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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 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 • Individual cases can undergo shared care with consultation b/w consultant and SMCA
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
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 • 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 • 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 • 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 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 • 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 • 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 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 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 • “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 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 • 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 • 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 • 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 • 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 • 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 • Check presenting part beginning around 30 weeks • Descent of presenting part is important as term approaches
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 • 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 • 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 • 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 • 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 • 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
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 • 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 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 • 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 • 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 • 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 • 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 • 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 • 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 • 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 • 36 year old P1 G2 first visit 11 weeks’ • POH GDM treated with diet • What model of care?
Scenario 1 • GTT early as possible • genetic counselling T21 risk 1/287 • low risk model of care
Scenario 2 • 29 year old P1 G2 • POH elective caesarean section for breech presentation • What model of care?
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 • 41 year old primigravida • What advice?
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 • 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)