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. 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

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

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

8. 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

9. 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

10. ?? 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

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

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

13. SCREENING…. BLOOD TESTS ANAEMIA RHESUS AND BLOOD GROUPING HIV VDRL BFMP **For all patients

14. SCREENING? GDM HEPATITIS B/C THALLASEMIA ANOMALY SCAN ?DOWN SYNDROME SCREENING **In those high risk patients

15. 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

16. ROUTINE MEDICAL EXAMINATION.. To be done by MO in the 1 st booking and also 3 rd 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 & LUNG!!

17. 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

18. 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

19. 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 )

20. 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

21. 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

22. 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

23. It is measured from the top of the mother's uterus to the top of the mother's pubic bone in centimeters

24. HOF (height of fundus) 34

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

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

32. Postnatal care

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

34. 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 .  

35. 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

36. 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

37. SCREENING !!!!

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

39. 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

40. 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.

41. 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

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

43. 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

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

45. 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

46. THANK YOU