Ante-Natal Care

Screening is the systematic testing of asymptomatic individuals for the disease so that early and more effective treatment may be given. In this context the common say of "prevention is better than cure" cannot be better applied to any situation more than ante-natal care. As a matter of fact this ante natal care should start even before pregnancy. Every woman, and for that matter evey man, should check that their health is at its best before starting a family. These ideas should therefore be more widely spread by all agencies responsible for health promotion and education.

Pre marriage and pre conception counselling should be thought and everybody should go for such counseling so as they can start their family life at a healthier basis. This is particularly applicable to close relative marriages like first degree cousins or families who have particularly known abnormalities. It is of interest to note that there are 6,000 different inherited abnormalities, of which 370 are chromosomally linked. At the time of counseling various illnesses can be discussed.

At The British Clinic, a comprehensive ante-natal care is provided following the NICE (National Institute for Health and Clinical Excellence) guidelines, United Kingdom. This includes the routine screening tests as well as PAPP-A test, ultrasound scanning using 3D/4D technology, nuchal transluscency measurement, Doppler and foetal echocardiography and foetal morphology/anomaly scan, CTG monitoring as well as the non-invasive prenatal genetic tests to identify foetal trisomies 21, 18 & 13, monosomy and sex chromosome linked abnormality.


The British Clinic offers pregnant women with the following conditions additional care :

  • Cardiac disease, including hypertension
  • Renal disease
  • Endocrine disorders or diabetes requiring insulin
  • Psychiatric disorders (being treated with medication)
  • Hematological disorders
  • Autoimmune disorders
  • Epilepsy requiring anticonvulsant drugs
  • Malignant disease
  • Severe asthma
  • Obesity (body mass index 30 kg/m2 or above) or underweight (body mass index below 18 kg/m2)
  • Higher risk of developing complications, for example, women aged 40 and older, women who smoke
  • Women who are particularly vulnerable (such as teenagers) or who needs social support


The British Clinic offers pregnant women who have experienced any of the following conditions in previous pregnancies  additional care :

  • Recurrent miscarriage (three or more)
  • Preterm birth
  • Severe pre-eclampsia, HELLP syndrome or eclampsia
  • Rhesus isoimmunisation or other significant blood group antibodies
  • Uerine surgery including caesarean section, myomectomy or cone biopsy
  • Antenatal or postpartum haemorrhage on two occasions
  • Puerperal psychosis
  • Grand multiparity (more than six pregnancies)
  • A stillbirth or neonatal death
  • A small-for-gestational-age infant (below 5th centile)
  • A  large-for-gestational-age infant (above 95th centile)
  • A baby weighing below 2.5 kg or above 4.5 kg
  • A baby with a congenital abnormality (structural or chromosomal).


THE BRITISH CLINIC NORMAL SCHEDULED ANTE-NATAL CARE AS FOLLOWS :


First Antenatal visit booking (ideally before 10 WEEKS)

Activity

  • Medical and family history including risk  profiles
  • Confirming pregnancy; Pregnancy test.
  • Clinical examination, breast, chest, heart, legs, teeth, abdomen, height, weight/BMI, pulse rate, temperature and blood pressure.
  • Blood tests for: Rubella susceptibility, Toxoplasma, CMV (Cytomegalovirus), HIV , Varicella, VDRL/RPR, Hep.B virus, CBC, Vit D, Haemoglobinopathy screening, ABO/Rh/Ab screen
  • Others as indicated.
  • Urine – dipstick and C&S
  • Vaginal ultrasound scanning
  • Cervical cancer screening  (if there is suspicious history)


Counseling and Education

  • Physical activity
  • Nutrition & diet including prenatal vitamins,  Vit D supplements, folic acid.
  • Progesterone, aspirin, DHEA support as indicated.
  • Nausea and vomiting
  • Importance of continuity of care
  • Physiology of pregnancy
  • Discuss antenatal screening including fetal aneuploidy screening.
  • Genetic Counseling


11-14 Weeks

Activity

  • Accurate recording of menstrual date
  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine – dipstick
  • Preterm labour screening
  • Review labs from previous visit
  • Ultrasound scanning, nuchal transluscency (NT), foetal nose.
  • Doppler ultrasound Resistance Index (R.I.)
  • Pulsatility Index (P.I.)
  • Mean Vascular Cerebral Velocity etc.
  • PAPP-A testing.
  • Offer  prenatal trisomies, monosomy, aneuploidies and sex chromosome testing.
  • Chorionic villus sampling (CVS) if indicated.
  • Schedule Anomaly scan to be done 20-22 weeks
  • If amniocentesis is indicated, this would be done after 16 weeks.


Counseling and Education

  • Nutrition and weight
  • List of medications, herbal supplements, vitamins.
  • Foetal growth
  • Breast feeding
  • Nausea & vomiting
  • Physiology of pregnancy
  • Follow-up of modifiable risk factors
  • Unsensitized Rh negative women require RhoGAM at 16 weeks, 25 weeks , 28 weeks and 34 weeks.
  • Continuity of care


18-22 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine dipstick
  • Foetal morphology/anomaly ultrasound.
  • Placental localization scan.


Counseling and Education

  • Follow-up of modifiable risk factors
  • Classes
  • Family issues
  • Length of stay
  • Gestational Diabetes mellitus (GDM)
  • Continuity of care


22-24 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Gestational Diabetes Mellitus screening (GTT)
  • HVS Culture for group B streptococcus
  • Repeat Rh antibody screen (if Rh negative)
  • CBC
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration , thickness, etc.


Counseling and Education

  • Follow-up modifiable risk factors
  • Discussing plans for work
  • Physiology of pregnancy
  • Foetal growth
  • Awareness of foetal movement
  • Continuity of care


28-30 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration , thickness, etc.
  • CTG monitoring at 30 weeks
  • RhoGAM at 28 weeks (If Rh negative)



Counseling and Education

  • Continuity of care
  • The value of stem cell/cord blood storage to be discussed.


32 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration , thickness, etc.
  • CTG monitoring




Counseling and Education

  • Continuity of care


34 WEEKS


Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration, thickness, etc.
  • CTG monitoring
  • RHoGAM at 34 weeks (If Rh negative)


Counseling and Education

  • Follow-up of modifiable risk factors
  • Travel
  • Breastfeeding
  • Episiotomy
  • Labor & delivery issues
  • Warning signs/pregnancy induced hypertension
  • Vaginal birth after cesarean (VBAC)
  • If elective caesarean section to be scheduled for 38 weeks


36 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Pelvic assessment
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration, thickness, etc.
  • CTG monitoring
  • HVS Culture for group B streptococcus



Counseling and Education

  • Follow-up of modifiable risk factors
  • Postpartum care
  • Breastfeeding
  • Pediatric care (care of new baby, vit K)
  • When to call the doctor
  • Vaginal birth after cesarean (VBAC)
  • Caesarean Section (C-S) consents and discussion of pain management
  • Epidural
  • TENS machine/relaxation/hypnotherapy
  • Consider weekly visits


37 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration , thickness, etc.
  • CTG monitoring
  • Pre-operative blood investigations


Counseling and Education

  • Continuity of care
  • Labour & delivery update


38 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Urine dipstick
  • Confirm fetal position by ultrasound scanning
  • Doppler ultrasound R.I., P.I., etc.
  • Placental scanning for volume, penetration , thickness, etc.
  • CTG monitoring
  • CBC



Counseling and Education

  • Follow-up of modifiable risk factors
  • Postpartum vaccinations
  • Options for post-term pregnancy
  • Labour & delivery update
  • Decision regarding stem cell/cord blood storage


39 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Pelvic assessment
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I, P.I., etc.
  • Placental scanning for volume, penetration, thickness, etc.
  • CTG monitoring



Counseling and Education

  • Continuity of care


40 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Fundal height
  • Pelvic assessment
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I, P.I., etc.
  • Placental scanning for volume, penetration, thickness, etc.
  • CTG monitoring


Counseling and Education

  • Continuity of care


41 WEEKS

Activity

  • Weight /BMI, blood pressure
  • Foetal heart tones
  • Pelvic assessment
  • Urine dipstick
  • Ultrasound scanning
  • Doppler ultrasound R.I, P.I., etc.
  • Placental scanning for volume, penetration, thickness, etc.
  • CTG monitoring
  • Offer membrane sweep
  • Offer induction of labour



Counseling and Education

  • Follow-up of modifiable risk factors


THE BIRTH

Normal Vaginal Birth

  • Normal vaginal birth is always aimed for. Husband’s presence encouraged. (Note that normal birth is a retrospective diagnosis)
  • Pre-operative blood investigations and pre-admission assessment to be completed.
  • If induction is decided, admission the night before. Prostaglandin vaginal application administered. Next morning, artificial ruptured of membranes (ARM) is done and Oxytocin drip starts.
  • Epidural analgesia to be instituted, if decided.
  • Early mobilization encouraged.
  • Expect hospital stay 48 hours


Caesarean section Birth

  • If elective caesarean section is planned . Pre-operative blood investigations and pre-admission assessment to be completed.
  • General anaesthesia or regional analgesia to be decided.
  • Early mobilization encouraged.
  • Expect hospital stay 3-4 days.



POST NATAL

  • During hospital stay, breast feeding encouraged and attending baby’s needs, instructions are given.
  • Early mobilization encouraged.
  • Pelvic floor exercises and physiotherapy.
  • When discharged, clinic follow-up visit in one week.

 


POST NATAL CHECK-UP

  • Check CBC, episiotomy or caesarean section scar and change dressing.
  • Check involution of uterus and lochia.
  • Check breasts
  • Discuss contraception
  • Discuss family support
  • Advice 6 weeks post partum check up.

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