Ch10. Prenatal Care

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Ch10. Prenatal Care

• ????? ???????
• R1 ? ? ?

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Overview of prenatal care

• By the end of the 20th century
• -prenatal care, important health service
• The median number
• -12.4 visit per pregnancy
• 17 or more visit (7)
• 2000??-90? 1st trimester ?
• prenatal care ??

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Overview of prenatal care

• Inadequate prenatal care
• social, ethic group, age , method of
• payment
• I didnt know that I was pregnant
• I didnt have enough money or
• insurance to pay for my visits
• inability to get an appointment

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Overview of prenatal care
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Overview of prenatal care

• Effectiveness of prenatal care
• supervision and care of the pregnant,
• parturient and puerperal woman as
• will enable her to pass through the
• danger fo pregnancy and labor with
• the least possible risk.

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Procedures for prenatal care

• Initial prenatal evaluation
• -as early as a few days after a missed
• menstrual period
• health status of the mother fetus
• determine the gestational age
• to initiate a plan for continuing
• obstetrical care

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Procedures for prenatal care
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Procedures for prenatal care

• Definition
• primipara ?? ? viability? ?? ?? ??? ??
• ? ??? ??? ? ??
•     
•     multipara  -?? ? viability? ?? ?? ??? ??
• ? ??? ??? ? ???? ?? (??
• ? ??? ??? ??? viability?
  ???
• ????? parity???)
• nullipara - ??? ??? ??? ?? ??? ????
• ??? ??? ?? ???? ?? ??

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• nulligravida - ??? ??? ?? ?? ??
• gravida - ??? ???? ????, ?? ??? ???
• ? ?? ??? ??? ??
•              (1st pregnancy
  primigravida,
• with successive pregnancy
  multigravida)
• parturient - ???? ??
• puerpera - ??? ??? ???? ??????? ??
• Term-Preterm-Abortion-Living

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Procedures for prenatal care

• Mean duration
•        -280 days or 40wks from the 1st day of LMP
  
• Naegele's rule
•        -1st day of LMP? date? 7
•        -1st day of LMP? month? 9 ?? -3 
•  incorrect delivery dates were predicted in 40 to
  60 percent of estimates,  with 5-days error being
  typical.

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Procedures for prenatal care

• gestational or menstrual age
•    - ?? ???? ?? ???, ????? ????? ??
• ?.
• ovulatory or fertilization age
•    - ?? embryologists ? reproductive biologist ?
  ??
• ???, gestational age?? 2? ??.

• Trimester
• 1st LMP 14?
• 2nd 15? 28?
• 3rd 29? 42?
•   
• _at_Precise knowledge of the age of fetus is
  imperative
•             for ideal obstetrical management!

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Procedures for prenatal care

• Hystory
• -?? ???? ?? ??? ??? ?? ??? ????
• ???? ??? ?? ??? ?????.
• Menstrual history
• -extremely important
•      
•  -?? ??? ???? regular, predictive, cyclic,
• spontaneous mens ? ??? ??? ??? ??
• ???? ??? ???.

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Procedures for prenatal care
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Procedures for prenatal care

• speculum examination
• -cervix? Bluish-red passive hyperemia 
• - Nabothian cysts dilated, occluded cervical
  glands
• bulging beneath the exocervicla mucosa   
• -Pap smear, N.gonorrhoeae , C.
  trachomatis     
•       -white mucoid discharge ? normal
•        foamy yellow liguid ? trichomonas
•        curd-like discharge  ? candida
•                  

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Procedures for prenatal care

• digital pelvic examination
• -cervix consistency, length, dilatation
•  fetal presenting part(??, ????)
• bony architecture of the pelvis   
• any anomalies of vagina perineum
• - colposcopy, biopsy, culture ,dark field
  examination
•           
• -Height of fundus
• ?? 18-32??? gestational age of
  fetus(wks)? uterine
• fundal height(cm)? ? ??
• symphysis pubis ???? fundus ??(with the
  bladder
• empty)  

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Procedures for prenatal care

• Subsequent prenatal visit
• - until 28 wks every 4wks
•         until 36 wks every 2wks
• ??   weekly
• fetal heart sounds
• -16??? 19???
•          20wks 80
• 21wks 90
• 22wks 100

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Procedures for prenatal care

• Prenatal surveillance
• Fetal
• -heart rate
• -size
• -amount of amnionic fluid
• -presenting part station
• -activity
• Maternal
• -BP, Wt
• -symptom (headache, altetred vision, abd.
  pain, nausea
• vomitimg, bleeding, dysuria)
• -HOF
• -vaginal examination

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Procedures for prenatal care

• Ancillary prenatal tests
• -Gestational DM2828wks
• -Chlamidia trachomatis not routine
• High
  risk-24wks
• -Bacteral vaginosis not routine
• screening at
  high risk group
• -Group B streptococcus ampicillin IV
  (mother)
• 
  penicillin G (infant)

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Nutrition

• ??? ???? 450 kcal/day??? ????
• ?? ???? ??? 250g? ????? ??? ???? ?? ??
• ??? ???? ???? ??? ??? ??? ???? ????? ??.
• ??? ?? ?? 33Ib (15kg)
• if lt16Ib ?? lt2500g

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Nutrition

• Recommendations for weight gain
• -20?? ?? 9.1kg
• HBP, ??? ??
• -1970s 11.4kg
• ??, growth restriction ??
• -1990s 11.5 16 kg
• BMI? ?? ??? ?

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Nutrition

• Hytten(1991) 12.5kg
• -Normal physiologic events 9 kg
•        fetus, placenta, amniotic fluid
• uterine hypertorphy
•        increse in maternal blood volume,
•        retained extravascular extracellular fluid
• -??? maternal storage fat

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Nutrition

• Weight gain 20wks ?? 1Ib /wk
• Schauberger(1992)
• -Wt. gain 13.0 /- 4.8 kg
• -Wt. loss 12.2 /- 4.6 kg
• -retained 1.4 /- 4.8 kg
• ??? ?? ?? large fetus
• c/sec ?? ????

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Nutrition
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Nutrition

• Nutritional risk group
• -multiple gestation
• -substance abuse
• -complete vegetarians
• -epileptics
• -hemoglobinopathies

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Nutrition

• Calories
• -?? 80,000 kcal ??
• -? ???? 300 kcal/day
• -energy ??? ??
• Protein
• -last 6 MO 1kg ?? (56 g/day)
• -animal source , ??, ???

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Nutrition

• Iron
• -300mg fetus placenta
• 500mg maternal Hb mass
• -during pregnancy 7mg/day
• -Scott(1970) ?? ???
• 30mg/day (elementary iron)
• -60100mg
• large women 
•         twin pregnancy
•    late in pregnancy       
• takes iron irregularly
•     somewhat depressed hemoglobin level  

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• ?? ? 4???? iron ???? ??
•  
• ? ? ???? ? ??? ???? ??.

? nausea vomiting ??? ??.        ??? iron
?? minimize GI reaction
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Nutrition

• Calcium
• ???? ? 30 g ? calcium? ???.
•            -???? ?? ???? ??? ???.
•            -??? ??? ??? ?? ?? calcium?? 2.5 ?
• ???? ??? ?? ??? ???? ?????
• ?? ?? ??.
• Phoaphorus
• nonpregnant level? ?? ??

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Nutrition

• Zinc
• -severe zinc deficiency
•          ?? ??
•         ?? ??
• ?? ?? ??
•  
• -profound zinc deficiency
•   dwarfism
•        hypogonadism 
• acrodermatitis enteropathica
• -15mg/day

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Nutrition

• Iodine
• -fetal requirements maternal renal losses?
  ??
•   -maternal iodine deficiency cretinism
• 
  ??? ????
• Magnecium
• Copper
• -Enzyme, metabolism
• Selenium
• -against free radical damage

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Nutrition

• Chromium
• - co-factor for insulin
• Potassium
• -decreased by about 0.5 mEq/L
• -prolonged nausea vomiting
• Sodium
• Flioride

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Nutrition

• Vitamins
• -?? ??? ???  ??
•       ??? ??
•        ?? ??
•   
• - ??? ?? ??? ???? ??? ?? calory?
• protein? ???? general diet???? ??? ???
• ??? ??? ??? ? ??

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Nutrition

• Folic acid
• -prevent neural tube dafect
• -0.4 mg/day (periconceptional period)
• Vitamin A
• -not recommended routinely
• Vitamin B12
• -????? ??? ???? ????? ???? ???
• ???? ???? ?? ??? ????? vitamin B12
• ??? ??
• -??? vitamin C ??
•         ? interfere with vitamin B12 absorption
  
• Vitamin C 70mg/day

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Nutrition

• Pragmatic Nutritional Surveillance
• 1. ???? ??? ?? ???? ??? ??
• ?? ? ?.
• 2. ??,????? ??? ???? ?? ??
• ? ??? ??
• 3. ??? 25 to 35 pound? ?? ?????
• ??? ??
• 4. ????? ?? ?? ??? ??? ?.
• 5. 1? 30 mg ? ??? ??? ?
• 6. 28 to 32 weeks? hematocrit or Hb
• concenturation? recheck

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Common concerns

• Exercise
• - ????? ???? ??? ??? ???? ??? ???
• ??? ? ??? ?? ??? ?? ??? ?? ??? ??
• ??.
• -a very sedentary existence.
• pregnancy induced hypertension
•      with 2 or more fetuses
•     suspected or having a growth retarded
  fetus
•       severe heart disease
• -???? ?? active labor ???, c/sec ?? ??, ?? ??
  ?
• fetal distress?? ??
• Employment
• -severe physical strain should be avoided
• - working day ???? ??? ????? ????.
• -?? ?????(????)? ?? ?????? ????? ??
• -?? ?? ?? ? 46??

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Common concerns

• Travel 
• -??? ????? ??? ??? ??? ??? ?? ???.
• -??? ??? ???? ??? ??? no unusual risk??.
•        ??? ? 2?? ?? ???????.
• -?? ??? ??? fetal injury? ???? ???? ???.
• Bathing
• - ??, ??? ?? ?? ??? ?? ??.
• -slip down ??
• Clothing
• -??? ??? ????? ? ?? ?? ?? ??.
• -??? ???? ??? ???? ?? ? ?? ???? ?
• ?
• Care of the teeth
• -?? ?? ??    

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Common concerns

• Bowel Habits
• -??? ??? ??? ?? lower bowel ??? prolonged
• transit time    
• -prevention of constipation by
•     close attention to bowel habits
•      sufficient quantities of fluid
•         reasonable amount of daily exercise
•     mild laxative(prune juice, etc.) 
•    stool-softening agents
•   
• Coitus
• -abortion or preterm labor threaten? ?? ??.
• - ?? ????? ??? 4????? ?? ??

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Common concerns

• Smoking
• -fetal injury, preterm birth, low birthweight
• -increased fetal carboxyhemoglobin
• reduced uteroplacental blood flow
• fetal hypoxia
• Alcohol
• -fetal alcohol syndrome
• growth restriction
• facial anomaly
• CNS dysfunction

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Common concerns

• Caffeine 
• -No evidence of teratogen reproductine risk
• Illicit Drugs
• -chronic use during pregnancy in large dose
  -opium
• derivative, barbiturate, amphetamineis-
  harmful to the fetus
•      -the sequence of drug withdrawal soon after
  birth          
• intrauterine distress
• low birthweight
• serious compromise
• Medications
• -?? ??? ????? ???? ??? ??? ? ??.
• -?? ? ??? ??? ??, ??? ?????? ???
• ?? ??? ???? ?? ? ?? ???? ???? ?
• ?.

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Common concerns

• Nausea Vomiting
• -???? common
• -?? ??? ??, ???? ??? ? ??.
• -??   not clear         
•      -?? 
•        eating small feedings at more frequent
  intervals
• ???? ?? ??
•          
• Backache
• - ???? ????? ?? ?? ??
• - ?? ??? ??
•         Reaching down ? ??? ???? ?? ??? ???
• ?? ? ??? ??? ???
• High-heeled shoes????        
•  -risk ??? back pain, obesity

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Common concerns

• Varicosities
• - generally resulting from congenital
  predisposition
• - ?? ??
•         prolonged standing
•        pregnancy
•      advancing age
• - ??
•         periodic rest with elevation of the legs
  
•     elastic stockings 
•          surgical correction during pregnancy
  is generally not advised
• Hemorrhoids 
• - ??? hemorrhoids? ??? ??
• - treatment
•        topical anesthetics
•         warm soaks
•  stool softner

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Common concerns

• Heartburn
• -most common
• -reflux of gastric contents
• -smaller meals avoidance of bending over
  lying flat
• Pica
• -interest in the alleged cravings for strange
  food
• Ptyatism
• -stimulation of salivary gland (unexplained)

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Common concerns

• Fatigue 
• - ????? ???? ???? fatigue desire for
• excessive periods of sleep ? ???
• Headache 
•   - ?? ??? ???.
• - ??? ? ? ?? ??? ?????
• - ?? ???? ???? ??? ??? ?? ?? ??.

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Common concerns

• - hyperestrogenemia? ?? cervical glands? mucus
  formation??? ??? ?? (not pathological)
•    
• Trichomoniasis
•         -?? ??? ???? 20?? ??.
•       -foamy yellowish leukorrhea with pruritus
  irritation  
• -?? metronidazole IV, PO -gt category B
• Candidiasis
• - ??? ???? ?25?? ??..
• - asymptomatic case require no treatment
• - ??? extremely profuse irritating
  discharge(curd-like) 
•              miconazole, clotrimazole, nystatin
  
•  - ??? ???, ?? ?? ?? ???.

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• Bacterial vaginosis
• - maldisposition of bacterial populations
   
• - Lactobacilli ?
• Anaerobic bacteria( Gardnerella
  vaginalis,
• Mobiluncus,
  some Bacterides ) ? 
• - ??
•             fish-smelling malodorous
   discharge-gt
• metranidazol 500mg
  bid po for 7 day