PRENATAL CARE

WILLIAMS OBSTETRICS 22nd edition

Chapter 8
Page 201-205
Menik Utami
Resident Obstetric Ginecology
Dr. Soetomo Hospital- Airlangga University

Introduction

1901 : Mrs. William Lowell Putnam began a

program of nurse visits to women enrolled in
the home delivery service of the Boston Lyingin Hospital.
1911 : this work was successful that an
outpatient prenatal clinic was established
1915 : J. Whitridge Williams reviewed 10,000
consecutive deliveries at Johns Hopkins
Hospital and concluded that 40 percent of 705
perinatal deaths could have been prevented
by prenatal care

Introduction

1954 : Nicholas J. Eastman credited organized

prenatal care
1960s : Jack Pritchard established a network of
neighborhood prenatal clinics located in the most
underserved communities in Dallas County
1990 : Merkatz and colleagues Organized
prenatal care in the United States was introduced
largely by social reformers and nurses.
In large part because of increased accessibility,
approximately 95 percent of medically indigent
women now delivering at Parkland Hospital
receive prenatal care

Importantly, many of these complications are treatable.

Frequency distribution of the number of

prenatal visits for the United States in 2001

Median 12,3
visits per
pregnancy

Percent of women in the United States with

prenatal care beginning in the first trimester
by ethnicity, 1989 compared with 2001

Inadequate Prenatal Care

KESSNER INDEX CRITERIA
Reasons for inadequate
prenatal care varied by
social and ethnic group,
age,
and
method
of
payment.
The most common reason
cited was that the woman
did not know she was
pregnant.
The
second
most
commonly cited barrier
was lack of money or
insurance for such care.
The third was inability to
obtain an appointment.

Effectiveness of Prenatal
Care

Over the past several decades, some have

concluded that prenatal care offers no benefits,
and indeed may be disadvantageous
Fiscella (1995) found no conclusive evidence
that prenatal care improved birth outcomes
Kogan and colleagues,(1998) when use of
prenatal care increased substantively, the rates
of low-birthweight and preterm birth increased in
the United States
Herbst and associates (2003) found that failure
to obtain prenatal care was associated with more
than a twofold increased risk of preterm birth

Effectiveness of Prenatal
Care

Vintzileos and colleagues (2002b) analyzed data for

the years 1995 to 1997 from the National Center for
Health found that prenatal care was associated with
an overall fetal death rate of 2.7 per 1000 compared
with 14.1 per 1000 for women without prenatal care.
Stated differently, failure to receive prenatal care
increased the adjusted relative risk of stillbirth 3.3-fold
Vintzileos and colleagues (2002a) reported that
prenatal care significantly lowered the rate of neonatal
death associated with several high-risk conditions,
including placenta previa, fetal growth restriction, and
postterm pregnancy. They also found that prenatal
care was associated with fewer preterm births

Effectiveness of Prenatal
Care

Prenatal care undoubtedly contributed to the

dramatic decline in maternal mortality from
690 per 100,000 births in 1920 to 50 per
100,000 by 1955 (Loudon, 1992)
Harper and co-workers (2003) found that
the risk of pregnancy-related maternal death
was decreased fivefold among recipients of
prenatal care.
Thus, in this context, prenatal care is not an
end in itself but an initial step for coordinated
intrapartum and postpartum care that often
extends even beyond into a woman's later life.

Organization of Prenatal
Care
The American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2002)
have defined prenatal care as: "A comprehensive
antepartum care program that involves a
coordinated approach to medical care and
psychosocial support that optimally begins
before conception and extends throughout the
antepartum period."
The content of such a comprehensive program
includes :
(1) preconceptional care, (2) prompt diagnosis of
pregnancy, (3) initial presentation for pregnancy
care, and (4) follow-up prenatal visits.

Preconceptional Care
Because health during pregnancy depends
on
health
before
pregnancy,
preconceptional care should logically be an
integral part of prenatal care.
A
comprehensive preconceptional care
program has the potential to assist women
by reducing risks, promoting healthy
lifestyles, and improving readiness for
pregnancy.

Diagnosis of Pregnancy
Sign and symtomps
Cessation of menses
Change in cervical mucous
Change in the breast
Skin changes
Changes in the uterus
Changes in the cervix
Fetal heart action
Perception of fetal movements
Chorionic Gonadotropin
Measurement of hCG
Home Pregnancy test
Ultrasonic Recognition of Pregnancy

Cessation of menses

The absence of menses is not a reliable

indication of pregnancy until 10 days or more
after the time of expected onset of the
menstrual period.
When a second menstrual period is missed,
the probability of pregnancy is much greater.
Uterine bleeding somewhat suggestive of
menstruation
occurs
occasionally
after
conception. One or two episodes of bloody
discharge, somewhat reminiscent of and
sometimes mistaken for menstruation, are not
uncommon during the first half of pregnancy.

Change in cervical mucous

Scanning electron microscopy

of cervical mucus obtained on
day 11 of the menstrual cycle.
(From Zaneveld and
associates, 1975, with
permission.)

Photomicrograph of dried
cervical mucus obtained from
the cervical canal of a woman
pregnant at 32 to 33 weeks. The
beaded pattern is characteristic
of progesterone action on the
endocervical gland mucus
composition. (Courtesy of Dr. J.
C. Ullery.)

Change in cervical mucous

The crystallization of the mucus depend on an increased

concentration of sodium chloride.
This concentration, and in turn the presence or absence of
the fern pattern, is determined by cervical glandular
response to hormonal action. Specifically, cervical mucus
is relatively rich in sodium chloride when estrogen, but not
progesterone, is being produced. Progesterone secretion
even without a reduction in estrogen secretionacts
promptly to lower sodium chloride concentration to levels
at which ferning will not occur.
During pregnancy, progesterone usually exerts a similar
effect, even though the amount of estrogen produced is
enormous. Thus, if copious thin mucus is present and if a
fern pattern develops on drying, early pregnancy is
unlikely.

Change in the breast

Generally, the anatomical changes in the
breasts that accompany pregnancy are
quite
characteristic
during
the
first
pregnancy
These are less obvious in multiparas, whose
breasts may contain a small amount of
milky material or colostrum for months or
even years after the birth of their last child,
especially if breast feeding was chosen.

TERIMA KASIH