ANTENATAL CARE

Presented by:

DM Obsgyn FK UNSYIAH – RSUDZA

March, 2013

Scope of ProblemMaternal Health

• 180–200 million pregnancies per year

• 75 million unwanted pregnancies

• 50 million induced abortions• 20 million unsafe abortions

(same as above)• 600,000 maternal deaths (1

per minute)• 1 maternal death = 30

maternal morbidities

Neonatal Health• 3 million neonatal deaths

(first week of life)• 3 million stillbirths

Maternal Mortality: A Global Tragedy• Annually, 585,000 women die of

pregnancy related complications – 99% in developing world– ~ 1% in developed countries

EVERY MINUTE:

• 380 women become pregnant• 190 women face unplanned or

unwanted pregnancy• 110 women experience a

pregnancy related complication• 40 women have an unsafe abortion• 1 woman dies from a pregnancy-

related complication

Global Causes of Maternal Mortality

24.8

14.9

12.96.912.9

7.9

19.8

Hemorrhage 24.8%

Infection 14.9%

Eclampsia 12.9%

Obstructed Labor6.9%Unsafe Abortion12.9%Other Direct Causes7.9%Indirect Causes19.8%

But WHY Do These Women Die?

• Supplies, personnel• Poorly trained personnel with

punitive attitude• Finances

• Mountains, islands, rivers — poor organization

• Lack of understanding of complications

• Acceptance of maternal death• Low status of women• Socio-cultural barriers to

seeking careTHREE

DELAYS MODEL

Delay in decision to seek

care

Delay in reaching

care

Delay in receiving

care

Interventions: Antenatal Care• ANC clinics started in US, Australia, Scotland (1910–1915)• New concept - screening healthy women for signs of disease• By 1930’s large number (1200) ANC clinics opened in UK• No reduction in maternal mortality• However, widely used as a maternal mortality reduction

strategy in 1980’s and early 1990’s

Is ANC important? YES!! Early detection of problems and birth preparation

ANTENATAL CARE• Program Antenatal care (prenatal), berasal dari model yang

dikembangkan di Eropa pada dekade awal abad yang lalu (Oakley 1982). Konsep ini muncul dari keyakinan baru terhadap kemungkinan menghindari kematian ibu dan juga kematian janin dan bayi.

• Pada tahun 1929, Dr Janet Campbell menyatakan, "persyaratan pertama dari layanan bersalin adalah pengawasan efektif kesehatan wanita selama kehamilan ...."

• Departemen Kesehatan Inggris: ANC harus dimulai pada sekitar 16 minggu, dan akan diikuti oleh kunjungan pada 24 dan 28 minggu, kemudian dua minggu sampai 36 minggu dan setiap minggu.

Oakley (1982)

ANTENATAL CAREAntenatal Care program terencana oleh tenaga kesehatan

1. observasi

Kehamilan aman

2. edukasi Ibu Hamil

Persalinan aman

3. penanganan medik

deteksi dini (kelainan obstetri)ANC, juga dikenal sebagai prenatal care,

adalah serangkaian intervensi yang diterima seorang wanita hamil dari pelayanan kesehatan yang terorganisir. (WHO)

Standar Pelayanan ANC• Pelayanan pada bumil

min 4 kali• BB dan LILA dg teratur

(BBLR)• BB rutin & TD

(preeklampsi)• TFU • Palpasi abdominal• Imunisasi TT

• Pemeriksaan Hb• Pemberian tablet zat besi• Pemeriksaan urine• Penyuluhan perawatan

diri• Mendiskusikan rencana

persalinan• Tersedianya alat-alat

kehamilan

Sasaran ANC

Ibu Hamil Suami Keluarga Masyarakat

Depkes RI (2001)

Aims Of Antenatal CareTo prevent, detect and manage those factors that adversely affect the health of the baby

To provide advice, reassurance, education and support for the woman and her family

To deal with the ‘minor ailments’ of pregnancy

To provide general health screening

Tujuan ANC• Memantau kemajuan kehamilan untuk memastikan

kesehatan ibu dan tumbuh kembang bayi• Meningkatkan dan mempertahankan kesehatan

fisik, mental, dan sosial ibu dan bayi.• Mengenali secara dini adanya ketidaknormalan atau

komplikasi yang mungkin terjadi selama hamil, termasuk riwayat penyakit secara umum, kebidanan dan pembedahan

• Mempersiapkan persalinan cukup bulan, melahirkan dengan selamat, ibu maupun bayinya dengan trauma seminimal mungkin

• Mempersiapkan ibu agar masa nifas berjalan normal dan pemberian ASI eksklusif

• Mempersiapkan peran ibu dan keluarga dalam menerima kelahiran bayi agar dapat tumbuh kembang secara normal.

• Membantu menyiapkan ibu menjalankan puerperium normal, dan merawat anak secara fisik, psikologis dan sosial.

Classification Of Antenatal Care

Sh

ared

Car

eHospital Maternity Team

General Practitioner (GP)

Community Midwives

Advice, Reassurance & Education

1. Nausea

2. Heartburn

3. Constipation

4. Shortness Of Breath

5. Dizziness

6. Swelling

7. Back-ache

8. Abdominal Discomfort

9. Headaches

Reassurance & explanation on pregnancy symptoms:

Confirmation of the pregnancy• Breast tenderness ● Nausea• Amenorrhea ● Urinary Frequency

Symptom of the pregnancy

• Positive urinary or serum pregnancy test are usually sufficient confirmation of a pregnancy.Pregnancy test

• Confirms the pregnancy and accurately dates it.Dating Pregnancy

Dating PregnancyA. Menstrual EDD

B. Dating by ultrasoundBenefits of a dating scan:1. Accurate dating women with irregular menstrual cycles or poor

recollection of LMP.

2. Reduced incidence in induction of labor for ‘prolonged pregnancy’

3. Maximizing the potential for serum screening to detect fetal abnormalities

4. Early detection of multiple pregnancies

5. Detection of otherwise asymptomatic failed intrauterine pregnancy

Booking History

Past Medial History

Past Obstetric History

Previous Gynaecological History

Family History

Social History

Booking Examination

Full Physical Examination

Cardiovascular

Respiratory Systems

AbdominalFull Pelvic Examination

Full Breast Examination

Examination for most healthy women: 1. Accurate measurement of blood pressure

2. Abdominal examination to record the size of the uterus

3. Recognition of any abdominal scars indicative of previous surgery

4. Measurement of height and weight for calculation of the BMI.

5. Urine examination

Pattern Of Follow Up Visits

The minimum number of ‘visits’ recommended by the Royal College of Obstetricians and Gynaecologists is 5

Occurring at 12, 20, 28-32, 36 and 40-41 weeks.

fortnightly visits 32 weeks to 36 weeksweekly visits

4 weekly appointments from 20 weeks until 32 weeks

Content Of Follow Up Visits

General questions regarding maternal well-being.

Enquiry regarding fetal movements (24 weeks).

Measurement of blood pressure (a screen for pregnancy-related hypertensive disorders).

Urinalysis, particularly for protein, blood and glucose: this is used to help detect infection, pre-eclampsia and gestational diabetes.

Examination for oedema: Oedema is common in pregnancy and is mostly an insensitive marker of pre-eclempsia. Oedema of the hands and face is somewhat more important as a warning feature of pre-eclampsia.

Abdominal palpation for fundal height:

If repeated symphysis–fundal height measurement are made throughout a pregnancy, the detection of fetal growth problems and abnormalities of liquor volume increased.

Auscultation of the fetal heart:

There is no evidence that this practice is of any benefit in a woman confident in the movements of her baby; however, it provides considerable reassurance and will occasionally detect an otherwise unrecognized intrauterine fetal death.

A full blood count and red cell antibody screen is repeated at 28 and 36 weeks.

Depending on the screening policy of the particular unit, women at 28 weeks may be tested for gestational diabetes.

From 36 weeks, the lie of the fetus (longitudinal, transverse or oblique), its presentation (cephalic or breech) and the degree of engagement of the presenting part should be assessed and recorded.

It is often at this appointment that a decision is made regarding the mode of delivery (i.e. vaginal delivery or planned Caesarean section).

At 41 weeks’ gestation, a discussion regarding the merits of induction of labour for prolonged pregnancy should occur.

An association between prolonged pregnancy and increased perinatal morbidity and mortality means that women are usually advised that delivery of the baby should occur by 42 completed weeks’ gestation.

This will usually mean organizing a date for induction of labour at approximately 12 days past the EDD.

“A woman’s ability to have a SAFE and healthy pregnancy and childbirth.”

What Is Safe Motherhood?

TERIMA KASIH

“Every Pregnancy Is at Risk”