Antenatal care

1. GOOD ANTENATAL CARE & HOW CAN WE IMPROVE POSTNATAL CARE…

2. ANTENATAL CARE

3. WHY IS IT IMPORTANT?? ANTENATAL CARE is one of the 4 pillars of safe motherhood -Family planning -Safe & Clean Delivery -Essential Obstetric care

4. 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)

5. AIMS…. Screening for risk factors Treating existing conditions & complications Providing information to patients

6. 1. SCREENING FOR RISK FACTORS Pregnancy is an normal process Assessing pregnant woman to identify any risks factor

7. 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 YELLOW Urgent referral to Hospital with O&G specialist/ FMS in clinic, shared care possible RED Urgent admission to the hospital

8. 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

9. ?? 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: Advise to stay with relative near MCH with DR or a hospital for the duration of her pregnancy Advise to stay in the nearest “halfway” accomodations which are available in some clinics in the state Nurses in remote clinics without DR should refer the patient via radio/ phone line to MO/FMS or Specialist

10. 2. TREATING EXISTING CONDITIONS AND COMPLICATIONS COMMON PROBLEM Nausea and vomitting Heart burn Constipation Haemorrhoids Varicose vein Vaginal discharge

11. COMMON COMPLICATIONS MATERNAL PIH / PE GDM APH VTE FETUS SGA IUGR Macrosomia

12. SCREENING ANAEMIA RHESUS AND BLOOD GROUPING HEPATITIS C HIV **For all patients

13. SCREENING? ?ANOMALY SCAN GDM ?DOWN SYNDROME SCREENING **In those high risk patients

14. 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

15. 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)

16. Frequency of follow up depends on risk factors Those with high risk required frequent follow up

17. 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

18. ULTRASOUND… ROLE OF ULTRASOUND In Sarawak, a total of 2 ultrasound scans is considered the minimum standard for low risk antenatal patient Dating scan: usually done in 1 st trimester Ultrasound scan somewhere during 3 rd trimester as a general screening for fetal growth, placenta localisation and liquor assessment

19. FREQUENCY… LOW RISK Dating scan at booking Detail scan at 18-24 weeks (if indicated) Around 28-32 weeks for growth, liquor & placenta HIGH RISK Dating scan at booking Detail scan at 18-24 weeks (if indicated) Serial growth scans, every 2 weeks from 24 weeks At 28-32 weeks for placenta location At 36 weeks to assess lie & presentation

20. SAY NO TO HOME BIRTH !! ** INCREASE MATERNAL MORTALITY ** INCREASE NEONATAL MORTALITY

21. Postnatal care

22. KEMENTERIAN KESIHATAN MALAYSIA GARIS PANDUAN PERAWATAN IBU POSTNATAL DI HOSPITAL BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA & BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA APRIL 2013

23. MINISTRY OF HEALTH….. Memberi perawatan postnatal yang berterusan kepada semua ibu postnatal, sesuai dengan polisi perkhidmatan ibu dan bayi semasa postnatal selain memenuhi hak ibu postnatal.   Memberi sokongan emosi dan moral kepada ibu postnatal kerana seringkali mereka yang berada di wad adalah dikalangan yang mengalami masalah kesihatan . Mengesan awal keadaan luar biasa atau komplikasi semasa postnatal seperti secondary PPH , Puerperal Pyrexia, Puerperal Sepsis, Puerperal Psychosis dan sebagainya Merujuk segera sebarang keabnormalan kepada Pegawai Perubatan . Mengurangkan kejadian morbiditi dan mortaliti dikalangan ibu postnatal.  

24. 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

25. EXAMINATIONS FOR POST NATAL MOTHER VITAL SIGNS HYGIENE BREAST XM HEIGHT OF FUNDUS LOCHIA ABILITY TO PU SX & SIGN OF VTE ADEQUATE PAIN RELIEF ADEQUATE SLEEP EARLY AMBULATION HEALTH EDUCATION

26. SCREENING !!!!

27. 1. VTE Pulmonary embolism is the main cause of maternal mortality in Malaysia and Sarawak

28. 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

29. 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.

30. 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

31. INFO ….. Provide information Nutrition, diet & supplement during post-partum period Breast feeding General hygiene & perineal hygiene Post-natal exercise Neonatal care Contraception Pap smear

32. 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

33. FAMILY PLANNING IN HIGH RISK MOTHER REDUCES THE RISK OF MATERNAL DEATHS!!

34. 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 TOGETHER WE ACHIEVE

35. THANK YOU