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Antenatal Care Workshop

Alison Goodfellow 2008

Why do Antenatal care ?

„ What is it ?
„ Intentional encounter between a pregnant woman
and a midwife or doctor to assess and improve
maternal and fetal well-being throughout pregnancy
and prior to labour
„ Risk assessment or disease recognition?
‰ Preventative
„ All women seek a healthy outcome to their
pregnancy, but not necessarily have the same
antenatal care as their neighbour

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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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Aims
BEFORE AFTER

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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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 different
options of care and be given an opportunity
to discuss this schedule with their midwife or
doctor.

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Appointment Schedules and Structure

„ Each antenatal appointment should be


structured and have focused content. Longer
appointments are needed early in pregnancy
to allow comprehensive assessment and
discussion. Wherever possible, appointments
should incorporate routine tests and
investigations 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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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 should
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 and


partnership
„ 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 veiled


women 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
„ <1:8 less indicates minimal or no immunity
‰ If not immune women can choose to be vaccinated after
giving birth
‰ Exposure in the 1st trimester has the most effect
„ Affects eyes, ears and cardiovascular and nervous system
„ Spontaneous miscarriage may occur

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Assessments

„ Hepatitis B
‰ Detected through the hepatitis B surface antigen (HbsAg)
‰ Effects
„ Maternal; fever, malaise, nausea, abdo; discomfort may be
associated with liver failure
„ Fetal/Neonatal: preterm birth, hepatitis infection, FDIU
„ Aim: to prevent transmission to the baby; perinatal
infection can be prevented by immunoprophylaxis at
birth

Assessments
„ Hepatitis C virus (HCV)
‰ Screening of women with risk
factors
‰ What are the risk factors?
„ Human immunodeficiency
virus (HIV)
‰ Universal screening +/-
„ RANZCOG – all women be
offered screening
„ ANCAHRD – selective offer of
testing
„ Infection rate increasing in
women
„ What are the advantages to
screening?

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Screening
„ Screening should be
„ Syphilis offered to:
‰ (TPHA) (TPPT) (RPR)
‰ Women at increased risk
„ Chlamydia trachomatis of STI’s
‰ Transmission occurs at birth ‰ Women younger than 25
‰ May result in ophthalmia
‰ Unmarried women
neonatorum or pneumonitis
in the newborn ‰ New or multiple sex
‰ Associated with preterm partners
birth ,IUGR, low birth weight
‰ Inconsistent use of
‰ rates have increased in
Australia, with the greatest barrier contraception
rates seen in adolescents ‰ Women living in
and young adults communities of high
‰ Notifiable disease
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 weight
Weight in kg
(height in m)2

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Risks related to obesity in pregnancy

For the mother For the baby


„ Increased risks include „ Increased risks include
„ • Maternal death or severe „ • Stillbirth and neonatal death
morbidity „ • Congenital abnormalities
„ • Cardiac disease „ • Prematurity.
„ • Spontaneous first trimester
and recurrent miscarriage
„ • Pre-eclampsia
„ • Gestational diabetes
„ • Thromboembolism
„ • Post caesarean wound
infection
„ • Infection from other causes
„ • Post partum haemorrhage
„ • Low breast feeding rates.

Table 1.4 “Saving Mothers’ Lives:


Reviewing maternal deaths to make motherhood safer - 2003-
2005”

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 of
caesarean section.

Hypertension

„ All women should be given appropriate written information about


blood pressure measurements and given the opportunity to
discuss the procedure (Three Centres Consensus Guidelines on
Antenatal Care 2001)
„ Complicates 10% of pregnancies
„ At first contact a women’s level of risk for developing pre
eclampsia 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 most


common cause of maternal mortality
‰ 5 deaths where hypertension deemed principal
cause of death
„ British report 2003 - 05
„ For every mortality there are hundreds of
cases of severe morbidity for mother and
baby

Recording BP in Pregnancy
DOH 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 this
level
„ 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 mercury


sphygmomanometer, automated devices and
ambulatory BP monitoring should not yet be used in
routine 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 anticipated
there 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 BP


reading 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/mmol
creatinine
„ 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 Centre
Consensus Guideline on Antenatal Care 2001

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Group B Streptococcus

„ GBS colonizes the genitourinary tract of 10-40% of


all women.
„ Leading cause of early onset neonatal sepsis in the
late 70’s
„ Use of intrapartum prophylaxis with antibiotics given
to 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

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Group B Streptococcus

„ Risk-based
‰ <37 weeks
‰ Ruptured membranes >18hrs
‰ Maternal fever ≥ 38˚C
‰ 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 Carbohydrate
Intolerance Study in Pregnant Women (ACHOIS) Trial Group 2005. Effect of
treatment of gestational diabetes mellitus on pregnancy outcomes.” New
England Journal of Medicine 352(24):2477-2486
„ Hung NW. “ Group B Streptococcus Infection in Pregnancy” Clinics in
Perinatology 34 (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 Health
2007,,(4) 139-140.
„ Pairman S et.al “Midwifery Preparation for practice” 2006 Elsevier Sydney.

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Thankyou

Questions ??

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