Antepartum Care:

Preconception and
Prenatal Care

Du Xue , PHD
Department of Obstetrics
& Gynecology
General Hospital of TianJin
Medical University
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 The importance and
definition of prenatal care
 Provide
---health promotion
---risk reduction
---diease prevention
 Definition: Prenatal care should be a
continuation of preconception counseling, a
physician-supervised program, provided for
the pregnant women.

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The objective of prenatal care
 to ensure every wanted pregnancy is
given the maximal chance of culminate
in the delivery of a healthy baby
 without impairing the health of the
mother.
 to prevent and manage conditions that
cause poor pregnancy outcomes.
•Premature labor and delivery, intrauterine
growth retardation, birth defects, perinatal
infections, post-term pregnancy
•hypertension, diabetes mellitus,
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The three basic Components
of pregnant care
 Early and continuing risk assessment
---a complete history
---a physical examination
---laboratory tests
---assessment of fetal growth and well-being
 Health promotion
 Medical and psychosocial interventions and follow-
up
---treatment of existing illness
---provision of resouces

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 Regular visit schedule
 The first visit may be in preconception or
most commonly present to the clinician
after missed menses.
 Additional prenatal visit are routinely
scheduled every 4 weeks until 28 week’s
gestation,every 2 to 3 weeks until 36
week’s gestation, and then weekly until
delivery.
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 The first prenatal visit
 Thorough history→
 A complete physical examination →
 routine test during pregnancy→
 Confirming Pregnancy and Determining Viability→
 Estimating Gestational age and Date of Confinement→
 Advice(alleviating unpleasant
symptoms,nutritional,lifestyle,breast feeding ):→
 Genetic Evaluation and Teratology （ omit ）

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 thorough history
 Medical history: (peripartum cardiomyopathy)
 Reproductive history:
1. Previous pregnancy history(preterm birth, low
birth weight, pre-eclampsia, stillbirth, DM)
2. Prior cesarean delivery circumstances(the cause of
cs,time ,fetal weight, et [Link] mode of current
pregnancy must be discussed).
 Family history
 Genetic history:congenital anomalies of
newborn or mother
 Nutritional history
 Social history/psychosocial history
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 Complete physical
examination
 Sign of normal pregnancy:
systolic murmurs, exaggerated splitting S3 during
cardiac auscultation, linea nigra(pigmentation on
midline of the lower abdomen), striae gravidarum on
inspection of the skin
 Breast examination:engorgement
 Pelvic examination:
uterus is soft and enlarge slightly. Hegar’s sign

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 Routine tests[1]

1. Complete blood count (anemia, leukemia and

thrombocytopenia)
 RBC COUNT and Hemoglobin and Hemotocrit
 WBC
 Platelet
2. Urinalysis and screen for bacteriuria (clean-catch
midstream urine specimen)
 protein, glucose, ketone body and et al.
 microscope examination (cast)
 other tests (bacterial culture or other methods)
3. Blood group, Rh factor, and antibody screen
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 Routine tests[2]
4. TORCH
 rubella antibody titer
 toxoplasma
 cytomegaly virus
 herpes simplex virus
 and others
5. Serology test for syphilis
6. hepatitis B surface antigen titer
7. test for HIV
8. Cervical cytology
 Threaten abortion
 cervical carcinoma 11
Commonly performed tests[1]
 blood glucose screen
 to screening GDM

 24-28 w for the first time

 50g glucose load: 1 hour 7.8mmol/L

 Glucose tolerance test

> 30y, obesity, family history of DM, previous
birth of macrosomic, previous stillbirth infant,
previous congenitally deformed infant, previous
polyhydramnious, history of recurrent abortions,
glycouria, previous gestational diabetes

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Commonly performed tests[2]
 AFP: serum а-fetoprotein (open neural tube defect)
 Ultrasonagraphy
 to confirm the gestational week if last menstrual
period is uncertain
 To distinguish congenital anomalies

 18-24 weeks(22w)

 Screeniong for the down”s syndrome and

congenital anomalies

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Estimating Gestational age and
date of confinement
 Accurate determination of gestational
age is very important for the
management of obstetric conditions such
as preterm labor,IUGR,postdate
pregnancy.
 LMP:the first day of the last menstrual
period
 EDC:adding 9 months and 7 days to the
LMP.
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Confirming Pregnancy and
Determining viability
 Pregnancy test
 Transvaginal ultrasonography
 Early pregnancy sign
 Physical examination

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 Pregnancy test
 Detects Human chorionic gonadotropin(hCG) in the
serum or the urine.
 first detectable 6 to 8 days after ovulation.
1. less than 5 IU/L : negtive,
2. above 25 IU/L :positive
3. 6~24 IU/L : equivocal, again in 2 days.
 In the first 30 days of a normal gestation, the level
of hCG doubles every 2.2 days,but in patients whose
pregnancies are destined to abort, the level of hCG
rises more slowly,plateaus,or declines.
 It’s important to differentiate a normal pregnancy
from a nonviable abort or ectopic gestation. 17
 Transvaginal
ultrasonography(1)
 Relationship between ultrasonography and hCG
Weeks---ultrasonography------hCG(IU/L)
5---------gestational sac------------1500
6---------fetal pole ------------------5200
7---------fetal cardiac motion-----17,500
 probable embryonic demise :
--gestational sac of 8 mm(mean sac diameter) without
a demonstrable yolk sac,
--16mm without a demonstrable embryo,
--or the absence of fetal cardiac motion in an embryo
with a crown-rump length of greater than 5 mm 18
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Advice(1) :Alleviating unpleasant
symptoms during pregnancy
 Nausea and vomiting
 Heartburn
 Constipation
 Hemorrhoids
 Leg cramps
 Backaches

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 Advice (2):Nutritional counseling

 BMI(Body mass index) =weight(kg)/height(m)2

BMI(before pregnancy) weight gained(pounds)
<19.8(underweight) 28-40
19.8~26(normalweight) 25-35
> 26 (overweight) 15-25
 Advice on nutrition
--balanced for at least 3 months before conception.
--obese is the great risk for obstetric complications,
(e.g. GDM,PIH, femal macrosomia)
 Sudden weight gain in the third trimester is a warning
sign of impending pre-eclampsia.

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Advice (2):Nutritional counseling
 Inadequate weight gain or <10pounds at 28 weeks is
associated with the risk of premature labor or IUGR
 Vitamin and iron supplementation:
--folic acid at least 0.4mg daily （ scrinanen 0.4mg,qd)
--ferrous iron
 non-anemia :30mg/d
 anemia patients:120mg/d for at least 6 weeks
--copper and zinc (for iron-taking anemic patients)
--vitamin A (excessive is not benificial )
--calcium supplement

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 Advice (3):Lifestyle
 Exercise:beneficial, same level, avoid Aggressive
exercise
 Work: Avoid fatigue,Heavy forms or Stressful work
(risk of preterm delivery and poor fetal growth)
 Travel and change in residence: Avoid fatigue and
stress
 Sexual intercourse: second trimester pregnancy
except in patients at risk for abortion or preterm labor,
or in patients with placenta previa.
 Breast stimulation can induce uterine activity.
 Labor may follow coitus near term.

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Follow-up visits--Objectives
 To monitor the pregression of the
pregnancy
 To provide education and recommended
screening and interventions
 To assess the well-being of the fetus
and the mother
 To detect and treat medical and
psychsocial complications

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 Follow-up visits(1)
 History:
--abnormal symptoms(preterm labor, pre-
eclampsia,labor near term)
--fetal movements(>20w)
--confirm gestational week
 PE:
--Genenal examinations:
----Weight gain,
----Bp(systolic and diastolic)
----HR(arrythmia ,Atrial tachycardiac, Vetricular
premature contraction)
----Edema
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 Follow-up visits(2)
--Abdomen examination(maneuvers of leopold)
---->28w
----Lie,positation,presentation
----uterine size
 Test:
--blood rutine (Hb)
--urine rutine(protein,glucose,ket)
--universal Screening for GDM(24-28w)
--repeated Test (sexually transmitted infections,
eg,syphilis)
--screening for maternal clonization of Group B
streptococcus(35-37 w)
--B ultrasonography and so on
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 Fundus height
 from the symphysis pubis to the top of the
fundus
 The discrepancy of greater than 2 to 3cm
suggests a size-for-dates problem
 Multiple gestation (size at least 3 cm more
than expected for dates)
 Intrauterine growth retardation (size at least
3 cm less than expected for dates)

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 lie
 Definition:
--the relationship of the long axis of the
fetus to the long axis of the mother.
 Class:

--Longitudinal
--transverse
--oblique

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 Lie
Longitudinal
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 Lie
Tansverse

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 Presentation
 Definition:
--the portion of the fetus that descends
first through the birth canal
 Class:
--longitudinal
----head(cephalic presentation)
----breech(breech presentation)
--Transverse
----shoulder

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 Presentation

head breech shoulder

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 Position
 Definination
--refers to the relationship of some definite part of the
fetus (the denominator ) to the maternal pelvis
 Denominator
----vertex ------------- occiput(O) --mentum(chin)
----breech------------- sacrum(S)
----Transverse-------- Scapula(Sc)
 Left or right
 Anterior, posterior, transverse (Occiput)
 Class
----LOA,LOP,LOT,ROA,ROP,ROT
----LMA,LMP,LMT,RMA,RMP,RMT
----LSA,LSP,LST,RSA,RSP,RST
----LScA,LScP,RScA,RScP 38
 Leopold maneuvers
 To determine the fetal location within
the uterus
 To be carried out at each visit during
the third trimester
 To identify an abnormal lie,
presentation, or position of the fetus.

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The procedure of Leopold
maneuvers--1

 To determine which
part of the fetus
occupies the fundus
 head(round,hard)
breech(irregular,soft)

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The procedure of Leopold
maneuvers--2

 To determine which
side the fetal back
lies
 back(linear,firm)
extemities(multiple
parts)

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The procedure of Leopold
maneuvers--3

 To determine the
presenting
part(head, breech)
 grasp the part using
thumb and the
finger, above the
symphysis
)

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The procedure of Leopold
maneuvers--4
 To determine the
fetal head position
(vertex)
 place both hands on
the lower abdomen
above the inlet
 press in the direction
of the inlet
 touch the occiput
(extended) or
brow(flexed)

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 Assessment of fetal
well-being

 Maternal assessment: fetal

movement(3/h)
 Nonstress test [learn on job]
 Ultrasonic assessment (real-time)
 Biophysical profile testing
 Contraction stress test [learn on
job]

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 Nonstress test
 Fetal heart beat response to fetal motion (degree and
time)
--Left lateral supine position
--20 minutes
 Reactive
--2 fetal motions
--fetal heart rate acceleration >15 bpm
-- acceleration >15 bpm for at least 15 senconds.
--Basic fetal heart beat:120-160/min
--Basic Fetal heart beat variation> 15 bpm
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 Ultrasonic assessment
 To determine the adequary of the amniotic fluid
 AFI(the amniotic fluid index)
----represents the total of the linear measurements in
centimeter of the largest amniotic fluid pockets noted
on the ultrasonic inspection of each of the four
quadrants of the gestational sac
----Oligohydramnios: AFI less than 5
----Polyhydramnios: AFI more than 23
 Fetal breathing (30/10min)
 fetal movements(3/10min)
 Placenta maturation (calcification)
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Biophysical profile test
 NST
 Amniotic fluid
 Muscle movement
 Respiratory movement
 Fetal tone

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 Contraction stress test
 To determine the uteroplacental function
 Definition: A diluted oxytocin is given to
establish at least 3 uterine contractions in
10 minutes
 Positive: late decelerations with each
contraction---delivered
 Suspicious: only one deceleration is
observed.

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Questions
1. How to culculate EDC recording to LMP
2. How to confirm pregnancy by test
3. What is the procedure of Leopold
maneuvers
4. How to assess NST/CST
5. Which parameter the biophysical profile
test includes
6. Definitions:
TORCH,Lie,Presentation,position

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