fit, rather than to reach peak fitness. Contact sports should be avoided and if the pregnant woman has any coexisting medical conditions, a more tailored exercise programme may be needed. However, there are very few pregnant women for whom some exercise is not appropriate and health care professionals can encourage women to maintain walking, swimming and other forms of non-contact exercise. Pelvic floor exercises during pregnancy and immediately after birth may reduce the risk of urinary and faecal incontinence in the future. Following delivery, generally it is safe to resume exercise gradually as soon as the woman feels ready. Table 2.1 Maternal and neonatal complications associated with increased BMI in pregnancy  The RCOG provides modified heart rate target zones for exercise in pregnancy. These are age dependent and are as follows: women 40 years of age: 125–140 bpm. Breastfeeding education Breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits for the mother and child, such as reducing the risk of obesity later in life. Breastfeeding has also been associated with a higher intelligence quotient (IQ) in children, although it is not clear whether this is a result of confounding. The World Health Organization (WHO) recommends initiation of breastfeeding within an hour of birth, exclusive breastfeeding for the first 6 months of life and continued breastfeeding beyond 6 months and at least up to 2 years of age. Although evidence for interventions to promote breastfeeding are limited, a recent systematic review demonstrated that the greatest improvements in initiation and continuation of breastfeeding were seen when education was provided concurrently across the various settings including home, community and the health system. Baby-friendly hospital support in the health system was the most effective intervention to improve rates of any breastfeeding. As a result, early education in pregnancy about breastfeeding is advocated to improve uptake and engage pregnant women with breastfeeding services to allow them to be fully prepared. Options for pregnancy care Following the booking visit and assessment of potential risks a woman may discuss their expectations for the pregnancy and discuss where they would like to receive their antenatal care and deliver their baby. Provided that there are no contraindications to midwifery-led care (such as medical comorbidities or previous obstetric complications that may warrant consultant-led care), the options available for delivery include: Home birth: according to the Birthplace Study, in England and Wales approximately 2% of women opt to deliver at home, cared for by a midwife. The advantages of home birth include familiar surroundings, no interruption of labour to go to hospital, no separation from other children or the woman’s partner during or after birth, continuity of care and reduced interventions. The disadvantages are that 45% of first time mothers (and 12% of multiparous mothers) planning home birth are transferred to hospital and a poor perinatal outcome occurs in approximately twice as many first time home birth mothers compared with first time mothers delivering in hospital (9.3 vs. 5.3 adverse perinatal events/1,000 births; adjusted odds ratio 1.75, 95% confidence intervals 1.07–2.86). Other disadvantages include limited analgesic options (e.g. no epidurals are available).  Midwifery units or birth centres: these may be stand-alone where they are located on a separate site to hospital birth centres or adjacent to hospitals (‘co- located’) with access to obstetric, neonatal and anaesthetic care. Advantages of midwifery units may include continuity of care, fewer interventions and convenience of location. Disadvantages include transfer out to a hospital birth centre (40% nulliparous women and 10% of multiparous women) and limited access to certain analgesic options. There was no difference in the risk of adverse perinatal outcomes between midwifery units and hospital units (4.5 adverse perinatal events/1,000 births in freestanding midwifery unit vs. 4.7 events/1,000 in alongside midwifery unit vs. 5.3 events/1,000 in obstetric unit). Hospital birth centre: in hospital birth centres midwives continue to provide care during labour but doctors are available should the need arise. There is direct access to obstetricians, anaesthetists and neonatologists. Disadvantages include lack of continuity of care and a greater likelihood of intervention (compared to midwifery units and home birth). Antenatal urine tests Asymptomatic bacteriuria is associated with increased risk of preterm delivery and the development of pyelonephritis during pregnancy. A mid-stream specimen of urine (MSU) should be sent for culture and sensitivity at the booking visit to screen for asymptomatic bacteriuria. Urinalysis is performed every antenatal visit. Urine is screened for protein (to detect renal disease or pre-eclampsia), persistent glycosuria (to detect pre-existing diabetes or gestational diabetes [GDM]) and nitrites (to detect urinary tract infections). If nitrites are detected on urine dipstick testing, a MSU is sent for microscopy, culture and sensitivity to detect asymptomatic bacteria and appropriate treatment initiated if a positive culture is identified. Blood pressure assessment Blood pressure falls by a small amount (a few mmHg) in the first trimester and increases to prepregnancy levels by the end of the second trimester. First trimester blood pressure assessment also allows the detection of previously unrecognized chronic hypertension; this enables early initiation of treatment including antihypertensive agents (to reduce episodes of severe hypertension in the mother) and low-dose aspirin, which improves maternal (reduced pre-eclampsia) and fetal (decreased perinatal mortality) outcomes in women with chronic hypertension. Booking tests in pregnancy Table 2.2 lists the booking tests often performed at the booking visit. Full blood count Full blood count (FBC) measurement allows identification of women with anaemia, to allow early initiation of treatment. Anaemia in pregnancy is defined as a haemoglobin (Hb)