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Routine Antenatal Care. Dr Penny Sheehan Obstetrician, Head Unit D and FMC RWH Dr Ines Rio, GP & GPLO RWH. “Low risk” pregnancy. Healthy women having a normal pregnancy Essentially the women suitable for shared care

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routine antenatal care

Routine Antenatal Care

Dr Penny Sheehan

Obstetrician, Head Unit D and FMC RWH

Dr Ines Rio, GP & GPLO RWH

low risk pregnancy
“Low risk” pregnancy
  • Healthy women having a normal pregnancy
  • Essentially the women suitable for shared care
  • Individual cases can undergo shared care with consultation b/w consultant and SMCA
routine antenatal care3
Routine Antenatal Care

Based on

  • Guidelines for Shared Maternity Care Affiliates - 11/02. RWH, MHW, SH
    • One arm 2 year DHS funded project
  • 3 Centres Consensus Guidelines - 10/01. MMC, RWH, MHW
    • evidence base of 16 issues. Classified according I-IV
slide4
Guidelines for Shared Maternity Care Affiliates- www.health.vic.gov.au/maternity care RWH website soon
  • 3 Centres - www.3centres.com.au
no and timing of antenatal visits specific questions
No and timing of antenatal visits - specific questions
  • Is reduced schedule of visits as effective as traditional 14 visits
    • in achieving positive perinatal outcome?
    • For women’s satisfaction with care?
    • As effective for primigravidas as for multiparas?
    • More cost effective?
no and timing of routine antenatal visits guidelines
No. and timing of routine antenatal visits - Guidelines
  • For low risk women traditional schedule of 14 visits may be safely reduced to 7-10 without adversely affecting perinatal outcomes LevelI
  • No and timing of visits should be flexible to suit the needs of individual women II
  • Women should be invited to choose additional visits as they, midwife, doctor perceive a need or as complications arise II
antenatal visits implementation rwh
Antenatal visits implementation RWH
  • 1st trimester - visits 1&2
    • PBC: history, risk assessment, screening tests, establish care options
  • 2nd trimester - visits 3 &4
    • monitor fetal growth, maternal well-being, signs pre-eclampsia
    • 18 week u/s, if GCT/GTT 24-28 weeks
antenatal visits implementation rwh8
Antenatal visits implementation RWH
  • 3rd trimester - visits 5-8
    • monitor fetal growth, maternal well-being, signs pre-eclampsia
    • assess and prepare for admission, labour and going home
    • GBS screen 35-37 weeks
at rwh this translated to
At RWH this translated to
  • 10 weeks - BIV, consultant, Initial tests
  • 16 weeks
  • 20 weeks
  • 26 weeks-Preadmission V, AN check - MW(VBAC)
  • 30 weeks
  • 33 weeks
  • 36 weeks - Consultant visit
  • 38 weeks
  • 40 weeks
  • 41 weeks - Consultant visit
models of antenatal care
Models of antenatal care
  • At each visit midwives and doctors should offer information, consistent advice, clear explanations and provide opportunity to ask questions III/IV
  • More likely to be satisfied with A/N care when perceive care givers are kind, supportive, courteous, respectful, recognise individual needs IV
models of antenatal care11
Models of antenatal care
  • Women should not be kept waiting for long periods or feel rushed through visits and investigations IV
  • Wherever possible should be offered continuity of care including continuity of carer I
  • Midwifery and GP led models of care for low risk women I, II, III
models of antenatal care12
Models of antenatal care
  • Routine involvement of obstetricians in care of low risk women at scheduled visits does not appear to improve perinatal outcomes II
  • Women should be offered option of carrying a copy of their antenatal record III
rwh models of care
RWH Models of Care
  • “High Risk” Maternal Fetal Medicine (2)
        • (A) L Kornman, (B) Prof S Brennecke
      • Specialist clinics eg RMC, DM, Fetal management, Prem labour, Thal etc
  • “Low risk” Maternity Care Program (2), Family Birth Centre
        • (C)J Quinlivan, (D) P Sheehan
    • linked with Shared care (strong commitment to SC)
    • Community Clinics (hospital visits) - B’dmeadows, Falkner, Kensington, Monee Ponds
rwh models of care14
RWH Models of Care
  • Pregnancy Booking Clinic
    • antenatal screening issues including prenatal screening
    • risk assessment by consultant
    • model of care assignment - if in “low risk’ can choose shared care
  • PHHR designed to reflect care and improve communication
standard antenatal check
Standard antenatal check
  • Obstetric assessment
  • Smoking history
  • BP check
  • measurement in Fundal height in centimetres
  • fetal auscultation from 20 weeks
  • fetal presentation from 30 weeks
  • inspection of legs for oedema
provision of smoking cessation interventions
Provision of smoking cessation interventions
  • Audits at RWH on women undertaking SC showed 42 - 56 % smoked
  • Evidence shows
    • Should be offered as routine to all who smoke or have recently quit I
    • Ask at every visit about smoking behaviour using multiple-choice question and record on A/N record II, III
    • Advise at every visit of risks to own and baby’s health - IUGR, prematurity I, IV
smoking cessation
Smoking cessation
    • Assess all identified as smokers or recently quit for willingness to quit or stay quit and document on A/N record II,III
    • assist to quit or remain quit by cognitive behavioural model of intervention I,III
    • If difficulty with quitting refer to outside agency, partners should be provided with information and support III
  • Information in both guidelines
routine bp measurement
Routine BP measurement
  • HT is defined when systolic BP is 140mmHg +/or DBP is 90 mmHg or there is an incremental rise of 30 systolic or 15 diastolic
  • Automated devices & ambulatory devices should not be used (Mercury devises seem best)
measurement symphyseal fundal height
Measurement Symphyseal Fundal height
  • Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth
  • measurement should start at the variable point (F) and continue to the fixed point (S)
  • SF measurement should be recorded in a consistent manner (therefore cms at RWH)
fetal presentation and descent
Fetal Presentation and Descent
  • Check presenting part beginning around 30 weeks
  • Descent of presenting part is important as term approaches
auscultation of fetal heart
Auscultation of fetal heart
  • Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion)
  • Should be offered at each visit after about 20 weeks
routine weighing at a n visits evidence
Routine weighing at A/N visits - evidence
  • weighing at every antenatal visit routine practice for many years
  • No conclusive evidence for weighing at each visit. Maternal weight not clinically useful screening tool for detection of IUGR, macrosomia or pre-eclampsia IV
  • Weighing at booking or other times may be indicated eg anaesthetic risk assessment (done BIV at RWH) or maternal weight concerns
urinalysis by dipstick for proteinuria evidence
Urinalysis by dipstick for proteinuria - evidence
  • high incidence of false +ve and - ve using dipsticks cf 24 hr urine collection
  • ureliable in detecting highly variable elevations in protein in pre-eclampsia
    • Gribble et al AJOG 1995; 173: 214-7
urinalysis by dipstick forn proteinuria evidence
Urinalysis by dipstick forn proteinuria - evidence
  • no statistical differences in rates of PAH, fetal distress, abruptio placentae, neonatal outcome in those with absent, mild or marked proteinuria by dipstick
  • US and Canadian Guidelines recommend screening for pre-eclampsia by BP measurement rather than dipstick
urinalysis by dipstick for proteinuria guidelines
Urinalysis by dipstick for proteinuria - guidelines
  • Routine screening for proteinuria in low risk pregnant women not recommended IV
  • assessment hypertensive pregnancies requires estimation of total protein in 24-hr collection IV
  • If detect hypertension then use dipstick for testing proteinuria
initial recommended tests
Initial recommended tests
  • FBE
  • MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low)
  • Blood group/Ab screen
  • HIV (level 1 evidence)
  • Hep B
  • Syphilis (ideally prior 16 weeks)
  • Rubella Abs
slide27
Urine testing- either 2 step or MSU+dipstick
  • PAP if due

Consider

  • Hep C
  • Ferritin
  • Vit D levels - common in patients at RWH
  • addit Thal screen
  • dating US
hepatitis c screening
Hepatitis C screening
  • Should be offered to all at increased risk
    • history of injecting drugs
    • partner who injected drugs
    • tattoo or piercing
    • been in prison
    • blood t/f later positive for Hep C
    • long-term dialysis or organ transplant before 7/92
prenatal testing
Prenatal testing

Down screening

  • Screening - : early US, 15-17 week MSST, Early combined screening(first trimester MSST and early US)
  • diagnostic testing - CVS, amniocentesis

Other testing according to history eg for CF, Fragile X, Thalassaemia, Huntington's disease

prenatal screening for down s syndrome
Prenatal screening for Down’s syndrome
  • All women should be offered screening irrespective of age III/IV
  • counselling given by appropriately trained staff and specific to age of each woman III/IV
down syndrome screening
Down syndrome screening
  • Screening should
    • include accurate dating by 1st T u/s IV
    • either by 2nd T biochem, or nuchal translucency alone or combination III
    • notify result irrespective of risk in understandable format II
    • if increased risk should be offered further counselling and diagnostic testing within 72 hrs or ASAP IV
down s syndrome screening
Down’s syndrome screening
  • Quality of counselling is of primary importance, non-directional, if chooses screening, should be single-step III
  • Nuchal translucency should be performed at 11-14 weeks by trained operators and risks derived in conjunction with gestation and maternal age IV
other recommended tests
Other recommended tests
  • 26 weeks (at hospital)
    • Gestational diabetes screening -
    • AB screen on all women
  • 36 weeks
    • GBS screen
    • (Ab if RH -ve has been ceased)
screening for gdm
Screening for GDM
  • In absence of high level evidence to either support or abandon screening reasonable to
    • not offer screening
    • selectively offer screening to all with risk factors
    • offer screening to all
  • if screening do so between 24-28 weeks
  • RWH screen all women at 26 weeks
prevention of early onset gbs
Prevention of Early Onset GBS
  • Swabs should be taken between 35-37 weeks’ III
  • Intrapartum antibiotics recommended if
    • <37 weeks’
    • ruptured membranes >18 before delivery
    • maternal temperature 38 C
    • previous GBS colonisation, bacteruria or infant with GBS III
antenatal anti d prophylaxis
Antenatal anti-D prophylaxis
  • Prophylactic Anti-D at 28 and 34 weeks’ gestation
  • No level I evidence
  • Level II and III evidence would suggest that the 1.5 percent immunisation rate could be reduced to 0.1-0.2% through antenatal prophylaxis (Huchet et al, 1987;Bowman and Pollock, 1978; Hermann et al, 1974)
  • www.health.gov.au/nhmrc/publications/pdf/wh27.pdf
scenario 1
Scenario 1
  • 36 year old P1 G2 first visit 11 weeks’
  • POH GDM treated with diet
  • What model of care?
scenario 138
Scenario 1
  • GTT early as possible
  • genetic counselling T21 risk 1/287
  • low risk model of care
scenario 2
Scenario 2
  • 29 year old P1 G2
  • POH elective caesarean section for breech presentation
  • What model of care?
scenario 240
Scenario 2
  • VBAC counselling expect 70%+ success
  • Document discussions, give information
  • What if CS at full dilatation for OP?
  • Low risk model of antenatal care
scenario 3
Scenario 3
  • 41 year old primigravida
  • What advice?
scenario 342
Scenario 3
  • risk miscarriage ~50%
  • T21 1/85
  • other chromosome abnormalities ~1/85
  • hypertensive disorders, GDM
  • caesar rate ~50%
  • combined care
other scenarios how to manage
Other scenarios - how to manage
  • Well primagravida
    • Breech at 32 weeks
    • Breech at 36 weeks
  • 26 week GTT is abnormal
  • 34 weeks / decrease fetal movements
  • 38 weeks ? HT
  • 30 weeks, FH 29cm, 33 weeks FH 31cm (good fetal movements)