A Good Fellow Update on Antenatal Care

8/14/2019 A Good Fellow Update on Antenatal Care

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Aims

Establishment of open communication and a relationship

of partnership between the woman and the professional

involved in her care

Source of information about all aspects of care and

empowering women to make informed choices.

Provision of appropriate support to promote

psychological, emotional and social well being in

pregnancy

Health education

Aims

Regular monitoring of the maternal and fetal

conditions in pregnancy to ensure early detection

of any deviations from normal and appropriate

referral, consultation and management. Preparation for labour and a safe birth

Fulfilling experience for both the woman and her

partner

Early parenthood education

Preparation for the period following birth including

family planning advice.


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AimsBEFOREBEFORE AFTERAFTER

Appointment Schedules and Structure

Three Centres Consensus Guidelines on Antenatal

Care Oct 2001

NICE Antenatal Care Guidelines 2003

A schedule of antenatal appointments should be

determined by the function of the appointments and

preference of the mother.

Low risk reduced from traditional 14, to 7 -10 irrespective of

model of care

Flexibility


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Early in pregnancy all women should receive

appropriate written information about the

likely number, timing and content of antenatal

appointments associated with differentoptions of care and be given an opportunity

to discuss this schedule with their midwife or

doctor.


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Each antenatal appointment should bestructured and have focused content. Longerappointments are needed early in pregnancyto allow comprehensive assessment anddiscussion. Wherever possible, appointmentsshould incorporate routine tests andinvestigations to minimise inconvenience to

women.

Appointment Schedules and Structure: 3

centre examples

Visits 1&2: 1st trimester Assess maternal and fetal well being

Risk assessment

Date pregnancy

Comprehensive history

Discuss smoking

Establish care options

Visits scheduled to offer 1st trimester screening


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centre examples

Visits 3 & 4 2nd trimester: Monitor

fetal growth

Maternal well being

Signs pre-eclampsia

Morphology U/S

Glucose Screening


centre examples

Visits 5 - 8 3rd trimester: Monitor

Fetal growth

Maternal well being

Signs of pre-eclampsia

Assess and prepare women for labour and going home

GBS screening

NB. The option and timing of additional visits shouldThe option and timing of additional visits should

be discussed with all women.be discussed with all women.


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Assessments

History taking Good communication skills

Non judgmental attitude

Building a positive relationship

How do you do this with Obstrix?

Midwife needs to be Well informed

Encouraging the development of mutual respect, trust andpartnership

Environment

Psychosocial issues Covered further by other speakers

Assessments

Blood tests at booking Antenatal screening

Blood group & Rh typing

Antibody screen

FBC

Hep B (HBV)

Rubella titre VDRL/RPR

Midstream urine

HCV/HIV

Vitamin D RANZCOG recommend dark skinned of veiledwomen be tested for deficiencies.

PAP smear


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Screening

Blood group and Rh typing Identify negative bloods groups

Anti-D prophylaxis

Further antibody screening 28 and 34 weeks

FBC Determine baseline

Hb booking and 28 weeks

WCC

Platelets

Asymptomatic bacteriuria 25-30% will develop UTI whilst pregnant

MSU at booking C&S

Screening

Rubella titre Diagnosis: IgG antibodies to rubella are measured to

determine immunity 1:10 > immune


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Assessments

Hepatitis B Detected through the hepatitis B surface antigen (HbsAg)

Effects

Maternal; fever, malaise, nausea, abdo; discomfort may beassociated with liver failure

Fetal/Neonatal: preterm birth, hepatitis infection, FDIU

Aim: to prevent transmission to the baby; perinatalinfection can be prevented by immunoprophylaxis at

birth

Assessments Hepatitis C virus (HCV)

Screening of women with riskfactors

What are the risk factors?

Human immunodeficiencyvirus (HIV)

Universal screening +/-

RANZCOG all women beoffered screening

ANCAHRD selective offer oftesting

Infection rate increasing inwomen

What are the advantages toscreening?


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Screening

Syphilis

(TPHA) (TPPT) (RPR)

Chlamydia trachomatis

Transmission occurs at birth

May result in ophthalmianeonatorum or pneumonitisin the newborn

Associated with pretermbirth ,IUGR, low birth weight

rates have increased inAustralia, with the greatestrates seen in adolescentsand young adults

Notifiable disease

Screening should be

offered to:

Women at increased risk

of STIs

Women younger than 25

Unmarried women

New or multiple sex

partners

Inconsistent use of

barrier contraception Women living in

communities of high

infection rate

Obesity in Pregnancy

Risk factor for a range of antenatal,

intrapartum and postnatal complications

Poses important OH&S concerns for staff

caring for obese women. Calculate BMI on booking, using pre-

pregnancy or early pregnancy weightWeight in kg

(height in m)2


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Table 1.4 Saving Mothers Lives:Reviewing maternal deaths to make motherhood safer - 2003-

2005

Risks related to obesity in pregnancy

For the mother Increased risks include

Maternal death or severemorbidity

Cardiac disease

Spontaneous first trimesterand recurrent miscarriage

Pre-eclampsia

Gestational diabetes

Thromboembolism

Post caesarean woundinfection

Infection from other causes

Post partum haemorrhage

Low breast feeding rates.

For the baby Increased risks include

Stillbirth and neonatal death

Congenital abnormalities

Prematurity.

Antenatal Management

Collaborative team approach

Sensitive and supportive

Neutral weight gain

Model of care


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Gestational Diabetes Screening

Screening at 26 - 28 weeks

Rise in prevalence of GD associated with increase in

maternal obesity

Australasian Carbohydrate Intolerance Study in Pregnant

women (ACHOIS) 2006

Large RCT

Showed conclusively that treatment of GD in the form of

dietary advice, blood glucose levels, reduces the rate of

serious perinatal complications, without increasing the rate ofcaesarean section.

Hypertension

All women should be given appropriate written information aboutblood pressure measurements and given the opportunity todiscuss the procedure (Three Centres Consensus Guidelines onAntenatal Care 2001)

Complicates 10% of pregnancies

At first contact a womens level of risk for developing preeclampsia should be assessed

How?


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Hypertension

Risk factor for cardiovascular disease later in

life: possible mechanisms

Share several common risk factors : diabetes,

obesity, renal disease

Long term metabolic and vascular abnormalities

increase overall risk of cardiovascular disease

Hypertension

Major cause of morbidity and mortality

PE and Eclampsia account for more than 50,000

maternal deaths a year world wide (most associated

with eclampsia)

Improved screening, preventative and treatment

strategies may not only optimize management

during pregnancy but have long-term life long

impact.


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Hypertension

In last Triennium (2000-2002) 4th mostcommon cause of maternal mortality 5 deaths where hypertension deemed principal

cause of death

British report 2003 - 05

For every mortality there are hundreds ofcases of severe morbidity for mother andbaby

Recording BP in PregnancyDOH circular 2004/14 & ASSHP 2000

Seated with feet supported for 2-3 minutes

Appropriate cuff size (33cm arm circumference)

Systolic pressure should be palpated at the brachial

artery and the cuff inflated to 20mmHg above thislevel

The cuff should be deflated slowly, at approximately

2mmHg per sec


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Recording BP in Pregnancy

DOH circular 2004/14 & ASSHP 2000

Should be recorded with a mercurysphygmomanometer, automated devices andambulatory BP monitoring should not yet be used inroutine clinical practice OH&S issues

If aneroid used then needs to be calibrated regularly

BP should be taken using both arms at the 1st A/N

visit and thereafter using the arm if as anticipatedthere is no difference between arms.

Definition of Hypertensive Disorders in

Pregnancy

Systolic blood pressure is 140mmhg or greater

and / or

Diastolic blood pressure (Korotkoff V) is 90mmhg or greater

Incremental rise of 30mmHg systolic or 15mmHg diastolic

Arising for the first time after 20 weeks gestation

It is recommended that diagnosis be confirmed after repeated BPreading over several hours at rest or after an overnight stay in hospital


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Hypertension

KIDNEY DYSFUNCTION - detected by

Proteinuria dipstick not reliable, only a guide

If any proteinuria detected -> Clean catch MSU to exclude contamination,

repeat dipstick if protein still detectable then

Send to lab for MSU and spot urine

Spot urine protein/creatinine ratio > or equal 30mg protein/mmolcreatinine

24hr urine specimen > or equal 300mg/day

Urinalysis by Dipstick

Use of dipstick measurement for routine screening

for proteinuria in low risk women is not

recommended

If hypertension is detected then the use of dipstick

testing for proteinuria is indicated

Screening for chronic renal disease and UTI is best

done by use of multi-stick at first A/N visit - Three CentreConsensus Guideline on Antenatal Care 2001


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Group B Streptococcus

GBS colonizes the genitourinary tract of 10-40% ofall women.

Leading cause of early onset neonatal sepsis in thelate 70s

Use of intrapartum prophylaxis with antibiotics givento women at risk prevents early onset sepsis In Australia incidence fell from 2.0/1000 births in 91-93 to

0.5/1000 in 95-97


Guidelines recommend either risk-based or

screening approach to identify women for

intrapartum antibiotic prophylaxis

NSW DOH PD 2002/28

Screening involves

Low vaginal and anorectal swab at 35-37 weeks gestation

Women that have GBS in a MSU should automatically

have intrapartum prophylaxis


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Risk-based

18hrs

Maternal fever 38C

Any women with a previously GBS infected baby

irrespective of colonisation status

All women with GBS bacteriuria

References & Websites

www.nice.org.uk

www.cdc.gov www.dhs.vic.au/ahs/quality/effect.htm

www.health.nsw.gov.au/policies/groups/ps_maternity.html

Crowther CA, Hiller JE, Moss JR et al 2005 Australian CarbohydrateIntolerance Study in Pregnant Women (ACHOIS) Trial Group 2005. Effect oftreatment of gestational diabetes mellitus on pregnancy outcomes. New

England Journal of Medicine352(24):2477-2486 Hung NW. Group B Streptococcus Infection in Pregnancy Clinics in

Perinatology34 (2007) 387-392. Lenton J, Freedman E, Hoskin K et.al. Chlamydia trachomatis infection among

antenatal women in remote far west New South Wales Australia Sexual Health2007,,(4) 139-140.

Pairman S et.al Midwifery Preparation for practice 2006 Elsevier Sydney.


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A Good Fellow Update on Antenatal Care