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Antenatal care. 1. 1. ANTENATAL CARE Dr Junita Aris Segamat 17 Nov 2012 1 2. 2. PERINATAL CARE MANUAL DIVISION OF FAMILY HEALTH DEVELOPMENT MINISTRY OF HEALTH MALAYSIA 2004 (1st edition) 2009 (2nd edition) June 28, 20132 3. 3. 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 4. 4. 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) 5. 5. 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 6. 6. The “PINK BOOK” June 28, 20136 7. 7. History taking • Detailed menstrual history - Last menstrual period (LMP)* - Regularity of cycles - Contraceptive usage * If patients 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 8. 8. 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 9. 9. 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 10. 10. PHYSICAL ASSESSMENT General examination - Height - Weight - Pallor, cyanosis & clubbing - Oral hygiene - Oedema - Varicose veins - The mothers gait – any bony deformity of pelvis June 28, 201310 11. 11. 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 12. 12. 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 13. 13. 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 14. 14. June 28, 201314 Heart rate Thyroid 15. 15. 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 16. 16. 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 17. 17. 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 18. 18. Subsequent visits High grade fever in pregnant mothers – refer O&G for opinion. June 28, 201318 19. 19. 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 20. 20. 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 21. 21. June 28, 201321 22. 22. 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 23. 23. 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 24. 24. 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 25. 25. 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 26. 26. 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 27. 27. YELLOW 1. Ibu HIV positif 2. Ibu Hepatitis B positif 3 Tekanan darah tinggi > 140/90 -

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