Transcript Three Centres Consensus Guidelines on Antenatal care

Routine Antenatal Care
Dr Penny Sheehan
Obstetrician, Head Unit D and
FMC RWH
Dr Ines Rio, GP & GPLO RWH
“Low risk” pregnancy
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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
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One arm 2 year DHS funded project
3 Centres Consensus Guidelines 10/01. MMC, RWH, MHW
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evidence base of 16 issues. Classified
according I-IV
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Guidelines for Shared Maternity Care
Affiliateswww.health.vic.gov.au/maternity care
RWH website soon
3 Centres - www.3centres.com.au
No and timing of antenatal
visits - specific questions
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Is reduced schedule of visits as
effective as traditional 14 visits
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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
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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
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1st trimester - visits 1&2
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PBC: history, risk assessment, screening
tests, establish care options
2nd trimester - visits 3 &4
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monitor fetal growth, maternal well-being,
signs pre-eclampsia
18 week u/s, if GCT/GTT 24-28 weeks
Antenatal visits
implementation RWH
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3rd trimester - visits 5-8
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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
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10
16
20
26
30
33
36
38
40
41
weeks - BIV, consultant, Initial tests
weeks
weeks
weeks-Preadmission V, AN check - MW(VBAC)
weeks
weeks
weeks - Consultant visit
weeks
weeks
weeks - Consultant visit
Models of antenatal care
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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
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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
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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
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“High Risk” Maternal Fetal Medicine (2)
(A) L Kornman, (B) Prof S Brennecke
Specialist clinics eg RMC, DM, Fetal
management, Prem labour, Thal etc
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“Low risk” Maternity Care Program (2),
Family Birth Centre
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(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
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Pregnancy Booking Clinic
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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
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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
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Audits at RWH on women undertaking
SC showed 42 - 56 % smoked
Evidence shows
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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
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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
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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
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Evidence supports either palpation or SF 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
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Check presenting part beginning around
30 weeks
Descent of presenting part is important
as term approaches
Auscultation of fetal heart
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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
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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
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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
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Gribble et al AJOG 1995; 173: 214-7
Urinalysis by dipstick forn
proteinuria - evidence
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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
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Routine screening for proteinuria in low
risk pregnant women not recommended
IV
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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
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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
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Hepatitis C screening
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Should be offered to all at increased
risk
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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
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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
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Screening should
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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
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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
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26 weeks (at hospital)
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Gestational diabetes screening AB screen on all women
36 weeks
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GBS screen
(Ab if RH -ve has been ceased)
Screening for GDM
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In absence of high level evidence to
either support or abandon screening
reasonable to
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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
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Swabs should be taken between 35-37
weeks’ III
Intrapartum antibiotics recommended if
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<37 weeks’
ruptured membranes >18 before delivery
maternal temperature 38 C
previous GBS colonisation, bacteruria or
infant with GBS III
Antenatal anti-D prophylaxis
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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/w
h27.pdf
Scenario 1
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36 year old P1 G2 first visit 11 weeks’
POH GDM treated with diet
What model of care?
Scenario 1
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GTT early as possible
genetic counselling T21 risk 1/287
low risk model of care
Scenario 2
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29 year old P1 G2
POH elective caesarean section for
breech presentation
What model of care?
Scenario 2
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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
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41 year old primigravida
What advice?
Scenario 3
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risk miscarriage ~50%
T21 1/85
other chromosome abnormalities ~1/85
hypertensive disorders, GDM
caesar rate ~50%
combined care
Other scenarios - how to
manage
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Well primagravida
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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)