Week 5 Pregnancy Booking Appointment & Antenatal Care (Australian PDF)

Week 5 Pregnancy booking appointment and overview of antenatal care Lecture notes: Antenatal detentions: Antenatal period - period between conception and birth Antenatal care - is a ‘planned visit between a pregnant woman and a midwife or doctor to assess and improve the wellbeing of the mother an...

Week 5 Pregnancy booking appointment and overview of antenatal care Lecture notes: Antenatal detentions: Antenatal period - period between conception and birth Antenatal care - is a ‘planned visit between a pregnant woman and a midwife or doctor to assess and improve the wellbeing of the mother and baby throughout pregnancy.’ - does not include appointment where soul purpose is to ind out if pregnant or not. Evolution of Antenatal Care (ANC) - 18th & 19th centuries – lying-in hospitals, traditionally for poor and unsupported women. Antenatal care was non-existent. - Widespread, institutionalised, routine ANC began less than 80 years ago. - Aimed and achieved reduction in maternal and perinatal mortality. - Focused on screening Screening for infections (eg stis), pre-eclampsia and fetal growth restriction. Detection and treatment of anaemia, mal-presentations and hypertension. Based within medical model and notion that pregnancy is a pathological. Reasons for providing antenatal care Three domains of ‘contemporary’ antenatal care identi ied: 1. To provide clinical care and therapeutic practices 2. To provide relevant and timely information (physiological, biomedical, behavioural and sociocultural) 3. To provide support (social, cultural, emotional and psychological) What constitutes a positive pregnancy experience? Downe et al., (2015) describes ‘a positive pregnancy experience’ as: Maintaining physical and social normality Maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death) Effective transition to positive labour and birth, and Achieving positive motherhood (including maternal self esteem, competence, autonomy. Who provides antenatal care? - GPs , hospital antenatal clinics (medical and midwifery) and obstetricians - Midwives can provide independent antenatal and postnatal care in the community f f  - Access to the pharmaceutical bene its scheme (PBS) - Access to the Medicare bene its schedule (MBS) - Antenatal care still evolving and evidence still building. - Some aspects of care not evidence based & there is lack of consensus e.g. Urinalysis at every - antenatal visit - ‘Evidence based guidelines’ have been developed to standardise care. Australian Antenatal care guidance documents - Pregnancy care clinical practice guidelines - Maternity Ehandbook - National Midwifery guidelines for consultation and referral - RANZCOG Australian context : a Snapshot - ANC a ‘routine’ part of pregnancy for the majority of women. - The Australian Pregnancy Care Guidelines (DOH, 2021) recommend that irst-time mothers with an uncomplicated pregnancy have 10 antenatal care visits during pregnancy (7 visits for subsequent uncomplicated pregnancies). - In 2021, 83% of women who have previously given birth attended 7 or more antenatal care visits and 58% of irst-time mothers attended 10 or more antenatal care visits.Attendance varies by where mothers live (less visits for ‘remote’ women) - Women in lowest socioeconomic status areas and indigenous women had later irst visit and less visits overall. (AIHW, 2023) - The Australian Pregnancy Care Guidelines (DOH, 2021) recommend that all women attend their irst antenatal care appointment before 10 weeks. - In 2021, 60% of women attended antenatal care within the irst 10 weeks of pregnancy. Frequency and timing of antenatal visits - Number and timing of visits individualised & communicated to women in early pregnancy. - The traditional pattern of antenatal visit is: 4-weekly from booking until 28 weeks gestation Fortnightly until 36 weeks, and Weekly until birth. Woman centred care: What are the woman’s thoughts, views and opinions re pregnancy? Planned, unplanned, sexual assault, stressors Ask open-ended questions and provide opportunities to discuss issues. Did it take you long to get pregnant? Who will be your main support during your pregnancy? Offer information - written and/or verbal on topics such as diet and lifestyle, available pregnancy care services, maternity bene its, screening tests, breastfeeding. Discuss involvement of the woman’s partner/family in antenatal care. Initially use gender and partnership status ‘neutral’ language. f f f f f f f f  ANC can’t address all issues but taking them into account can help to understand a woman's situation and provides the opportunity for early intervention (e.g. social work, counselling). Booking visits Purpose: - Undertake a comprehensive history - Perform clinical assessment - Order/ review essential investigations - Provide information and plan for care Length of visit - Booking visits are generally longer than regular antenatal appointments. - Consider allowing additional time for women who have: Limited experience of the health system Limited English (ensure interpreter available and booked) Hearing impairment Past experiences that affect their trust in health professionals Psychosocial circumstances Booking visit: history Current pregnancy - planned, unplanned, woman wishes to proceed with/terminate pregnancy Medical - history, medications, family history, cervical smears, immunisation, breast surgery Obstetric - previous experience of pregnancy and birth Infant feeding experiences Nutrition and physical activity Smoking, alcohol and other substance misuse Expectations, partner/ family involvement, cultural and spiritual issues, concerns, knowledge Psychosocial factors including experience of trauma or family violence Factors that may affect the pregnancy or birth (e.g. female genital mutilation (FGM)) discuss models of care available Booking visit: clinical assessment - Discuss conception and date of last menstrual period (LNMP). Ultrasound for gestational age assessment offered between 8 and 14 weeks of pregnancy (8/40 – 14/40) - Height & weight – BMI - Mental health: previous episodes, psychosocial factors. Administer the Edinburgh Postnatal - Depression Scale (EPDS). - Urinalysis - proteinuria - Blood pressure - Assess risk of pre-eclampsia and advice women at risk that low-dose aspirin from early pregnancy may be helpful in its prevention - Auscultation of FHR after 12 weeks using doppler Booking a visit: investigations Weight and body mass index - Recording weight at every antenatal visit practiced routinely for many years. - Guidance changed as maternal weight not clinically useful screening tool for detection of fetal growth restriction, macrosomia or pre-eclampsia. - Current recommendation is to weigh women where it is likely to in luence clinical management. - ↑ Prevalence of obesity in the past few decades and Australia amongst those countries with the highest prevalence. - ↑ risk of complications for women who are overweight, obese or underweight during pregnancy. - Calculate body mass index (BMI) at irst visit (weight (kg) / height (m2)). - Advice about weight gain, ongoing monitoring of weight in pregnancy and speci ic risk assessments are based on pre-pregnancy BMI. Guidelines for weight gain in pregnancy f f f  Booking visit: information - Models of care Options available at that health service. May include team midwifery, MGP, shared GP care, GP obstetrician care. - Diet Essential nutrients. Supplements (pregnancy multivitamins, iron, folate, vitamin D). Food safety (listeria, salmonella, mercury). Avoiding toxoplasmosis and cytomegalovirus infection. Smoking, alcohol and drugs in pregnancy. Physical activity in pregnancy. Expected schedule of visits. When to come in to hospital/ who to call for help or advice. Vaccinations Vaccinations not only protect the mother from illness during pregnancy, but also offer immunity to the baby by the transferring of antibodies through both the placenta and breastmilk! DISCUSS AT BOOKING AND RECOMMEND: Pertussis: Victorian government funded immunisation program to prevent pertussis in 2015. Several amendments since then. - Boostrix free for all pregnant women from 20 weeks gestation during every pregnancy. - Free for partners of women who are in the third trimester (if the partner has not had a booster in the past 10 years). - Available to parents /guardians of babies under 6 months of age if they have not received a booster in the past 10 years. In luenza: Flu vaccination free and recommended for all pregnant women. Increased risk of severe lu complications and mortality during pregnancy. Immunising during pregnancy not only protects the woman, but provides ongoing protection to a newborn baby for the irst six months after birth. COVID-19: pregnant women are a priority group to receive P izer or Moderna (MRNA vaccines) Pregnant women with COVID-19 have a higher risk of severe illness compared to non- pregnant women with COVID-19 of the same age. This includes an increased risk of: Hospitalisation admission to an intensive care unit invasive ventilation. Covid-19 during pregnancy also increases the risk of complications for the baby including a higher risk of stillbirth and of being born prematurely. Pregnant women should be offered the COVID-19 vaccine at any stage of the pregnancy. Global evidence has shown that the P izer and Moderna vaccines are safe for pregnant women. “Pregnant women should get vaccinated and continue to follow the current guidelines to prevent the spread of COVID-19 after they are vaccinated. Vaccination signi icantly reduces the risk of becoming infected with COVID-19. Vaccination also reduces your risk of transmitting the virus to others, including your baby. Everyone should continue with hand f f f f f f hygiene, masks where social distancing cannot be maintained, testing when symptoms are present and isolation, when appropriate.” (RANZCOG, 2024) Booking visit: consultation and referral During booking, assess for risk factors: physical, social and emotional Consult and/or refer as necessary using guidelines for consultation and referral Consider referral to other interprofessional colleagues such as dietician, physiotherapy, psychologist etc. Routine antenatal visits Antenatal visits - all visits Provide woman-centred care. Discuss EDC and check blood group. Check in re woman’s expectations & experiences. Check any outstanding results. Ask about general health & wellbeing. ASSESSMENTS: Blood pressure Leg oedema Abdominal examination – fundal height assessment (more in assessment of fetal wellbeing lecture) Psychosocial assessment – domestic violence Offer to weigh, encourage self monitoring of weight gain and discuss weight change, diet and level of physical activity Smoking history If woman identi ies as ‘smoker’, ask at every visit about smoking and record on A/N record Advise at every visit of risks to own and baby’s health – IUGR/FGR, prematurity Offer referral to outside agency, provide partners with information. Antenatal visit: 16 -19 weeks - offer fatal anatomy scan to be carried out at 18 and 20 weeks gestation Antenatal visit: 20-27 weeks Test for hyperglycaemia (glucose tolerance test) between 24 and 28 weeks. Repeat ferritin testing if levels were low in irst trimester. From 20 weeks: Discuss and assess fetal movements: normal patterns, timing etc. Test for proteinuria in women who have clinical indications of pre-eclampsia (e.g. high blood pressure). Antenatal visit: 28 weeks Test for anaemia, blood group and antibodies. Recommend Anti-D to rhesus negative non-isoimmunised women. Administer EPDS. f f Antenatal visit: 29-34 weeks Give information with an opportunity to discuss issues and ask questions on preparation for labour and birth, including the birth plan, recognising active labour, and positively managing the pain of normal labour. Discuss breastfeeding including bene its and ways to encourage successful breastfeeding (e.g. skin to skin, rooming in etc.). Offer repeat ultrasound at 32 weeks to women whose placenta extended over the internal cervical os in the 18-20 week scan. Recommend a second dose of Anti-D to rhesus negative non-isoimmunised women at 34 weeks. Antenatal visit: 35 - 37 weeks Give information, including: Care of the new baby. Reducing risk of sudden and unexpected death in infancy (SUDI). Newborn screening tests and vitamin K prophylaxis. Psychosocial support available in the postnatal period including maternal and child health services and psychosocial supports. Assess fetal presentation by abdominal palpation from 36 weeks and con irm suspected malpresentation by ultrasound. For women whose babies are not a cephalic presentation, discuss a range of options, including external cephalic version for breech presentation. Offer testing for group B streptococcus if organisational policy is to routinely test all women. Antenatal visit: 40 weeks Routine visit Make sure woman knows when to come in to hospital, where to go. From 40 weeks consider discussing natural induction of labour methods (evidence based!). Offer “stretch and sweep” at 40 weeks in primiparous women. Antenatal visits: 41+ weeks Discuss natural IOL methods. Discuss options for prolonged pregnancy, including local policy on induction of labour for postdates induction. Offer stretch and sweep in multiparous women at 41 weeks (and again in primiparous women). How and why are we assessing these things Blood pressure in pregnancy: How? Appropriately sized cuff. If upper arm circumference is >33cm, use large cuff. Many recommend L arm. Be consistent! Manual sphygmomanometer* Systolic BP = the irst sound heard (Korotkoff 1) f f f  Diastolic = the disappearance of sounds completely (Korotkoff 5). If no K5, K4 (muf ling) is accepted. May need to repeat readings over several hours. NB: *...automated devices... give similar mean blood pressure values to mercury sphygmomanometry, there is wide intra-individual error and their accuracy may be further compromised in preeclamptic women. Only a few automated blood pressure monitors have been validated for use in normotensive or mildly hypertensive pregnant women. In women with preeclampsia, especially those with severe hypertension, the accuracy of [2 devices] declined and...cannot be recommended for use in preeclampsia. (Somanz 2014. P.4) Blood pressure in pregnancy: Why? Hypertension can be exceptionally dangerous for the pregnant woman and her fetus Hypertension is de ined as systolic ≥ 140mmhg and/or diastolic ≥ 90mmhg. Severe – systolic ≥ 170mmhg and/or diastolic blood pressure ≥110mmhg (SCV, 2024). Rise from booking in BP maybe signi icant (≥30mmhg systolic +/- 15mmhg diastolic) but not supported by current evidence (SOMANZ, 2014). SOMANZ identi ies four classi ications of hypertension: Gestational hypertension (onset at 20 weeks gestation or more). Preeclampsia. Chronic hypertension. Preeclampsia superimposed on chronic hypertension. Gestational diabetes WHY? Gestational diabetes is caused by insulin resistance that develops in pregnancy. Poorly controlled gestational diabetes can be dangerous for the woman and her fetus. HOW? There is a lack of an agreed gold standard for diagnosis gestational diabetes. The pregnancy care guidelines recommend that testing for hyperglycaemia is offered to ALL women between 24 and 28 weeks gestation. Most organisations will do this in the form of a glucose tolerance test at around 26-28 weeks. Test usually done with an FBE and antibody screen as well. Group B Streptococcus WHY? Group B streptococcus (GBS) is a common bacterium that can live in the gi tract, vagina and urethra. GBS is transmitted to the baby in 1-2 per 1000 live births. Colonisation in the newborn can lead to serious infections (including late onset up to 3 months of age). Intravenous antibiotic treatment during labour can prevent early onset GBS infection in close to 90% of newborns of mothers colonised with the bacteria. HOW? Some organisations offer routine screening of GBS at 35-36 weeks by conducting a vaginal +/- rectal swab (including rectal swab results in higher sensitivity than vaginal swab alone). f f f f f Oral health advice HOW? Encourage dental check up early in pregnancy. Dental treatment can be safely provided during pregnancy if the dentist is informed of the pregnancy. WHY? Pregnancy doesn’t cause dental problems but physiological changes make them more likely Vomiting exposes teeth to acid: Reduce the impact by rinsing mouth with bicarb soda solution after vomiting. Avoid brushing teeth immediately after vomiting (effect of erosion increased by brushing an already demineralised tooth surface). Physical activity during pregnancy advice HOW? Assess activity levels during each antenatal visit. Provide advice – explain the bene its of regular physical activity and appropriate types of activity. Provide information on local supports, group activities. Assist women to identify ways of being physically active that are appropriate to their cultural beliefs and practices. WHY? Physical activity in pregnancy can: Reduce back and pelvic pain. Decrease risk of pregnancy complications such as pre-eclampsia and gestational hypertension. Control weight gain. Reduce risk of anxiety and depression. Sexual activity during pregnancy advice WHY? Women and their partners may ask about the safety of sexual activity during pregnancy. HOW? Discuss concerns – including a change in desire for sex as pregnancy progresses, and after the birth. There is little evidence of harm to low risk pregnancies. Reassure women that sex is not likely to harm the pregnancy or increase the risk of pre-term birth. At the end of every contact Communication – sharing of information. Documentation - Victorian Maternity Record or hospital based charts/ EMRS. Appropriate referral and consultation. Clarifying issues. Planning. f  Conclusion Antenatal care improves outcomes for women and babies. Evidence for the optimal number of visits suggests 7 – 10 visits for low risk women. Individualised and woman-centred care. Speci ic outcomes for each visit i.e. ‘Care schedule’. Remember, each visit is an opportunity to make a difference! f