GOOD ANTENATAL

CARE

& HOW CAN WE

IMPROVE POSTNATAL

CARE…

ANTENATAL CARE

WHY IS IT IMPORTANT??

ANTENATAL CARE is one of the 4 pillars of

safe motherhood

-Family planning

-Safe & Clean Delivery

-Essential Obstetric care

EVIDENCES…

Inadequate antenatal visits are associated

with increased neonatal mortality in the

present or without high risk pregnancy (Chen

2007)

Marginal increase in neonatal death in the

reduced antenatal visit (Dowstell T 2010)

SUMMARY FROM CEMD REPORT 2006-2008

Principal cause of maternal deaths are obstetric

embolism, medical disorders in pregnancy,

PPH & hypertensive disorder

The risk of maternal death was higher in

woman aged >40 years & in mothers who had

>6 childrens

Deaths due to associated medical illness are

rising

Maternal death tagged with the green code

increased from 26.6% in 2006 to 32.3% in 2008

AIMS….

1. Screening for risk factors

2. Treating existing conditions & complications

3. Providing information to patients

4. Offer intervention

1. SCREENING FOR RISK

FACTORS

Pregnancy is an

normal process

Assessing pregnant

woman to identify

any risks factor

Ministry of Health has introduced colour

coding for the level of obstetric care

COLOUR

CODING

RISK & LEVEL OF CARE

WHITE Low risk- level of care by PHN/ JM in clinics

GREEN Level of care- MO in health clinic- shared care with

nurses under supervision of MO

YELLOW Urgent referral to Hospital with O&G specialist/ FMS in

clinic, shared care possible

RED Urgent admission to the hospital

Antenatal patient coded GREEN or YELLOW

can be seen by health nursing staff as part of

shared antenatal care

Antenatal patients who are coded RED and

are admitted to the hospital should have the

colour coded changed appropriately by the

doctors managing the patient upon discharge

if she has not delivered yet

?? LOGISTIC PROBLEMS

Antenatal patients who are coded YELLOW or GREEN but lives in an inaccessible area of Sarawak or who are unable to see MO/FMS or Specialist should:

1. Advise to stay with relative near MCH with DR or a hospital for the duration of her pregnancy

2. Advise to stay in the nearest “halfway” accomodations which are available in some clinics in the state

3. Nurses in remote clinics without DR should refer the patient via radio/ phone line to MO/FMS or Specialist

2. TREATING EXISTING

CONDITIONS AND

COMPLICATIONS COMMON

PROBLEM

Nausea and

vomitting

Heart burn

Constipation

Haemorrhoids

Varicose vein

Vaginal discharge

COMMON COMPLICATIONS

MATERNAL

- PIH/ PE

- GDM

- APH

- VTE

FETUS

- SGA

- IUGR

- Macrosomia

SCREENING….

BLOOD TESTS

ANAEMIA

RHESUS AND BLOOD GROUPING

HIV

VDRL

BFMP

**For all patients

SCREENING?

GDM

HEPATITIS B/C

THALLASEMIA

ANOMALY SCAN

?DOWN SYNDROME

SCREENING

**In those high risk

patients

VTE SCORING….

According to

SARAWAK VTE RISK

ASSESSMENT

AIMS To reduce

maternal mortality

from venous

thromboembolism

Scoring should be

done for every patient

and must be

documented inside

antenatal card

ROUTINE MEDICAL

EXAMINATION..

To be done by MO in the

1st booking and also 3rd

trimester

To examine patient from

head to toe to detect any

problem, so that early

referral can be made and

management can be done

appropriately

# NOT ONLY HEART &

3. PROVIDING INFORMATION

Provide and giving information

- regarding pregnancy status, fetal status

- Safe deliveries, labour & birth, post natal care

- Breast feeding

Provide additional care

- nutrition & diet, supplement, life style modifications

LIFESTYLE…

NUTRITION

-Normal diet

-Fibre intake

-Folic acid supplement

-Ferrous fumarate

-Calcium supplement

EXERCISE

-safe

SEXUAL INTERCOURSE

-avoid if PP/PPROM

ALCOHOL

-Fetal alcohol syndrome

-IUGR

SMOKING/ DRUGS

-IUGR

Offer intervention that should have known

benefits and acceptable to pregnant woman (but

need to ensure the availability of the facilities

before offering any intervention)

FOLLOW UP

Frequency of follow up depends on risk factors

Those with high risk required frequent follow up

Level of care depends on the coding

HISTORY & EXAMINATION

AIMS- TO ASSESS MATERNAL & FETAL

STATUS

BP, urine albumin, urine glucose, weight

Haemoglobin

SFH (Symphisiofundal height) and HOF (Height

of fundus)

EFW (estimated fetal weight)

Fetal heart rate

SIMPHYSIOFUNDAL HEIGHT

(SFH)

SFH is a measure of the size of the uterus

It is used to assess fetal growth &

development during pregnancy

Simple & not expensive

It is measured from the top of the mother's uterus

to the top of the mother's pubic bone in

centimeters

HOF (height of fundus)

34

Fundal height roughly corresponds to

gestational age in weeks between 16 to 36

weeks for a vertex fetus.

When a tape measure is unavailable, finger

widths are used to estimate centimeter

(week) deviations from a corresponding

anatomical landmark.

However, landmark distances from the pubic

symphysis are highly variable depending on

body type.

In clinical practice, recording the actual fundal

height measurement is standard practice

beginning around 20 weeks gestation

34

At xiphisternum, HOF

either 36 or 40 weeks

- 40 weeks if there is

fullness of flank

- 36 weeks if no

fullness of flank

2 finger breath below

xiphisternum, HOF

either 34 or 38 weeks

- 38 weeks if there is

fullness of flank

- 34 weeks if no

fullness of flank

At umbilicus equal 22

weeks

At symphisis pubis

equal to 12 weeks

Most caregivers will record their patient's fundal

height on every prenatal visit.

Measuring the fundal height can be an indicator

of proper fetal growth and amniotic fluid

development

Any discrepancy may require IMMEDIATE

referral to MO or specialist TRO IUGR or

MACROSOMIA

IUGR is a SERIOUS matter as it will increase

perinatal morbidity and mortality

ULTRASOUND…

ROLE OF ULTRASOUND

In Sarawak, a total of 2 ultrasound scans is

considered the minimum standard for low risk

antenatal patient

1. Dating scan: usually done in 1st trimester

2. Ultrasound scan somewhere during 3rd trimester

as a general screening for fetal growth, placenta

localisation and liquor assessment

FREQUENCY…

LOW RISK

1. Dating scan at booking

2. Detail scan at 18-24 weeks (if indicated)

3. Around 28-32 weeks for growth, liquor & placenta

HIGH RISK

1. Dating scan at booking

2. Detail scan at 18-24 weeks (if indicated)

3. Serial growth scans, every 2 weeks from 24 weeks

4. At 28-32 weeks for placenta location

5. At 36 weeks to assess lie & presentation

WELL DOCUMENTED

CLEAR plan of management for

1.Antenatal check –up

2.Mode of delivery

3.Timing of delivery

4.Place of delivery

5.Post natal plan for mother &

baby

** INCREASE MATERNAL

MORTALITY

** INCREASE NEONATAL

MORTALITY

POSTNATAL CARE

KEMENTERIAN KESIHATAN MALAYSIA

GARIS PANDUAN PERAWATANIBU POSTNATAL DI HOSPITAL

BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA&

BAHAGIAN KEJURURAWATANKEMENTERIAN KESIHATAN MALAYSIA

APRIL 2013

MINISTRY OF HEALTH…..

Memberi perawatan postnatal yang berterusan kepadasemua ibu postnatal, sesuai dengan polisi perkhidmatan ibu danbayi semasa postnatal selain memenuhi hak ibu postnatal.

Memberi sokongan emosi dan moral kepada ibu postnatal kerana seringkali mereka yang berada di wad adalah dikalanganyang mengalami masalah kesihatan.

Mengesan awal keadaan luar biasa atau komplikasi semasapostnatal seperti secondary PPH, Puerperal Pyrexia, Puerperal Sepsis, Puerperal Psychosis dan sebagainya

Merujuk segera sebarang keabnormalan kepada PegawaiPerubatan.

Mengurangkan kejadian morbiditi dan mortaliti dikalangan ibupostnatal.

Ministry of Health has introduced colour

coding for the level of post-natal care

COLOUR

CODING

RISK & LEVEL OF CARE

RED Early referral to Hospital

YELLOW Refer to MO/ FMS at Health Clinic

WHITE Normal postnatal check up

EXAMINATIONS FOR POST NATAL

MOTHER

VITAL SIGNS

HYGIENE

BREAST XM

HEIGHT OF

FUNDUS

LOCHIA

ABILITY TO PASS

URINE

SX & SIGN OF VTE

ADEQUATE PAIN

RELIEF

ADEQUATE SLEEP

EARLY

AMBULATION

HEALTH

EDUCATION

SCREENING !!!!

Pulmonary embolism is

the main cause of

maternal mortality in

Malaysia and

Sarawak

Need to screen for any evidence of VTE (deep

vein thrombosis or pulmonary embolism) as

currently VTE is the main cause of maternal

mortality in Malaysia

It is preventable cause of maternal death

The VTE Risk Management programme was

implemented in all MOH hospitals in the state

of Sarawak in July 2013

2. Postnatal blues…

At each postnatal contact, women should be asked about their emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day to day matters.

Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.

E-NOTIFICATIONS…

E-NOTIFICATION is one form of communication in between hospital and health clinic in managing both high risk antenatal and postnatal mothers

HIGH RISK patient that will be discharged from hospital will have E-NOTIFICATION

Any information pertaining to the patient, plan upon discharge, treatment or follow up will be e-mail to the respective clinic to ensure that the patient will not be lost in follow up and the plan of management will be continue

Some time the nurse will be required to do regular home visit for certain patient

INFO…..

Provide information

1. Nutrition, diet & supplement during post-partum period

2. Breast feeding

3. General hygiene & perineal hygiene

4. Post-natal exercise

5. Neonatal care

6. Contraception

7. Pap smear

CONTRACEPTION

The right contraception choice improves

effectiveness and compliance

It promotes planned safer future pregnancies

and prevents unplanned risky pregnancy

Appropriate counselling is vital for a successful

family planning programme

FAMILY PLANNING IN HIGH RISK MOTHER

REDUCES THE RISK OF MATERNAL

DEATHS!!

MDG 5 (Millenium Developmental Goals)

MDG 5: improve maternal health

Target 5.A. Reduce by three quarters,

between 1990 and 2015, the maternal

mortality ratio

Target 5.B. Achieve, by 2015, universal

access to reproductive health

THANK YOU