Post on 25-Dec-2015
Routine Antenatal Care
Dr Penny SheehanObstetrician, Head Unit D and
FMC RWHDr 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 Level I
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 dueConsider 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, amniocentesisOther 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 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 risk miscarriage ~50% T21 1/85 other chromosome abnormalities
~1/85 hypertensive disorders, GDM caesar rate ~50% combined care