a good fellow update on antenatal care
TRANSCRIPT
-
8/14/2019 A Good Fellow Update on Antenatal Care
1/19
-
8/14/2019 A Good Fellow Update on Antenatal Care
2/19
2
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.
-
8/14/2019 A Good Fellow Update on Antenatal Care
3/19
3
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
4/19
4
Appointment Schedules and Structure
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.
-
8/14/2019 A Good Fellow Update on Antenatal Care
5/19
5
Appointment Schedules and Structure
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
6/19
6
Appointment Schedules and Structure: 3
centre examples
Visits 3 & 4 2nd trimester: Monitor
fetal growth
Maternal well being
Signs pre-eclampsia
Morphology U/S
Glucose Screening
Appointment Schedules and Structure: 3
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.
-
8/14/2019 A Good Fellow Update on Antenatal Care
7/19
7
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
8/19
8
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
9/19
9
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?
-
8/14/2019 A Good Fellow Update on Antenatal Care
10/19
10
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
11/19
11
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
12/19
12
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?
-
8/14/2019 A Good Fellow Update on Antenatal Care
13/19
13
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.
-
8/14/2019 A Good Fellow Update on Antenatal Care
14/19
14
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
15/19
15
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
16/19
16
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
17/19
17
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
Group B Streptococcus
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
-
8/14/2019 A Good Fellow Update on Antenatal Care
18/19
18
Group B Streptococcus
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.
-
8/14/2019 A Good Fellow Update on Antenatal Care
19/19
Thankyou
Questions ??