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 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)