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Antenatal care.

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o&g update course 2012 hospital segamat

o&g update course 2012 hospital segamat

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    Antenatal care. Antenatal care. Presentation Transcript

    • ANTENATAL CARE Dr Junita Aris Segamat 17 Nov 2012 1
    • PERINATAL CARE MANUAL DIVISION OF FAMILY HEALTH DEVELOPMENT MINISTRY OF HEALTH MALAYSIA 2004 (1st edition) 2009 (2nd edition) June 28, 20132
    • Antenatal visit - AIM  Early antenatal care (1st trimester)  to identify and manage women with medical complications  to screen woman for risks factors that may have bearing on the progress of the pregnancy and its outcome  to encouraged involvement of the spouse or family (possibly once or twice)  provide emotional support in time of need for the expectant mother. It also helps in areas pertaining to compliance and advice for the mother.  to identify the mothers‟ needs and wants and to discuss the plan for delivery. June 28, 20133
    • Frequency of visits Recommended schedule for normal, uncomplicated pregnancy (white tagged): June 28, 20134 Primigravida (weeks) Multigravida (weeks) 12 12 18 20 24 28 28 32 32 36 36 38 37 40 38 39 Reference : NICE Guideline 40 (published March 2008)
    • Booking visit  The first visit is most important  should be done as soon as possible (preferably by 12 weeks POA).  MDG 4 Indicator: New antenatal register between 0 -12 weeks POG. TARGET 70%  Even if the first visit may be late in her pregnancy it is still regarded as the booking visit. June 28, 20135
    • The “PINK BOOK” June 28, 20136
    • History taking • Detailed menstrual history  - Last menstrual period (LMP)*  - Regularity of cycles  - Contraceptive usage  * If patient‟s period is irregular or stopped contraceptive pills less than 6 months of LMP or unsure of date, refer for dating by ultrasound. June 28, 20137
    • Medical Surgic al Social Obstetric *Allergies *Blood Transfusion *Medical problems Infections *Previou s Operati on *Occupati on *Smoking *Alcohol *Education al Level *Previous Pregnanc y *Pre-term labour *Previous LSCS, IUD/END HISTORY TAKING Family *Diabetes *Hypertension *Heart Disease *Renal disease *Psychiatric *PTB *Multiple Pregnancy END =Early Neonatal Death PTB = Pul. Tuberculosis
    • Medical history  - Allergies  - Blood transfusion  - Medical problems  - Infections Family history:  - Diabetes mellitus  - Multiple pregnancy Socio-economic background  - Occupation of both the woman and her partner  - Smoking, drugs and alcohol consumption  - Education level Past obstetric history  - Previous miscarriage or termination of pregnancy  - Intrauterine growth restriction and preterm labour  - Previous LSCS  - Intrauterine death  - Early neonatal death June 28, 20139
    • PHYSICAL ASSESSMENT General examination  - Height  - Weight  - Pallor, cyanosis & clubbing  - Oral hygiene  - Oedema  - Varicose veins  - The mother‟s gait – any bony deformity of pelvis June 28, 201310
    • Blood pressure Thyroid enlargement & signs of hypo/hyperthyroidism Breast Cardiovascular system Spine – kyphosis/scoliosis Abdomen  Scars of previous operation  Palpation – uterine size/other masses Vaginal examination – when indicated June 28, 201311
    • Investigations Urinalysis : protein (albumin); sugar (glucostix); urine biochemistry (when indicated) Blood:  Haemoglobin  ABO and Rhesus group  Syphilis (VDRL) – if positive perform TPHA and refer for treatment  HIV (Rapid test) – if positive proceed with Western Blot test for confirmation  BFMP  Hepatitis B (HBs Ag) antigen June 28, 201312
    • ROUTINE MEDICAL EXAMINATION BY MO  RME 1 @ booking  RME 2 @ 36/52 Pegawai Perubatan perlu mengenalpasti kes- kes yang sesuai untuk bersalin di rumah atau di Pusat Bersalin Alternatif (Rujuk Senarai Semak) June 28, 201313
    • June 28, 201314 Heart rate Thyroid
    • Ultrasound scan  At booking: for dating. Strongly recommended during booking visit if facilities are available.  At 20/52 for fetal anomaly  At 28/52 for placenta localization if earlier suspected to be low lying  At 36/52 for estimated birth weight, AFI, presentation June 28, 201315
    • Management  Folic acid supplementation: (Hematinics supplement > 12 weeks)  Nutritional advice  Health education e.g smoking cessation  Give information on the antenatal screening test i.e benefits and limitations June 28, 201316
    • Subsequent visits Ask relevant symptoms if present  Anaemia, IE, hypo/ hyper, asthma, UTI,  Weight and blood pressure  Urine for protein and glucose  Symphysio-fundal height – to be plotted on SFH chart to alert the observer to possible growth retardation  Assess the lie and presentation of the fetus after 32 weeks. June 28, 201317
    • Subsequent visits  High grade fever in pregnant mothers – refer O&G for opinion. June 28, 201318
    • Screening for risk factors  Checklist should be assessed and documented. The care plan should be based on the protocol given. (Appendix 1) Senarai semak ini perlu digunakan seperti berikut : (a) Kali pertama semasa booking (b) Kali kedua semasa kandungan 13-20 minggu (c) Kali ketiga semasa kandungan 21-28 minggu (d) Kali keempat semasa kandungan 29-32 minggu (e) Kali kelima semasa kandungan 33-36 minggu June 28, 201319
    • PENJAGAAN ANTENATAL & SISTEM KOD WARNA Berdasarkan “tahap penjagaan” menurut keperluan pengendalian klinikal Merah : Kemasukan segera ke Hospital Kuning : Rujukan segera untuk pengendalian di Klinik Pakar O&G Hospital/Pakar Kesihatan (dalam masa 48 jam) Hijau : Pengendalian di Klinik Kesihatan oleh Pegawai Perubatan & Kesihatan Putih : Penjagaan oleh Jururawat Kesihatan / Masyarakat di Klinik Kesihatan dan Klinik Desa (sekiranya tiada terdapat faktor risiko yang disenaraikan berikan kod warna putih). June 28, 201320
    • June 28, 201321
    • RED 1. Eklampsia 2. Preeklampsia (tekanan darah tinggi dengan urin albumin) atau dengan kehaidran symptom atau BP > 160/110 mmHg 3. Sakit jantung semasa mengandung dengan tanda-tanda dan gejala (sesak nafas, berdebar- debar) 4. Sesak nafas ketika melakukan aktiviti ringan (aktiviti seperti sapu sampah, cuci pinggan) 5. Bagi ibu yang diabetic yang tidak terkawal dengan kehadiran urin keton (≥1+) June 28, 201322
    • RED 6. Pendarahan antepartum (termasuk keguguran) 7. Denyutan jantung janin yang abnormal • FHR ≤110/min pada dan selepas 26/52 • FHR > 160/min selepas 34/52 (denyutan jantung mungkin tinggi jika pramatang) 8. Anemia dengan symptom pada mana- mana gestasi 9. Kontraksi rahim pramatang 10. Keluar air likuor tanpa kontraksi 11. Serangan asma yang teruk June 28, 201323
    • PLAN - RED 1. Stabilisasi jika perlu seperti kes: - Antepartum Hemorrhage - Eklampsia - Serangan asma yang akut 2. IM Dexamethasone 12 mg stat dos bagi kes: - Kontraksi pramatang - Keluar air ketuban pramatang - Pendarahan antenatal sebelum 36 minggu 3. Urusan penghantaran pesakit hendaklah menggunakan ambulan sama ada dari Klinik Kesihatan atau “Flying Squad” June 28, 201324
    • A. Bagi kes 22 minggu ke atas:- a) Maklumkan kepada anggota di Bilik Bersalin (Labour Room) mengenai kes yang dirujuk b) Kes yang tiba di hospital hendaklah dimaklumkan pada Pegawai Perubatan / Pakar yang bertugas c) Butir-butir rujukan hendaklah didokumentasikan dalam kad KIK 1/96A June 28, 201325
    • B. Bagi kes kurang 22 minggu:- 1. Rujukan kemasukan kes ke wad Ginekologi 2. Kes yang tiba di hospital hendaklah dimaklumkan pada Pegawai Perubtan / Pakar yang bertugas 3. Butir-butir rujukan hendaklah didokumentasikan dalam Kad KIK 1/96A 4. Pengendalian akan dilakukan oleh hospital mengikut protocol hospital masing-masing 5. Pesakit yang stabil akan dirujukan kembali ke Klinik Kesihatan berserta:- a. Pelan tindakan disediakan oleh pihak hospital (discharge summary) b. Ringkasan pengendalian kes disertakan di dalam kad KIK 1A/96 June 28, 201326
    • YELLOW 1. Ibu HIV positif 2. Ibu Hepatitis B positif 3 Tekanan darah tinggi > 140/90 - <160/110 mmHg dengan urin albumin negative 4 Ibu diabetic 5 Pergerakan janin kurang semasa kandungan ≥ 32 minggu 6 Kandungan melebihi 7 hari dari EDD 7 Ibu dengan masalah perubatan yang 8 memerlukan rawatan bersama dengan hospital 8. Ibu yang terlibat dalam isu Mediko-legal 9. Ibu tunggal dan Ibu remaja June 28, 201327
    • PLAN - YELLOW  Dirujuk ke hospital berhampiran dalam masa 48 jam Prosedur rujukan: 1. Dapatkan temujanji dari Pakar O & G / FMS 2. Sertakan surat rujukan serta dokumenkan ke dalam kad KIK IA/96 apabila merujuk 3. Kes yang dirujuk akan didendalikan mengikut protocol hospital masing-masing 4. Kes yang stabil boleh dirujuk kembali ke Klinik Kesihatan bersama dengan pelan pengendalian kes dari hospital tersebut. June 28, 201328
    • GREEN (*Penilaian sekali sahaja ) Nota : Ibu mesti diperiksa oleh Pegawai Perubatan dalam tempoh 2 minggu dari tarikh booking 1 *Rh negative 2 *Berat badan ibu sebelum mengandung atau ketika booking <45kg 3 *Masalah perubatan semasa (termasuk psikiarik dan kecacatan fizikal) 4 *Pembedahan ginekologi yang lalu 5 *Ketagihan dadah/merokok 6 *LNMP yang tidak pasti 7 *3 kali riwayat keguguran yang berturutan June 28, 201329
    • GREEN 8. Riwayat obstetric yang lalu : i) Pembedahan caesarean ii) Riwayat lalu PIH/Eklampsia/Diabetes iii) Kematian Perinatal iv) Mempunyai sejarah bayi dengan berat lahir kurang daripada 2.5kg atau lebih daripada 4kg v) Koyak perineum 3rd degree vi) Lekat uri vii) Pendarahan selepas bersalin viii) Kelahiran instrumental ix) Sakit bersalin lama 9 Kandungan lebih dari satu 10 Tekanan darah tinggi (140/90 mmHg) tanpa urin albumin June 28, 201330
    • GREEN 11 Haemoglobin kurang dari 11g% 12 Gula dalam air kencing 2kali 13 Air kencing mempunyai albumin ≥1+ 14 Pertambahan berat badan yang mendadak melebihi 2 kg dalam seminggu 15 Berat badan melebihi 80 kg semasa “booking” 16 Tinggi rahim (SFH) kecil atau besar dari tarikh jangka masa 17 Menyongsang/oblique/melintang dengan tidak ada tanda sakit bersalin pada 36 minggu kehamilan 18 Kepala bayi tinggi (Head not engaged) semasa cukup bulan (37 minggu) bagi primigravida) June 28, 201331
    • PLAN - GREEN 1. Kes dirujuk kepada Pegawai Perubatan 2. Pegawai Perubatan tersebut akan mengendali dan membuat keputusan samada - Pengendalian berterusan oleh Pegawai Perubatan - Pengendalian oleh Jururawat Kesihatan di Klinik Kesihatan - Pengendalian oleh Jururawat Desa di Klinik Desa 3. Pegawai Perubatan boleh merujuk kes-kes kepada FMS jika perlu 4. Pelan pengendalian perlu disediakan oleh Pegawai Perubatan atau FMS June 28, 201332
    •  Nurses to refer the patients to be seen by doctors accordingly  Doctors may change the coding of the patients according to current circumstances. June 28, 201333
    • KOD PUTIH (BERSALIN DI HOSPITAL) 1. Primigravida 2. Ibu berumur kurang 18 tahun atau lebih 40 tahun 2 Gravida 6 dan ke atas 4 Jarak kelahiran kurang dari 2 tahun atau melebihi 5 tahun 5 Ibu dengan masalah tertentu : i) Ukuran tinggi kurang dari 145 cm June 28, 201334
    • KOD PUTIH (DIBENARKAN BERSALIN DI RUMAH / PUSAT BERSALIN ALTERNATIF) • Sekiranya memenuhi syarat-syarat seperti berikut 1 Gravida 2-5 2 Tiada masalah obstetric yang lalu 2 Tiada masalah perubatan yang lalu 4 Tiada komplikasi semasa mengandung 5 Persekitaran rumah ibu yang sesuai 6 Ukuran tinggi lebih dari 145 sm 7 Ibu berumur lebih 18 tahun dan kurang 40 tahun 8 Ibu berkahwin dan mempunyai sokongan keluarga 9 POA >37 minggu atau <41 minggu 10 Anggaran berat bayi > 2 kg dan < 3.5 kg June 28, 201335
    • Immunisation  Anti-tetanus vaccination (ATT)  Primigravida – at quickening and repeated 4 weeks later  Multigravida – a single dose is given in the third trimester before 37 weeks of gestation June 28, 201336
    • Home visits  Home visit should be provided for patients who defaulted follow-up and for high-risk mothers.  White tag – at least 3-4 visits  At booking, at second trimester, at third trimester, at term if not delivered yet  High risk pregnancy – more frequent, as per required June 28, 201337
    • PROTOCOL ON HOME VISIT  Enter the house only after obtaining permission  Respect the mother and the family  Communicate well with the mother in order to develop rapport  Describe the objectives of the visit clearly to the mother  Avoid making any unfavourable comment or judgement about the patient and family  Educate the mother and family about personal hygiene and better sanitation sanitation unit) for follow up June 28, 201338
    •  If the mother prefers home delivery and meets all the criteria, the health worker should check the intended birth site and advise the mother regarding necessary preparation,  If the mother requires delivery at a hospital or Alternative Birthing Centre, she should be advised with regards to the facility and its locality  A history and physical examination can be done after you have developed a rapport with the mother. First ascertain the progress of the pregnancy and the well being of the mother. The antenatal book should be updated. June 28, 201339
    • Problems with home visit 1. Mother not at home. 2. Staff not allowed to come in the house 3. Limited time 4. Weather 5. Transport 6. Wrong address 7. Wrong phone number So what do you do? June 28, 201340
    • FETAL MONITORING AND SURVEILLANCE Fetal monitoring during the antepartum period consists of tests for: A. Fetal growth B. Fetal well being June 28, 201341
    • A. Fetal growth  Symphysio-fundal height (SFH): tape measurement should be performed routinely from 22 weeks onwards in all pregnancies Discrepancy SFH and POA of +/- 3cm re-evaluated with regards to the 1. accuracy of the LNMP AND 2. REFERRED FOR AN ULTRASOUND. This can be an early indicator of impaired fetal growth.  Maternal weight gain: should be a progressive increase in weight of approximately 10 – 12.5 kg (25% of her non-pregnant weight) throughout the pregnancy. Generally the weight gain should be about 0.5 kg /month for the first 20 weeks and 0.5 kg/week from 20 weeks onwards. June 28, 201342
    • Ultrasound  Ultrasound scanning for dating is reliable if the parameters are taken before 24 weeks.  For fetal growth assessment, serial scan should be done every 2 – 3 weeks. June 28, 201343
    • SYMPHYSIO-FUNDAL HEIGHT(SFH)
    • UTERINE SIZE BY WEEK
    • June 28, 201346 Uterus larger than dates Uterus smaller than dates Wrong dates Wrong dates Polyhydramnios Oligoydramnios Multiple pregnancy Intrauterine growth retardation Big baby # Ultrasound scanning for dating is reliable if the parameters are taken before 24 weeks. # For fetal growth assessment, serial scan should be done every 2 – 3 weeks.
    • B. Fetal monitoring Fetal heart auscultation: Pinards Fetoscope. Should be routinely practiced from 24 weeks onward using a If Daptone is available, fetal heart can be detected as early as 14 weeks. CTG should be performed in cases where there is high risk of fetal compromise such as decrease fetal movement, hypertension, diabetes, IUGR or postdates. June 28, 201347
    • Fetal Kick Chart  Over the past 30 years, fetal movement counts have been recommended to women in the second half of pregnancy as a way of monitoring fetal wellbeing and providing an early warning of fetal distress. June 28, 201348
    • Fetal Kick Chart  Fetal kick chart is an indirect tool for monitoring of fetal wellbeing.  All mothers should be given the fetal movement chart (Cardiff „count-to-ten‟) for recording of fetal movements from 28 weeks gestation onwards and should be told to report to any health facility if movements are less than 10 in 12 hours.  This observation should be done at regular intervals everyday. June 28, 201349
    • June 28, 201350
    • HEALTH EDUCATION
    • Health education topics to be given to every antenatal mothers during clinic session : No. Topics (ANTENATAL) 1 Jagaan antenatal 2 Kepentingan datang awal ke klinik semasa mengandung. 3 Persediaan psikologi semasa mengandung 4 Masalah ringan semasa hamil dan cara mengatasinya 5 Pemakanan antenatal & postnatal 6 Kepentingan & cara yang betul pengambilan vitamin 7 Jagaan payu dara 8 10 topik dalam penyusuan susu ibu 9 Senaman antenatal & postnatal June 28, 201352
    • June 28, 201353
    • No. Topics 10 Aktiviti seksual semasa hamil 11 Carta pengerakkan janin 12 Persiapan bersalin 13 Kepentingan pengetahuan kelahiran 14 Tanda – tanda bersalin Proses kelahiran Perancang Keluarga June 28, 201354
    • (Keadaan luar biasa semasa mengandung) No. Topics 1 Pre eclampsia (darah tinggi semasa mengandung) 2 Tanda – tanda impending eclampsia 3 Diabetes semasa mengandung 4 Anaemia semasa mengandung 5 Pendarahan semasa mengandung 6 Masalah perubatan June 28, 201355
    • Postnatal Topics No. Topic (Postnatal) 1 Jagaan postnatal 2 Jagaan episiotomy 3 Jagaan bayi baru lahir 4 Neonatal jaundis 5 Perancang Keluarga 6 Pap Smear June 28, 201356
    • Register Client NEW CASE/TRANSFER IN - Preferable < 12/52 POA - Register in KIB 101 Return Case /Referrals ( Subsequent visits ) History Taking INVESTIGATIONS * Tracing of blood result & document. Physical Examination - FKC @ POA 28/52 ACTION PJK KJK JKA JT JM FLOW CHART A/N CHECK UP
    • Unsure LMP RME All HRM ** Routine examination @ POA 34 onwards RISK IDENTIFICATION & TAGGING ( Inclusive of QAP FP Tagging for HRM @ POA 36/52 REFER DOCTO R HEALTH EDUCATION (Inclusive QAP FP) Haematinic compliance ACTION PJK KJK JKA JT JM YES NO
    • IMMUNISATION PRIMI - @ quickening & Repeat 4/52 later MULTIP – single dose in the 3rd trimester < 37/52 ABORTION CASE – NO ATT to be given DOCUMENTATION - KIB 101 including total number of visits - Transfer out cases – ensure clinics concerned receive case ANTENATAL CLASSES ( Base on local setting only done in big clinics ) HOME VISIT Make appointment for visit. ( For HIGH RISK Cases, defaulters ) ACTION PJK KJK JKA JT JM Hom e
    • MANAGEMENT OF COMMON DISORDERS IN PREGNANCY  Anaemia in Pregnancy  Gestational Diabetes Mellitus  Vaginal Bleeding in pregnancy - Antepartum Haemorrhage (ACUTE OBSTETRIC EMERGENCY AND LIFE THREATENING CONDITION)  Group B Streptococal infection in pregnancy ( Preterm labour or rupture of membranes for more than 18 hrs.)  HIV ( CPG HIV )  PIH ( Training Manual Mx of PIH )  Heart Disease in pregnancy ( CPG and training Manual on Mx. Of heart disease)
    • THANK YOU June 28, 201362