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Antenatal Care
About
Dr.Samina Zafar
Throughout your pregnancy you
should have regular care, either at a hospital antenatal clinic or with your own
GP or midwife. This is to check that you and the baby are well and so that any
problems can be picked up as early as possible. This is the time to get answers
to any questions or worries and to discuss plans for your baby's birth.
The first visit
Most women have their first, and
longest, antenatal check-up around the 8th to 12th week of pregnancy. The
earlier you go the better. You should allow plenty of time as you will probably
see a midwife and a doctor, and may be offered an ultrasound scan.
Questions
You can expect a lot of
questions on your health, on any illnesses and operations you have had, and on
any previous pregnancies or miscarriages. You will be asked for any information
you have on your own family and your husband's family (whether there are twins
on your side or any inherited illness, for example).
All this
information will help to build up a picture of you and your pregnancy so that
any special risks can be spotted and support provided.
The
midwife or doctor will want to know the date of the first day of your last
period, to work out when the baby is due. You will probably want to ask a
lot of questions yourself. This is a good opportunity. It's important to find
out what you want to know and to express your own feelings and preferences.
Let your
midwife or doctor know if:
- there
were any complications in a previous pregnancy or delivery, such as pre-eclampsia
or premature delivery;
- you
are being treated for a chronic disease such as diabetes or high blood
pressure;
- you, or
anyone in your family, have previously had a baby with an abnormality, or
there is a family history of an inherited disease such as thalassaemia.
Weight
You'll be weighed. From now
on, your weight gain will probably be checked regularly, although this is not
done everywhere. Most women put on between 10 and 12.5 kg (22-28 lbs) in
pregnancy, most of it after the 20th week. Much of the extra weight is due to
the baby growing, but your body will also be storing fat ready to make breast
milk after the birth.
Height
Your height will be recorded
on the first visit because it is a rough guide to the size of your pelvis. Some
small women have small pelvises and although they often have small babies they
may need to discuss their baby's delivery with their doctor or midwife.
General
physical examination
The doctor will check your
heart and lungs and make sure your general health is good.
Urine
You will be asked to give a
sample of urine each time you visit. This will be checked for a number of things
including:
- sugar
- pregnant women may have sugar in their urine from time to time but, if it
is found repeatedly, you will be checked for diabetes (some women develop a
type of diabetes in pregnancy known as 'gestational diabetes' which can be
controlled during pregnancy usually by a change of diet and, possibly,
insulin; the condition usually disappears once the baby is born);
- protein,
or 'albumin', in your urine may show that there is an infection that needs
to be treated; it may also be a sign of pregnancy-induced hypertension
Blood
pressure
Your blood pressure will be
taken at every antenatal visit. A rise in blood pressure later in pregnancy
could be a sign of Pre-eclampsia
Blood
tests
You will be asked for a blood
test to carry out a number of checks. Discuss these with your doctor. The tests
are for:
- your
blood group;
- whether
your blood is rhesus negative or positive - a few mothers are rhesus
negative (usually this is not a worry for the first pregnancy. Some rhesus
negative mothers will need an injection after the birth of their first baby
to protect their next baby from anaemia; in some units, rhesus negative
mothers are given injections called 'anti-D' at 28 and 34 weeks as well as
after the birth of their baby - this is quite safe and is done to make sure
that the blood of future babies is not affected by rhesus disease;
- whether
you are anaemic - if you are, you will probably be given iron and folic acid
tablets to take (anaemia makes you tired and less able to cope with losing
blood at delivery);
- your
immunity to rubella (German measles) - if you get rubella in early
pregnancy, it can seriously damage your unborn baby and if you are not
immune to rubella and come into contact with it, blood tests will show
whether you have been infected; if so, you'll be offered the option of
ending your pregnancy after discussing the possible problems your baby might
have;
- for
syphilis - it is vital to detect and treat any woman who has this sexually
transmitted infection as early as possible;
- for
hepatitis B- this is a virus that can cause liver disease and may infect the
baby if you are a carrier of the virus or are infected during pregnancy.
Your baby can be immunized at birth to prevent infection, so you will be
offered a test to check if you are carrying the virus.
Tests
A number of tests will be performed
at your first visit, and some of these will be repeated at later visits. You are
under no obligation to have any test, although they are all done to help make
your pregnancy safer or to help assess the well-being of your baby. If you are
found to be HIV positive, or already know that you are, your doctor will need to
discuss the management of your pregnancy and delivery with you.
- There
is a 1 in 6 chance of your baby being infected.
- 20%
of HIV infected babies develop AIDS or die within the first year of life, so
it's important to reduce the risk of transmission.
- Treatment
may reduce the risk of transmitting HIV from you to the
baby.
- Your
labour will be managed to reduce the risk of infection to your baby. This
may include an elective Caesarean delivery.
- Your
baby will be tested for HIV at birth and at intervals for up to two years.
If the baby is found to be HIV infected, pediatricians will be able to
anticipate certain illnesses, which occur in infected babies, and so treat
them early. All babies born to HIV positive mothers will appear to be HIV
positive at birth but many later test negative because antibodies passed to
them by their mothers disappear.
- You
will be advised not to breastfeed because HIV can be transmitted to your
baby in this way.
Internal
examination
Occasionally, the doctor
might consider it necessary to do an internal examination. You can discuss the
reasons for this with the doctor. By putting one or two fingers inside your
vagina and pressing the other hand on your abdomen, your doctor can judge the
age of your baby. Most doctors prefer to use an ultrasound scan for this purpose
either at the first or a later visit.
Cervical
smear
You will be offered a
cervical smear test now if you haven't had one in the last three years. The test
detects early changes in the cervix (the neck of the womb), which could later
lead to cancer if left untreated. By sliding an instrument called a speculum
into your vagina, the doctor can look at your cervix. A smear is then taken from
the surface of the cervix and will be examined under a microscope. The test may
feel a bit uncomfortable but it is not painful and won't harm the growing baby.
Herpes
If you, or your partner, have
ever had genital herpes, or you get your first attack of genital blisters or
ulcers during your pregnancy, let your doctor or midwife know. This is important
because herpes can be dangerous for your newborn baby and he or she may need
treatment.
Later visits
Later visits are usually shorter.
Your urine and blood pressure, and often your weight, will be checked. Your
abdomen will be felt to check the baby's position and growth. And the doctor or
midwife will listen to your baby's heartbeat. You can also ask questions or talk
about anything that is worrying you. Talking is as much a part of antenatal care
as all the tests and examinations.
From now
on, antenatal checks will usually be every four weeks until 28 weeks, every two
weeks until 36 weeks, and then every week until the baby is born. If pregnancy
is uncomplicated, you may be offered the option of less frequent antenatal
appointments.
Ultrasound
scan
This test uses sound waves to
build up a picture of the baby in the womb. Most hospitals will offer women at
least one ultrasound scan during their pregnancy. An ultrasound scan can be used
to:
- check
the baby's measurements - this gives a better idea of the baby's age and can
help decide when your baby is likely to be born - this can be useful if you
are unsure about the date of your last period or if your menstrual cycle is
long, short or irregular; your due date may be adjusted according to
ultrasound measurements;
- check
whether you are carrying more than one baby;
- detect
some abnormalities, particularly in the baby's head or spine;
- show
the position of the baby and the placenta - in some cases, for example where
the placenta is low in late pregnancy, special care may be needed at
delivery or a Caesarean section may be advised;
- check
that the baby is growing and developing normally (this is particularly
important if you are carrying twins or more).
The scan
is completely painless, has no known serious side-effects on mothers or their
babies, and can be carried out at any stage of pregnancy. Most hospitals scan
all women at 18 to 20 weeks to check for certain abnormalities.
You will
probably be asked to drink a lot of fluid before you have the scan. A full
bladder pushes your womb up and this gives a better picture. You then lie on
your back and some jelly is put on your abdomen. An instrument is passed
backwards and forwards over your skin and high-frequency sound is beamed through
your abdomen into the womb. The sound is reflected back and creates a picture,
which is shown on a TV screen. Since ultrasound provides an image of the baby in
the womb, it detects structural abnormalities, particularly of the spine and
head. Recently, however, it has been found to be useful in screening for Down's
syndrome and some other abnormalities of chromosome number.
Alpha-fetoprotein
(AFP) test
This test is performed at
about 15 to 20 weeks to find out the level of alpha-fetoprotein (AFP) in your
blood. This protein is made by your baby and passes into your blood during
pregnancy. High levels are associated with spina bifida and so an ultrasound
scan will then be offered to check for this. High levels may be seen in normal
pregnancy and also in twin pregnancy. Low levels of AFP are associated with
Down's syndrome pregnancies. Ultrasound and amniocentesis will then be suggested
to achieve a diagnosis.
Serum
screening
This is the term used for a
test of the mother's blood, which screens for Down's syndrome. It combines the
AFP result (and so gives information about the risk of spina bifida) with the
measurement of other blood chemicals to give the relative risk of having a baby
with Down's syndrome. There are various tests available ('double test', 'triple
plus test', etc.) which differ slightly from each other, but they are all types
of serum screening. They are not helpful in twin or other multiple pregnancies.
Some units
give the result as 'screen negative' or 'screen positive'. A negative result
means that Down's syndrome is unlikely. A positive result means that Down's
syndrome is more likely. An amniocentesis will be suggested to give more
information. Other units give a numerical result, for example 1:250 risk of
Down's syndrome. You may like to compare this risk to that for your age (about
1:900 at 30) or to the risk of miscarriage with amniocentesis (about 1:100).
Your doctor will explain the significance of the result to you.
Amniocentesis
This test may be performed
from 14 weeks of pregnancy:
- to
women who have an AFP, serum screening or nuchal translucency scan result
which indicates an increased risk of Down's syndrome;
- when
an ultrasound scan detects an abnormality which is associated with a genetic
disorder;
- when
a woman's past or family history suggests that there may be a risk of her
baby having a genetic disorder such as Down's syndrome.
An
ultrasound scan is performed to check the position of the baby and placenta.
Whilst continuing to scan with the ultrasound probe, a fine needle is passed
through the wall of the abdomen into the amniotic fluid which surrounds the
baby. A small sample of this fluid is drawn off and sent to the laboratory for
testing. Most women feel only mild discomfort.
Within the
fluid are cells, which contain the same chromosomes as the baby. Looking at
these chromosomes is a complex process, which is why the results take up to
three weeks. This test will reveal your baby's sex. Some disorders such as
haemophilia and muscular dystrophy are only found in boys (although girls may
carry the disorder in their chromosomes and pass it on to their sons). Tell your
doctor if these or other genetic disorders run in your family, as it may then be
important to know your baby's sex.
Amniocentesis
is associated with a 0.5-1% risk of miscarriage. At most, one test in a hundred
will result in pregnancy loss. When deciding whether or not to go ahead with
this test try to balance the risk of miscarriage against the value of the result
to you. Remember that a normal result only reassures you about the number of
chromosomes unless specific tests for disorders such as cystic fibrosis have
been done.
Chorionic
villus sampling (CVS)
This test is usually only
available in large hospitals but smaller units are able to refer to these units
if necessary. It tests for genetic disorders. It does not give information about
spina bifida.
CVS can be
carried out earlier than amniocentesis at around ten weeks but may carry a
slightly higher risk of miscarriage, at about 1%. CVS before ten weeks has been
associated with a slightly increased risk of limb deformities. Women at risk of
having a child with an inherited disorder such as cystic fibrosis or muscular
dystrophy may accept the increased risk of miscarriage in order to obtain an
earlier diagnosis.
The test
takes 10 to 20 minutes and may be a little uncomfortable. Using ultrasound as a
guide, a fine needle is passed through the woman's abdomen, or sometimes a fine
tube through the vagina and cervix, into the womb. A tiny piece of the
developing placenta, known as chorionic tissue, is withdrawn. Again, the
chromosomes in the cells of this tissue are looked at.
The
results take up to two weeks.
POSITION
The following abbreviations
are used to describe the way the baby is lying - facing sideways, for example,
or frontward or backwards. Ask your doctor to explain the way your baby is
lying.
Relation
to brim At the end of
pregnancy your baby's head (or bottom, or feet if it is in the breech position)
will start to move into your pelvis. Doctors 'divide' the baby's head into
'fifths' and describe how far it has moved down into the pelvis by judging how
many 'fifths' of the head they can feel above the brim (the bone at the front).
They may
say that the head is 'engaged' - this is when 2/5 or less of the baby's
head can be 'felt' (palpated) above the brim. This may not happen until you are
in labour. If all of the baby's head can be felt above the brim, this is
described as 'free' or 5/5 'palpable'.
Blood
pressure (BP) This
usually stays at about the same level throughout pregnancy. If it goes up a lot
in the last half of pregnancy, it may be a sign of pre-eclampsia which can be
dangerous for you and your baby
Fetal
heart 'FHH' or
just 'H' means 'fetal heart heard'. 'FMF' means 'fetal movement felt'.
Oedema
This is another word for swelling, most often of the feet and hands.
Usually it is nothing to worry about, but tell your doctor if it suddenly gets
worse as this may be a sign of pre-eclampsia.
Hb This
stands for 'haemoglobin'. It is tested in your blood sample to check you are not
anaemic.
Date
This is the date of your
antenatal visit.
Weeks
This refers to the length of your pregnancy in weeks from the date of
your last menstrual period.
Presentation
This refers to which way
up the baby is. Up to about 30 weeks, the baby moves about a lot. Then it
usually settles into its head downward position, ready to be born head first.
This is recorded as 'Vx' (vertex) or 'C' or 'ceph'
(cephalic). Both words mean the top of the head. If your baby stays with its
bottom downwards, this is a breech ('Br') presentation. 'PP' means
presenting part, that is the bit of the baby that is coming first. 'Tr'
(transverse) means your baby is lying across your tummy.
Urine
These are the results of your urine tests for protein and sugar. '+' or
'Tr' means a quantity (or trace) has been found. 'Alb' stands for 'albumin',
a name for one of the proteins detected in urine. 'Nil' or a tick or 'NAD' all
mean the same: nothing abnormal discovered. 'Ketones' may be found if you
have not eaten recently or have been vomiting.
Height
of fundus By gently
pressing on your abdomen, the doctor or midwife can feel your womb. Early in
pregnancy the top of the womb, or 'fundus', can be felt low down, below
your navel. Towards the end it is well up above your navel, just under your
breasts. So the height of the fundus is a guide to how many weeks pregnant you
are. This column gives the length of your pregnancy, in weeks, estimated
according to the position of the fundus. The figure should be roughly the same
as the figure in the 'weeks' column. If there's a big difference (say, more than
two weeks), ask your doctor about it. Sometimes the height of the fundus may be
measured with a tape measure and the result entered on your card
in centimetres.
Making the most of Antenatal Care
Having regular antenatal care is
important for your health and the health of your baby. However,
sometimes-antenatal visits can seem quite an effort. If the clinic is busy or
short-staffed you may have to wait a long time and, if you have small children
with you, this can be very exhausting. Try to plan ahead to make your visits
easier and come prepared to wait.
At your
first antenatal visit, your doctor will enter your details in a record book and
add to them at each visit. Take your notes or card with you wherever you go.
Then, if you need medical attention while you are away from home, you will have
the information that's needed with you.
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