In India one woman dies every 5minutes from pregnancy related causes and about 80% fetal death occur in antepartum period due to maternal and fetal complications. Most of these deaths can be prevented or can be avoided if appropriate measures are taken and adequate care is available .To reduce maternal & perinatal mortality rate antenatal assessment plays an important role .In this unit we will discuss in detail about antenatal assessment.
DEFINITION:
Systematic examination and investigation of mother & fetus during pregnancy, is called -antenatal assessment.
AIMS
1.To screen high risk cases.
2.To prevent or to detect and treat at earliest any complication.
3.To ensure continued risk assessment & to provide ongoing primary preventive health care.
4. To educate the mother about the physiology of pregnancy labor.
5.To discuss with the couple about the place,time & mode of delivery& care of newborn. •
6. To ensure satisfactory growth and well being of the fetus throughout pregnancy.
7.To screen out the high risk factors that affect the growth of the fetus.
OBJECTIVE:-The objective is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
MONITORING MEASURES OF ANTENATAL ASSESSMENT:
Monitoring measures of antenatal assessment includes -
1.Maternal monitoring measures.
2.Fetal monitoring measures.
A. Maternal monitoring measures:
1.History taking:
A detailed history is gathered from the mother like biographical data, gravida, duration of marriage ,period of gestation, history of present pregnancy, history of any present illness, obstetric history, past medical history, past surgical history, family history etc.
2.Examination:
1.General examination-general examination of the mother includes head to toe examination to find out normal changes of pregnancy like skin changes, vital signs, breast examination, height and weight as well as any abnormal findings like examination for abnormal oedema and varicocities.
2.Abdominal examination:
The steps of of abdominal examination are:
1.Inspectiopn:- For shape & size and for visual fetal movements.
2.Skin changes:-linia nigra &striae gravidarum, LSCS scar..
3.Fundal height:- it should be correspondence to the period of amenorrhea (Measured after 12 weeks of pregnancy).
Note: Each 4weeks equal to a middle 3 finger width.
4.Abdominal girth.
5.Palpation: There are 4 types of palpation:
a.Fundal palpation (First maneuvers):- Used in assessment of fetal lie and position.
b.Lateral palpation(Second maneuvers):-Used to determine the position of fetal back.
c.Pelvic palpation(Third Maneuvers):-Used to determine fetal presentation & flexion of fetal head.
d.Pawlik's palpation(Fourth Maneuvers):-Used to know about the engagement of presenting part of the fetus.
6.Auscultation:-
Auscultation of fetal heart sound using stethoscope can be done by18-20 weeks of pregnancy to know that fetus is alive or not. Normal fetal heart rate is 120-160 beats/min.
3.Vaginal examination:-Vaginal examination is done for diagnosis of pregnancy and also to ensure normalcy and adequacy of pregnancy..
4. Laboratory investigation:
✓ Urinalysis: for sugar and protein.
✓ Complete blood count..
✓ABO Blood grouping and rhesus factor identification:- it is important to identify blood group and Rh factor, so that the hemolytic disease of newborn can be prevented and to prepare for blood transfusion when it is needed.
✓ VDRL test:- it is performed for identification of syphilis.
✓ HIV antibodies test:- it is performed to prevent vertical transmission of HIV to the fetus
5.Radiological examination:
*Ultrasound:- An imaging study which uses high frequency sound waves to create an image of internal organs. USG in obstetrics can be done by two approachges i.e. trans vaginal and trans abdominal method to check for fetal growth, to know about the due date of pregnancy, to check position of placenta, to identify any congenital malformation of the fetus,to check for amniotic fluid volume.
6.Biophysical profile:
It is the combination of five five fetal biophysical variables to assess fetal health.it was designated as biophysical profile by Manning et al.
* Non stress test:->2 acceleration of >15 bpmfor >15 sec. in 20 - 40 min
*Fetal breathing movement:->1 episode pf rhythmic breathing >30sec. within 30min.
*Fetal movement:->3 discrete body or limb movement within 30min.
*Fetal tone:->1 episode of movement of extremity with flexion or opening or closing of hands. *Amniotic fluid volume :-Single vertical pocket>2c.m.
Scoring
Min.-0
Max.-10
Interpretation:
10- Best score which indicates normal, non asphyxiated fetus.
0-2-Almost certain fetal asphyxia.
B. Fetal monitoring measures:
It includes two methods:
*Non-invasive methods
*Invasive methods
Non-invasive methods:
1. Ultrasound - To detect normal growth of the fetus & to detect any congerniatal malformation.
2.Fetal movement count:-Two methods are used :
*Cardiff count10 formula:
The fetal movement count starts at 9 AM & the counting comes to an end as soon as 10 movements are perceived.Less than 10 counts in 12 hours in2 succeessive days & no fetal movement must be reported to the gynaecologist
*Daily fetal movement count: Three counts each of 1 hour duration( morning,evening, night) than the no. of total counts is multiplied by four gives daily fetal movement count.
3. Non stress test:
It is the continuous monitoring & recording of the fetal heart rate with fetal movements. There is an observed association of fetal heart rate with fetal movement which when present indicates healthy fetus.
Interpretation:
a..Reactive: 2 or more acceleration of 15 beats per min. above baseline and of >15 sec. in 20 min. duration test.
b.Non-reactive :-No any fetal reactivity.
4.VAS ( Vibroacoustic stimulation): It is used to change the fetal sleep state from quiet sleep (non REM) to active sleep(REM) sieep.it is done prior to NST.
5.Contraction stress test:
It is the test which is performed during pregnancy to verify whether the unborn baby's heart is able to withstand labor. The fetal heart rate is analyzed in conduction with uterine contraction. Uterine contractions are induced either by nipple stimulation (release of oxytocin from posterior pituitary) or by use of oxytocin infusion.
6.Cardiotocography:
It is the continuous electronic fetal heart rate monitoring. The test is performed from 20 weeks onwards of pregnancy & the frequency is twice in a week.
Invasive methods :
1.Amniocentesis:
An ultrasonography guided procedure in which the amniotic fluid is taken from the uterus using a long needle inserted through abdominal wall. Through this test, we can detect various fetal anomalies like neural tube defect.
..Shake test: The test is performed using amniotic fluid to check for fetal lung maturity.
..Estimation of pulmonary surfactant: It is done by lecithin/sphingomyelin ratio estimation.At 35 weeks it is about 2.L/S ratio more than 2 indicates fetal lung maturity.
2.Chorionic villus sampling: An alternative of amniocentesis,to detect any chromosomal abnormalities.It can be performed earlier in pregnancy (9-13 weeks). A small sample of placenta is obtained from the uterus.
3.Cordocentesis:
This technique is used to withdraw a sample of blood during pregnancy in order to screen for chromosomal abnormalities and other disorders affecting bloods or cell.
Summary:
Antenatal assessment is the important aspect of antenatl care i9n order to deliver a healthy baby from a healthy mother. In this unit we discussed about the various antenatal assessment of mother & fetus.
Bibliography:
1. Dutta D.C."text book of obstetrics", & edition published by new central book agency (P) LTD.page no.106-125.
2.Fraser M.Diane & Cooper A MARGARET,"Myles test book for midwives 15 edition, published by oxford Churchill livingstone, page no.268 -277
. 3.Mudaliar AL & Menon Krishna MK"text book of clinical obstetrics" 11" edition published by Universities pess(india) private limited page no 86-89.
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