PERINATAL CARE MANUAL

PRE-PREGNANCY CARE
SECTION 1

MINISTRY OF HEALTH MALAYSIA

PERINATAL CARE MANUAL

PRE-PREGNANCY CARE SECTION 1

DIVISION OF FAMILY HEALTH DEVELOPMENT MINISTRY OF HEALTH MALAYSIA 2002 (1st editio ! 2010 (2
d

editio !

CONTENTS Page Preface How to use this manual Objectives Introduction Rationale Objectives of pre pregnanc! care Opportunit! #roups Pre pregnanc! %are clinic Postnatal %are (tandard Operating Procedure )(OP* (uggestions for Incorporation (etting up pre pregnanc! %are services .low process of pre pregnanc! care Pre pregnanc! Ris/ factors Pre Pregnanc! %are screening .ormat Pre Pregnanc! Health 1ducation Pre Pregnanc! %ounseling

1.1 1.2 1.3 1." 1.$ 1.& 1.' 1.+ ,ppendices ,ppendi- 1 ,ppendi- 2 ,ppendi- 3 ,ppendi- " ,ppendi- $ ,ppendi- &

2 2 2 3 3 " " " $ ' + 10 12 1"

1.2

(tandard Operating Procedure 1 3 Pre e-isting chronic medical illness 2 3 4halassemia 3 3 Histor! of %ongenital ,nomalies " 3 Previous surgical histor! $ 3 Recurrent abortions & 3 Histor! of une-plained perinatal deaths ' 3 5rug histor! + 3 (e-uall! 4ransmitted Infection 2 3 Infertilit!

12 20 21 21 22 23 2" 2$ 2&

,bbreviations 6embers of the wor/ing groups 7 ,c/nowledgements

PREFACE 4he 6inistr! of Health 6ala!sia is committed to reduce child and maternal mortalit! to achieve the 6illennium 5evelopment #oals b! 201$. 4his manual was developed to help prevent maternal and neonatal morbidit! and mortalit! b! identif!ing and ta/ing timel! and appropriate action when problems occur in the pre pregnanc!8 pregnanc!8 deliver!8 postnatal and neonatal period. It supports a standard approach to general basic care and management of common problems encountered b! the pregnant women and their newborns.
3

.or this second edition8 the intrapartum and postpartum care have been e-panded as separate sections. 9here appropriate8 national guidelines are cited to help in the decision ma/ing process. 4he information provided should not substitute the sound professional clinical judgment of a competent health care professional. I hope this manual will be helpful in meeting the needs of pregnant women and neonates. I would li/e to place on record m! appreciation for the hard wor/ and untiring efforts of the various wor/ing groups in developing the contents. 4his manual is dedicated to health care professionals who are striving to provide :ualit! care in the maternal and neonatal health arena.

DR. SAFURAH BT. JAAFAR 5irector 5ivision of .amil! Health 5evelopment 6inistr! of Health 6ala!sia

HOW TO USE THIS MANUAL 4his manual is not intended to replace standard te-tboo/s used for teaching. It is to be /ept at hand at !our wor/ place which can be referred for guidance. 4he manual consist of five sections pre pregnanc!8 antenatal8 intrapartum8 postnatal and neonatal care. Section One Pre Pregnancy are .ocus on specific group of women in the reproductive age group with counseling on appropriate medical care to optimi;e pregnanc! outcomes. It includes ris/ assessment chec/ list management of various conditions. In future editions the manual will broaden care to include all women in reproductive age.
4

Section T!o Antenata"

are

describes activities and screening services for each trimester. It e-plains how to diagnose and manage common conditions8 which can be identified during routine e-amination of the mother. It provides standard operating procedures for :uic/ reference in the management of common complications and high ris/ cases. Section T#ree Intra$art%& are

understanding the process of normal labour and deliver! allows optimal care for the mother and timel! recognition and intervention of abnormal events. Section Fo%r Po't$art%& are

provides information for appropriate care8 reassurance and earl! recognition of postpartum problems. Section Fi(e Neonata" are

outlines the comprehensive approach to neonatal care. .low charts and chec/lists are available to enable health care wor/ers to provide :ualit! care and initiate and facilitate referrals whenever necessar!.

OBJE TI)ES *enera" o+,ecti(e' 4o develop a comprehensive training manual and reference for general use b! health care provider who are entrusted with the care of mothers and their newborns. (pecific objectives< 1. 4o serve as a guide containing the basic /nowledge and s/ills re:uired in the care for women beginning at pre pregnanc! and e-tending to the neonatal period.
5

2. 3.

4o provide management of certain common conditions which occur during the different stages of pregnanc! and neonatal period. 4o serve as a guide for health care providers the e-pected standard of care in the deliver! of the respective services in an endeavor to improve maternal and neonatal outcomes and reduce the morbidit! and mortalit!

PRE-PREGNANCY CARE
-.INTRODU TION Every mother has the right to expect her baby to be born alive and healthy just as every baby has the right to a living and healthy mother. 6a/ing pregnanc! safer is an important component of 6aternal and child health )6%H* services. ,s the nation develops8 the profile of the woman embar/ing upon a pregnanc! changes. , greater number of them are been categori;ed as high ris/ pregnanc!. 1arl! intervention and treatment can reduce the incidence of maternal and neonatal complications in these women.
6

4he couple or women in reproductive age in good ph!sical and ps!chological health8 living in a good socio economic environment8 will benefit both the mother and child. ,s such8 pre pregnanc! care and consultation can assist the couple and women in reproductive age to choose the appropriate time to conceive and thus reduce ris/ of complication to the mother and bab!. 5efinition< , set of intervention that aim to identif! and modif! biomedical8 behavioural8 and social ris/s to a woman=s health or pregnanc! outcome through prevention and management8 emphasi;ing those factors that must be acted on before conception or earl! in pregnanc! to have ma-imal impact.
Samuel FP, Kay J, Christopher P, et al. The National Summit on Preconception Care: A Summary of concepts and Recommendations. aternal al Child !ealth J "#$$%& '$:S'()*S

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RATIONALE 6a/ing pregnanc! safer8 policies primaril! focuses upon optimi;ing antenatal and intrapartum care. ,nd pre pregnanc! care is limited to premarital counselling courses8 HI> screening and 4halassemia screening program and screening for medical condition. 1vidence suggests that appropriate pre pregnanc! care has improved pregnanc! outcomes. 4he increase in the number of high ris/ pregnancies re:uires readil! available formali;ed pre pregnanc! care services. ,s such8 pre pregnanc! care should be formali;ed into our health care services.

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OBJE TI)ES General: 4o provide couples8 men and women in reproductive age with an avenue to achieve a safe and successful pregnanc!. Specific: i. 4o screen and counsel future mothers appropriatel!8 for earl! intervention and treatment8 aimed to reduce maternal and perinatal morbidit! and mortalit!. ii. 4o enable prospective parents and women in reproductive age to plan for pregnanc! through< Provision of appropriate and ade:uate information.
7

 iii.

Health promotion and education %ounseling

4o emphasi;e the prospective parents and famil! members to understand and practice the health! lifest!le and initiative in ma/ing pregnanc! safer.

-.0

TAR*ET *ROUPS *enera"1 i. Prospective couple intending to get married ii. 9omen who are married8 planning a pregnanc! iii. 9omen in reproductive age )1$ 3 "" of age? 9HO definition 9omen=s Health .act (heet 33" @ov 2002* 6ale

iv.

S$eci2ic1 i. 9omen above 3$ !ears old8 planning a pregnanc! ii. %lients with medical illnesses iii. %lients with previous miscarriages7 still births7 earl! neonatal death. iv. %lients with inherited abnormalities v. %lients with babies who have inherited abnormalities vi. %lients with congenital structural abnormalities vii. %lients with babies with congenital structural abnormalities viii. %lients with famil! histor! of genetic disorders I.3 I. ENTR4 POINTS Outpatient 5epartment )OP5* 9ellness %linic Premarital HI> (creening Program 4halassemia (creening Program ,dolescent %linic Referral from #eneral Practitioners 7 private medical centers %ommunit! Outreach Program Alini/ 1 6ala!sia 6aternal and %hild Health (ervices .amil! Planning (ervices %hild Health (ervices Postnatal (ervices
8

II.

III.

(pecialist %linic %ardiolog! %linic @ephrolog! %linic #eneral 6edical %linic Paediatric %linic Obstetrics B #!naecological %linic Other specialist clinic Hospital In patient ),ll 5isciplines* ,mbulator! %are %entre Others CPPA@ 7 R(,4 7 PCA@ 7 .P, )Aedah (tate* 7 .ederation of Reproductive Health ,ssociation of 6ala!sia ).RH,6 previousl! /nown as ..P,6* 7 Dniversit! Hospitals 7 #eneral Practitioners 7 Private 6edical %enters

I> > >I

-.5

PLA E OF PRE PRE*NAN 4

ARE SER)I E

O6* S$ecia"i't "inic 7 coordinator 7 provider of pre pregnanc! care services at hospital level8 preferabl! under the supervision of 6aternal .etal 6edicine (pecialist. Ot#er '$ecia"i't c"inic' 8&e9ica" : '%rgica" : $'yc#iatry etc; '#o%"9 a"'o acti(e"y in(o"(e9 in $ro(i9ing $re $regnancy care 'er(ice' Hea"t# "inic at primar! care level. Pre pregnanc! %are will be integrated into current )6%H* services8 headed b! .6( 7 6BHO. O%t $atient 'er(ice' at 9i'trict #o'$ita"' Ho'$ita" !it#o%t '$ecia"i't 8(i'iting O6* S$ecia"i't' an9 ot#er '$ecia"i't' o2 ot#er 9i'ci$"ine;

I.<

SETTIN*7UP
Appendi+ '&

PRE7PRE*NAN 4

ARE

LINI

"Refer

I.=

FLOW PRO ESS "Refer Appendi+ #&

-.>

THE MAJOR A TI)ITIES DURIN* A PRE7PRE*NAN 4 )ISIT IN LUDE1 I. (creening for ris/ factors< Histor! ta/ing Ph!sical e-amination %linical laborator! tests Identification of ris/ factors ),ppendi- "* ,ppropriate management according to identified ris/ factors. Referral to pre pregnanc! care clinic Health education. %ounseling Investigations ,ppropriate referral

II. III. I>.

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1.11

PRE PRE*NAN 4 S REENIN* FORMAT "Refer Appendi+ ,& POSTNATAL ARE "Refer to section -&

-.-.

STANDARD OPERATIN* PRO EDURE 8SOP; (tandard operating procedure is designed to assist health care providers in managing the patient. 4he conditions are selected based on ris/ factors present. (OP1 Pre e-isting chronic medical illness (OP2 4halassemia (OP3 Histor! of congenital anomalies (OP" Previous surgical histor! (OP$ Recurrent abortions (OP& Histor! of une-plained perinatal death (OP' 6edication 7 substance abuse (OP+ (e-uall! transmitted infection (OP2 (ubfertilit!

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SU**ESTIONS FOR IN ORPORATION I. In the co curriculum of the following courses Dnder graduate medical course Post graduate training in O B # and .6( 6idwifer! course %ommunit! nurse training program
10

 II. III. >. >I. >II. >III.

,ssistant 6edical Officer training program 5iploma In @ursing

4halassaemia screening programme ,nemia prevention programme Premarital courses Ereast feeding course @%5 %ourses and 4raining Program High Ris/ Pregnanc! and .amil! Planning %ourse

11

APPENDI@ SETTIN* UP OF A PRE PRE*NAN 4 1. 2. 3. ". $. (cope of activities (creening "Refer Appendi+ -& 5iagnosis 4herapeutics Referrals %ounseling "Refer Appendi+ %& Supplementation !ealth education Focus .roup /iscussion Infrastructure 1-amination room )ensure privac!* %ounseling room )ensure privac!* Caborator! (upport Health 1ducation Room %linic (chedule ,s appropriate for the centre Human Resources ,s appropriate for the center Obstetrician B #!necologists Other specialists (@ 7 F6 trained in PP% .6( 6O (taff @urses 9ith 6idwifer! @urses 1ducator e.g. 5iabetic 1ducator 7 Eronchial ,sthma 1ducator Pegawai (ains 6a/anan 7 5ietician %ounselor ,ssistant 6edical Officer ARE LINI

4raining Paramedics 5octors %ounselors

12

APPENDI@ . FLOW HART OF PRE7PRE*NAN 4

9al/ in or referral case

ARE AT PRIMAR4

ARE LE)EL

(creening and histor! ta/ing using pre pregnanc! screening format ),ppendi- 3* )Paramedics* 5edicated 7 integrated Pre pregnanc! clinic

@o ,n! ris/ factorG ),ppendi- "*

Hes

#ive advice7 health education ),ppendi- $* )Paramedics* Hes Re:uest counselin g

Refer 6O7.6(

Pre pregnanc! care management )6O7 .6(*

%onduct investigations )6O7 .6(7 Paramedics*

@o @o Re:uire further management Hes Refer pre pregnanc! service at tertiar! level )6O7.6(* 1nd

1ntr! of patients )refer to 1.$ for full list*< 1. 6aternal and child health services .amil! Planning %hild Health (ervices Postnatal (ervices 2. Out patient (ervices 9ellness (ervices Premarital (creening 4halassemia (creening ,dolescent (ervices Referral from #P7 @#O 3. (pecialist %linic Ph!sician %ardiolog! @ephrolog! Pediatric Others )reproductive unit8 genetic 1. Histor! ta/ing unit8 (4I clinic* 2. Ph!sical e-amination 3. 5iagnosis and confirm possible ris/ ". %ounseling $. Investigation APPENDIX 3 13

BORANG SARINGAN PRE-PREGNANCY CARE DI KEDAH (refer to the edited version in nother fi!e" PPC #$%&#& #' BIODA(A DIRI 1.1 Nama:............................................................ 1.2 No.K.Pengenalan/ Passport.................................................... 1.3 Umur: tahun (ARIKH)

1.4 lamat rumah:........................................................................................................................ 1.5 !arganegara: a. "arganegara #ala$s%a &. 'u(an "arganegara ). Pemastaut%n tetap 1.6 *ahap pen+%+%(an: a. *%+a( &erse(olah &. se(olah ren+ah ). se(olah menengah +. (ole,/%nst%tus%/ un%-ers%t% 1.7 Pe(er,aan:............................................... 1.8 Pen+apatan se%s% rumah: .#................................/se&ulan0 1.9 1tatus per(ah"%nan a. &u,ang &. &er(ah"%n ). ,an+a/&alu 1.10 Par%t$: Keguguran:

1.11: No. *el:........................................... /leta( +% atas0 2en%s ru,u(an: .u,u(an +ar% (es%hatan. N$ata(an333333333333333333 .u,u(an +ar% hosp%tal / un%t. N$ata(an333333333333333333333 .u,u(an +ar% (l%n%( / hosp%tal s"asta. N$ata(an33333333333333333333 14

%' PENGA*BI+AN RI,AYA(

2.1 4mmun%sas% : a. .u&ella &. 6epat%t%s ' ). tetanus $a $a $a t%+a( t%+a( t%+a( +. 5a%n la%n %mun%sas%:.........................

2.2 1e,arah ha%+ har%

#enar)he *empoh t%a+a

thn har%

(%taran 7$smenorrohea a+a

2.3 Peran)ang (eluarga 89P 'arr%er 4n,e)t%on

4U7

ster%l%sat%on

"%th+ra"al

*ra+%t%onal mt+

%mplant

*%+a( #engamal

2.4 1e,arah u&at:u&atan /mo+en +an tra+%s%onal0

1tero%+s

ant%ep%lept%) +rugs

"ar;ar%n

15

5a%n la%n

U&at tra+%s%onal

2.5 1e,arah peru&atan 6$pertens%-e +%a&etes mell%tus N$ata(an:.................... renal +%sease heart +%sease ep%leps$ asthma )ollagen +%s th$ro%+ 5a%n la%n

2.6 1e,arah Pem&e+ahan <a n$ata(an:.................................. t%+a(

2.7 1e,arah o&stetr%( +an =%ne(olog% 1e,arah o&stetr%( o o o o o o Pre-%ous )aesar%an se)t%on 1e,arah (e)a)atan &a$% 'erat lah%r > 4(g .e)urrent a&ort%on Per%natal +eath Pre-%ous uter%ne repa%r $a t%+a( $a t%+a(

1e,arah g%ne(olog% o o *an+a:tan+a -ag%nal +%s)a, *an+a:tan+a per%menopausal $a

2.8 1e,arah (eluarga 1e,arah pen$a(%t genet%( 9ongen%tal stru)tural anomal%es 3 -AK(OR RISIKO

t%+a(

16

3.1 5%;est$le ha&%t /9ara h%+up &er%s%(o t%ngg%0 #ero(o( #engam&%l al(ohol Pengam&%lan +a+ah 5a%n:la%n? n$ata(an............................ $a

$a

t%+a(

3.2 Pen$a(%t mental Neuros%s Ps$)hos%s 5a%n:la%n? n$ata(an:...................... $a

t%+a(

3.3 Pen+eraan +omest%( . @%A%(al 1e(sual #ental

t%+a(

PE*ERIKSAAN -I/IKA+ .'# Pe0eri1s n A0!)

Ket%ngg%an:..................)m 'erat &a+an:................(g '#4: ...................(+/m2 'P:..................mm6g P.:...................&pm +a /Normal Pallor 9lu&&%ng 2aun+%)e 8ral h$g%ene *h$ro%+ 'reasts Pe+al oe+ema 17 t%a+a/ &normal

Bar%)ose -e%n

*ar%(h +%ru,u( (epa+a 7r:...............................................

*ar%(h +%per%(sa oleh 7r:..................................................

.'% S2ste0i3) S5e3if2) 6eart 5ung 5%-er 1pleen K%+ne$ 8ther a&+om%nal ;%n+%ngs 'on$ +e;orm%t%es o; the pel-%s 'on$ +e;orm%t%es o; the sp%ne

Nor0 !

A4nor0 !

*AK*A+ ( 7i1

d indi1 si"

6&.........................gmC U@D#D............................................... Pap smear / B4 ....................................

6 7

.u,u(an #anagement plan:

$a $a

t%+a( t%+a(

18

N$ata(an:............................................................................................................................. ............................................................................................................................................. ..................

Nama 7o(tor:

9op Kl%n%( Kes%hatan:

APPENDI@ 0
19

PRE PRE*NAN 4 RISA FA TORS *enera" Ri'B 2actor' -. Age Wo&en "e'' t#an -= year' o"9 < 4eenage pregnancies are associated with fetal structural abnormalities. Wo&en a+o(e /3 year' o"9 < ,dvanced maternal age is associated with fetal chromosomal abnormalities. .. Li2e'ty"e #a+it' S&oBingC a"co#o"i'& an9 '%+'tance a+%'e < 4hese ma! have teratogenic effect resulting in fetal abnormalities and growth restriction Hig# ri'B 'eD%a" +e#a(ior < Increases the ris/ of maternal and fetal infection. O+e'ity : %n9er!eig#t< 6etabolic disorders have a detrimental effect during pregnanc! both on the fetus and mother. It ma! also affect mode of deliver!. Pet'< (ome household pets such as cats and birds ma!be associated with infections )eg. 4o-oplamosis8 Psittacosis and Eird flu*. 4hese infections affecting a pregnant mother ma! result in poor fetal outcome. /. S$eci2ic Ri'B Factor' I. O+'tetric #i'tory Recurrent miscarriage Dne-plained 7 une-plained B uninvestigated intrauterine death Previous abnormal bab! 1arl! neonatal death Histor! of bleeding in pregnanc! )ectopic8 ,PH8 massive PPH I 1.$ C or re:uiring blood transfusion* Instrumental deliver! Eig bab! ) "/g and above* Poorl! spaced pregnanc! ,EO 7 Rhesus group (mall bab! )1.$ /g or less* #rand multipara )Para $ and above*

II.

Me9ica" Hi'tory 8 #ronic &e9ica" i""ne''e'; H!pertension Heart disease

20

 III.

5iabetes mellitus 4h!roid disease 1pileps! Eronchial asthma %onnective tissue diseases such as (C1 Renal disorders Infections )eg. 4E8 HI>8 6alaria* Elood disorders Other medical conditions 6alignanc!

Ane&ia 8'ee a$$en9iD < WHO WeeB"y iron an9 2o"ic '%$$"e&entation $rogra&&e' 2or !o&en o2 re$ro9%cti(e age An ana"y'i' o2 +e't $rogra&&e $ractice' .?--; Me9ication' "Refer to list& S%rgica" #i'tory %aesarean section Dterine surger! Pelvic surger! Eowel surger! 4ransplant surger! )eg. Civer B renal* Fa&i"y #i'tory %onsanguinit! .amilial or genetic disorders %ongenital structural abnormalities

I>. ).

)I.

)II. Socia" #i'tory1 5omestic >iolence (tress at wor/ (tress in relationship Occupational ha;ard Cower socioeconomic status 6arginali;ed group

)III. )accination ,ctive 7 Passive immuni;ation Rubella

21

Hepatitis E %hic/en po-

22

APPENDI@ 3 PRE7PRE*NAN 4 HEALTH EDU ATION -. To!ar9' a Hea"t#y an9 #a$$y 2a&i"y , health! married couple is the basic foundation for a happ! famil!. .actors which influence the health of an individual8 famil! and the communit! include< Cifest!le #enetics .amilial factors 1nvironmental factors .. Practicing a #ea"t#y Li2e'ty"e 2.1 Ealanced diet , diet which contains all the necessar! nutrients in the right proportions according to calorie caloric needs and right proportion based on the food p!ramid. Husband and wife must be supportive and activel! participate in enhancing each other=s health. %ouples should practice mutual respect and consent for a satisf!ing and e:uitable se-ual relationship. 2.3 #ood dail! living habits ,ll men and women in reproductive age should have health! lifest!le? avoid unhealth! habits li/e smo/ing8 consuming alcohol and other t!pes of drug abuse. Regular e-ercises /eep !our bod! health!8 lower stress as well as /eep !our bod! health!. It lowers the ris/ of heart diseases8 stro/es and h!pertension. (even hours of sleep a da! in order to sta! health!.

2.2 (ocial interactions

2." Rela-ation

2.$ ,de:uate rest and sleep /. *enetic 2actor'

%ouple8 men and women with< %onsanguineous marriage )eg. ,utosomal recessive disorders* Previous child with genetic disorders )eg. 4halassemia* %lose blood relation with genetic disorders )eg. autosomal recessive disorders* 9omen at ris/ for genetic disorders at a particular age group )eg. 5own=s (!ndrome* 6ale disorders )eg. J lin/ed disorders 3 5uchene 6uscular 5!stroph!8 Haemophilia*
23

Dne-plained 7 uninvestigated fetal loss should be counsel for possible genetic problems. .amil! histor! with genetic disorders.

0. Fa&i"y P"anning It is encouraged for man B women to plan their pregnanc! in order to contribute positivel! to the eventual maternal and fetal outcome. Health care provider should be consulted and be able to provide information regarding the appropriate and effective contraceptive method. 3. Birt# an9 $regnancy P#y'ica" &at%rity an9 age o2 t#e &ot#er 4he appropriate age for a woman to get pregnant is at the legal age 1+ and above. 9omen above 3$ !ears are at higher ris/ of pregnanc! complication. Pre(ention in2ection' 6en and women in reproductive age group are advised about infections such as se-uall! transmitted diseases as well as lifest!le diseases which can affect reproductive potential and the unborn child. Hepatitis E and Rubella vaccinations are encourage to all women who are not immune. Antenata" #ea"t# care 6en B women who are planning to start a famil! should in optimal health. , pregnant woman and partner should attend antenatal clinic before 12 wee/s of amenorrhea. S%$$"e&entation .olic acid supplementation should be emphasi;ed to all women at least 3 months prior to a pregnanc!. ,ppropriate supplementation as advised b! health care provider8 wee/l! iron and folic acid supplementation after screening for thalassemia 8WHO WeeB"y iron an9 2o"ic aci9 '%$$"e&entation $rogra&&e' 2or !o&en o2 re$ro9%cti(e age An ana"y'i' o2 +e't $rogra&&e $ractice' .?--;. Brea't2ee9ing Ereast mil/ is the best food for the newborn as it contains all the necessar! nutrients8 in the right proportions8 for the optimum health and growth of the newborn. 1-clusive breast feeding for first & months of the newborn and encourage to continue for 2 !ears.
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#i"9+irt# 1ach pregnant woman must be advised on the appropriate place of deliver!. #i"9 care 1ver! child must be immuni;ed according to the recommended schedule.

&. (creening P,P (mear according to national guideline (4I screening as indicated. %linical Ereast 1-amination. 5iabetes and h!pertension screening should be offered annuall!.

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APPENDI@ 5 PRE7PRE*NAN 4 OUNSELLIN*

, recommendation for preconception counselling should be given to all men women with ris/ of pregnanc! complications. (uch counseling can reduce the incidence of maternal and fetal mortalit! and morbidit!. O+,ecti(e' o2 $re7$regnancy co%n'e"ing inc"%9e < -. on9%cting an initia" a''e''&ent .. a full histor! )personal8 social8 medical8 surgical8 past obstetric8 ps!chiatric and famil! histor!* general ph!sical e-amination identification of appropriate screening tests where necessar!

A""aying or re9%cing anDiety It is necessar! reduce an-iet! in women with bad obstetric histor! e-ample previous unsuccessful pregnancies or major obstetric complications. %ounseling should include< 4he effect of pre e-isting disorder on pregnanc! and pregnanc! on the disorder. 4he li/elihood of possible recurrence of previous complications and how this ma! possibl! be reduced )e.g. intrauterine or neonatal death8 h!pertension8 deep vein thrombosis8 abortion or preterm labour8 mechanical problems o labour or deliver!*.

/.

Pro(i9ing genetic in2or&ation 4he ris/ of familial or other handicapping disorder in a future child 3 e-pert advice from clinical geneticist 7 pediatrician will usuall! be needed8 but factual preliminar! guidance should be available in a pre pregnanc! clinic.

0.

Deter&ining 2itne'' 2or $regnancy Pregnanc! should be deferred and contraception be offered to allow further evaluation and management of /nown disorders or new findings )eg. anemia8 heart disease8 diabetes and h!pertension*. 4reatment and optimi;ation of medical and surgical disorders ma! be re:uired. Reproductive issues should be managed appropriatel!.
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Health care providers who interact with men and women of childbearing age should understand the potential benefits of pre pregnanc! counseling this prepare the health care providers to approach the pregnanc! evaluation in a thorough manner. $. .ollow up intervals 6inimum of 2 !ears or till further management

Factor' A22ecting Pregnancy -. Socia" +e#a(ior %ommon social behaviors affecting pregnanc!< (mo/ing ,bortion8 low birth weight8 placenta previa8 placenta abruptio8 infant respirator! tract infection8 sudden infant death s!ndrome8 impaired fertilit! ,bortion8 fetal alcohol s!ndrome8 placenta abruption8 fetal intrauterine growth restriction8 low birth weight8 central nervous s!stem abnormalities ,bortion8 premature birth8 placental abruption8 ID#R8 congenital anomalies8 neonatal %@( d!sfunction Cow birth weight8 ID#R

,lcohol

%ocaine

%affeine

,n! form of substance abuse can affect pregnanc! and its outcome. .. Me9ication , potential preventable group of disorders are drug induced anomalies. 6edications during pregnanc! should be avoided as far as possible.

27

Ta+"e -.- 1 E22ect' o2 &e9ication' on Pregnancy A*ENTS EFFE TS ,nti convulsants Incidence of congenital malformations in children born to epileptic mothers is about &K. 4his appears to be largel! due to teratogenic effects of anticonvulsant. %ombining drugs increases the incidence congenital defects. Increase ris/ of neural tube defect to about 171000 pregnancies Increase in cardiovascular abnormalit! >arious congenital malformations including abnormalities of the %@( and the nose and bon! epiph!ses Cow birth weight8 microcephal!8 congenital heart disease and mental retardation 4eratogenesis in first trimester8 virilisation of female fetus .etal tach!cardia ID#R

(odium >alproate Cithium %arbonate 9arfarin ,lcohol ,ndrogens ,tropine Eeta 3bloc/ers

%!clophosphamide

4eratogenesis in first trimester

28

A*ENTS 5iuretics 5ia;epam 5ieth!l stilboesterol ID#R Respirator! depression

EFFE TS

#enital anomalies8 female ma! develop clear cell carcinoma of the vagina man! !ears later8 male infertilit!

6ethothre-ate Phenobarbitone Phen!toin 4erbutaline 4etrac!cline 4halidomide ,ngiotension %onverting 1n;!me Inhibitor and angiotension receptor bloc/er /.

@eural 4ube 5efects 5!smorphic facies8 h!pocalcaemia and coagulation defects 1mbr!opath! includes d!smorphic facial features8 microcephal! and motor and intellectual retardation H!pogl!caemia 4ooth enamel h!poplasia and cataract Phocomelia Oligoh!dramnios8 bon! malformation8 prolonged h!potension8 renal failure

N%tritiona" Stat%' , deficient nutritional status in woman of reproductive age affects not onl! the general health condition but also the fertilit! capacit!. .olic acid supplementation is essential to prevent neural tube defect. Me9ica" #i'tory Pre e-isting medical conditions ma! adversel! affect mother and fetus. Pre pregnanc! intervention is important in counseling regarding ris/ and in optimi;ing medical management.

0.

Ta+"e -..1 Me9ica" i""ne''e' A22ecting Pregnancy

29

ILLNESS 5iabetes 6ellitus

RISA Fetus : multiple congenital malformations )>(58 @458 s/eletal malformation* fetal macrosomia other: Pre eclampsia8 urinar! tract infection8 candidiasis.

PRE PRE*NAN 4 INTER)ENTION Elood glucose and Hb,1c monitoring and control prior to embar/ing on a pregnanc!. .olic supplementations.

4h!roid disease< H!poth!roid

Fetus: 6aternal 4h!roid hormone ,bortion8 ID#R8 fetal goiter replacement. and cretinism. other: Impaired fertilit! and h!poth!roid complications

H!perth!roidism

Fetus: 4h!roto-icosis8 ID#R other: 4h!roid storm8 h!pertension

,nti th!roid therap!

5eep venous thrombosis

Fetus: .etal warfarin s!ndrome other: Eleeding complications8 osteoporosis with prolonged heparin therap! Heparin induced thromboc!topenia

9arfarin interacts with oral contraceptive pills. Proph!lactic therap! with C69H is preferred to conventional heparin or warfarin therap!. Planned pregnanc! with advise from health care providers

(ei;ure disorder

Fetus: %ongenital heart disease8 %left lip and palate8 s/eletal8 %@(8 gastrointestinal8 genitourinar! abnormalities8 increased ris/ of epileps!.

4r! to minimi;e or stop medication prior to pregnanc! ideall! allow pregnanc! after 1+ months fit free. .olic acid
30

ILLNESS

RISA

PRE PRE*NAN 4 INTER)ENTION supplement. (afet! of the newer of anti epileptic is not /nown. 1%# at least annuall! ,im EP below 1"0720. ,void angiotensin converting en;!me ),%1* inhibitors8 angiotensin receptor bloc/er8 anti lipid agents and diuretics. 6a! need to consider aspirin from 12 wee/s onwards. ,ssess /idne! function and blood pressure. Pregnanc! reasonabl! safe if renal function is normal. 4arget EP less than 1"0720 ,dvice against pregnanc! for severe renal insufficienc! .or specific renal disorders refer nephrologist or ph!sician. Cow dose aspirin should be given in first trimester. (!mptomatic mother should be seen b! a cardiologist 7 ph!sician. 6other with mechanical valve change to C69H. 5etail scan for fetal anomal!. (erial growth scans. %ontraception continued until optimi;ation of the heart condition. (pecific disorders should be managed b! the cardiologist.

other: "0K ris/ of increased sei;ures %hronic H!pertension Fetus: Placenta abruption8 ID#R other: (tro/e8 renal failure8 cardiac failure8 cardiac failure8 pre eclampsia

Renal disease

Fetus: (tillbirth8 2nd trimester abortion8 neonatal death8 ID#R8 premature labor and deliver!. other: Increase in H!pertension8 pre eclampsia8 decrease in renal function

Heart disease in pregnanc!

Fetus: $ 10K Increase incidence of congenital heart disease in the fetus with mother with congenital heart disease. Higher ris/ of ID#R in c!anotic heart disease other: Primar! Pulmonar! H!pertension and 1isenmenger (!ndrome have

31

ILLNESS

RISA high ris/ of maternal mortalit! and should avoid pregnanc!. Increased ris/ of pulmonar! embolism8 stro/e and (E1 more common in prostatic valve.

PRE PRE*NAN 4 INTER)ENTION

Ta+"e -./1 In2ectio%' Di'ea'e' co&&on"y a22ecting $regnancy INFE TION Rubella PRE PRE*NAN 4 MANA*EMENT Rubella vaccination in women not immuni;ed8 avoid pregnanc! for at least 3 months after immuni;ation #ood food h!giene and avoid eating under coo/ed meat 7 food )eg. sushi*

4o-oplasma gondii

%hlam!dia8 gonorrhea8 human papilloma virus8 s!philis

,ppropriate treatment of (4I. Refer to dermatological clinic appropriatel!. %onsider HP> vaccination for suitable women. %ounseling7screening for Hepatitis E surface antigen8 consider vaccine Offer universal screening8 counsel ris/ of transmission8 offer ,R> therap!.

Hepatitis E HI>

32

STANDARD OPERATING PROCEDURE

33

STANDARD OPERATIN* PRO EDURE Proce9%re n%&+er Na&e o2 con9ition Ri'B Factor' A''e''&ent 1 1 1 Pre e-isting %hronic 6edical Illness La+oratory in(e'tigation an9 $#y'ica" eDa&ination .E( Hb,1c Cipid profile Renal profile C.4 6icroalbuminuria urine protein .unduscop! 1%# EP "a''i2icatio n Manage&ent are P"an Le(e" o2 $er'onne" Le(e" o2 care

5iabetes 6ellitus

5isease severit! %omplications %o morbidities

Dncomplic ated 5iabetes with 4O5 5iabetes with 4O.

refer to appropriate disciplines 6according to %P# .amil! planning PP% counseling refer to appropriate disciplines 6according to %P# .amil! planning PP%

6O7.6(7 Ph!sician 7 1ndocrinologi st

Hospital with 7 without specialist 7 H%

H!pertension

5isease severit! %omplications %o morbidities

.E( Cipid profile Renal profile 6icroalbuminuria urine protein 1%# %JR )if indicated* EP

Dncomplic ated HP4 H!pertensi on with 4O5 HP4 with 4O. Houng HP4

6O7.6(7 Ph!sician

H%7 Hospital with 7 without specialist 7 H%

34

Ri'B Factor' A''e''&ent

La+oratory in(e'tigation an9 $#y'ica" eDa&ination

"a''i2icatio n

Manage&ent counseling

are P"an Le(e" o2 $er'onne"

Le(e" o2 care

@HH, .unctional %lassification Heart 5isease Heart disease with co morbidit!

.E( Cipid profile 1%# %JR )if indicated* 1chocardiograph! Renal Profile 1-ercise (tress 4est EP

@HH, %lass 1 B 2 @HH, %lass 3 B " Heart disease with complicatio n

refer to appropriate disciplines @HH, %lass 1 B 2 Primar! %are @HH, 3 B "3 Hospital %are 6according to %P# .amil! planning PP% counseling

6O7.6(7 Ph!sician7 %ardiologist

H%7 Hospital with or without specialist

Renal 5isease

%A5 (taging

.E( Cipid profile

trace results

refer to appropriate

6O7.6(7 Ph!sician7

H%7 Hospital
35

Ri'B Factor' A''e''&ent

La+oratory in(e'tigation an9 $#y'ica" eDa&ination

"a''i2icatio n %A5 (tage 1B2 )Primar! %are* %A5 3 3 $ )Hospital %are* Renal 5isease with co morbidit! )Hospital %are* trace result %omplicate d7 uncomplica ted 4h!roid disease with co morbidit!

Manage&ent

are P"an Le(e" o2 $er'onne"

Le(e" o2 care

)%A5 1 3 $ with or without proteinuria* Renal disease with co morbidit!

Renal profile 6icroalbuminuria 2"hrs urine protein e#.R Dltrasound ADE 1%# %JR )if indicated* EP

disciplines refer to appropriate disciplines 6according to %P# .amil! planning PP% counseling refer to appropriate disciplines refer to appropriate disciplines 6according to %P# .amil! planning PP%

@ephrologist

with or without specialist

4h!roid 5isease

H!poth!roid and h!perth!roid s!mptoms 4h!roid disease with complications 4h!roid disease with c morbidit!

.E( Cipid profile 4(H 7 free4" 7 free .ree 43 1%# EP

6O 7 .6( 7

Ph!sician 7 1ndocrinologi st

H%7 Hospital with or with specialist

36

Ri'B Factor' A''e''&ent

La+oratory in(e'tigation an9 $#y'ica" eDa&ination

"a''i2icatio n

Manage&ent counseling

are P"an Le(e" o2 $er'onne"

Le(e" o2 care

Eronchial ,sthma

(everit! of E, according to guidelines )eg. #I@, guidelines* E, with recurrent admissions E, with co morbidit!

refer to appropriate %ontrol 7 P1.R disciplines (pirometr! fairl! 6,sthma %ontrol control 7 according 4est ,ssessment poorl! to %P# %JR )if indicated* control .amil! E, with co planning morbidit! PP% counseling STANDARD OPERATIN* PRO EDURE

6O7.6(7

Ph!sician 7 Respirator! ph!sicians

H%7 Hospital with or without specialist

Proce9%re n%&+er < Na&e o2 con9ition < Ri'B Factor'

2 4halassaemia are P"an "a''i2ication Manage&ent Le(e" o2 Le(e" o2 $er'onne" care 6O .6( Ph!sician H% Hospital with or without specialis
37

La+oratory in(e'tigation an9 $#y'ica" eDa&ination 4halassaemia (!mptoms .amil! assessment (creening %onsanguinit! .EP marriage Peripheral (everit! of anaemia blood film HE

Sign' an9 'y&$to&' A''e''&ent

6ild ,dvice regarding consanguinit! 6oderate %ounseling on (evere ris/ of pregnanc! (!mptomati ,dvice famil! c7 spacing and limit as!mptomat

Ri'B Factor'

Sign' an9 'y&$to&' A''e''&ent

La+oratory in(e'tigation an9 $#y'ica" eDa&ination electrophrosis for both couple )blood serum to be sent to nearb! hospital with facilit!* .amil! screening Symptomatic: Cetharg! Ereathlessness 6alaise palpitation ,bdomen distended Pallor Faundice Hepatosplenom egal!

are P"an "a''i2ication ic Manage&ent no of children ,dvice on vitamin supplement for folic acid8 >itamin c >itamin E and good nutrition .amil! Planning HE L + gmK should refer to hospital. Le(e" o2 Le(e" o2 $er'onne" care Pediatricia t n

.EP ED(1 C.4 (erum .erritin

Refer to hospital for further management

6O7 Ph!sician

Hospital

38

Ri'B Factor'

Sign' an9 'y&$to&' A''e''&ent

La+oratory in(e'tigation an9 $#y'ica" eDa&ination

are P"an "a''i2ication Manage&ent Le(e" o2 Le(e" o2 $er'onne" care

STANDARD OPERATIN* PRO EDURE

Proce9%re n%&+er 1 Na&e o2 con9ition 1 Ri'B Factor' 3 Histor! of congenital anomalies Sign' an9 'y&$to&' A''e''&ent La+oratory in(e'tigation an9 $#y'ica" eDa&ination Oral glucose tolerance test Diagno'tic criteria an9 9i22erentia" 9iagno'i' 5iabetes 6ellitus are P"an Manage&ent Peri pregnanc! folic acid at least 1 month before and 3 months after pregnanc! ,dvise on balanced diet and diet rich in folate
39

Le(e" o2 $er'onne" 6O7.6(

Le(e" o2 care H%

Histor! of neural ,s!mptomatic tube defects

(!mptomatic Pol!uria Pol!dipsia

Ri'B Factor'

Sign' an9 'y&$to&' A''e''&ent Pol!phagia @octuria

La+oratory in(e'tigation an9 $#y'ica" eDa&ination

Diagno'tic criteria an9 9i22erentia" 9iagno'i'

are P"an Manage&ent ,dvise on earl! boo/ing and detailed scan at least 1+ 20 wee/s %ounseling on genetic .6( screening Refer to 6.6 unit H% Le(e" o2 $er'onne" Le(e" o2 care

%hromosomal disorders Histor! of previous child with chromosomal disease

,ge I 3$

%hromosomal studies to be .amil! histor! of done at hospital chromosomal level with facilit! disorders

.amil! histor! of %ongenital congenital structural abnormalities or anomalies previous child with congenital structural abnormalities

Parental /ar!ot!ping Ph!sical abnormalit!

Refer to geneticist 7 O B # 7 pediatrician 7 6.6 specialist #enetic counseling

6O 7 .6( 7 #eneticist 7 Pediatrician s7OB# specialist

H% 7 Hospital with or without specialist

40

STANDARD OPERATIN* PRO EDURE Proce9%re n%&+er 1 Na&e o2 con9ition 1 Ri'B Factor' Sign' an9 'y&$to&' " Previous surgical Histor! La+oratory in(e'tigation an9 2in9ing Diagno'tic criteria an9 9i22erentia" 9iagno'i' are P"an Manage&ent Le(e" o2 $er'onne" Le(e" o2 care H% Hospital Refer to hospital OB# if suspected of specialist recurrent fibroid ,dvise on famil! spacing7 %ommunit! planning health nurse7 (taff nurse %H%7 H%

Previous uterine (ub fertilit! surger!< 6enorrhagia 6!omectom! 5!smenorrhoe a Irregular menses ,bdominal %aesarean mass (ection Pelvic surger! e.g c!stectom!

Hb )if indicated* Recurrent P,P smear fibroid Dltrasound 1ndometrial sampling )if indicated8 done at hospital level*

,dvise on famil! .6( planning7 6O spacing

STANDARD OPERATIN* PRO EDURE

41

Proce9%re n%&+er 1 Na&e o2 con9ition 1 Ri'B Factor'

$ Recurrent ,bortions Sign' an9 'y&$to&' La+oratory in(e'tigation an9 2in9ing Diagno'tic criteria an9 9i22erentia" 9iagno'i' 4o-oplasmosis Rubella %!tomegalovirus Herpes (imple(!philis O#44 Cupus anticoagulant 5iabetes mellitus %ollagen disease are P"an Manage&ent Le(e" o2 $er'onne" Le(e" o2 care H%

Recurrent (!mpto abortions )3 times matic and above* %hronic vaginal discharge %hronic medical illness< 56 %ollage n diseases

4reatment given 6O7.6( according to /nown and treatable causes )investigation findings* .ollow latest edition %P# Refer ph!sician 6O7.6( Ph!sician

H% Hospital with specialist

(ubsta 4hrombophilic nces abuse< screening alcohol8 drugs.etc Dltrasound

Dterine abnormalit!

Refer to OB# OB# specialist7 specialist .etomaternal specialist

STANDARD OPERATIN* PRO EDURE

42

Proce9%re n%&+er 1 Na&e o2 con9ition Ri'B Factor' 1

& Histor! of Dne-plained Perinatal 5eaths Sign' an9 'y&$to&' La+oratory in(e'tigation' an9 $#y'ica" eDa&ination Diagno'tic criteria an9 9i22erentia" 9iagno'i' 4o-oplasmosis Rubella %!tomegalovirus Herpes (imple(!philis O#44 5iabetes mellitus are P"an Manage&ent Le(e" o2 $er'onne" Le(e" o2 care H%

Histor! of une-plained perinatal death

,s!mptomatic (!mptomatic %hronic medical illness< 56 %onnective 4issue 5isease ,n! (ubstance abuse< alcohol8 drugs %ongenital anomalies

4reatment given 6O 7 .6( according /nown and treatable causes 6O 7 .6( .ollow latest edition %P# Refer Ph!sician Refer to O B # specialist7 .etomaternal (pecialist Ph!sician OB# specialist

H% Hospital with or without specialist

Cupus anticoagulant %ollagen ,@, 7 ds 5@, disease Dterine abnormalit!

STANDARD OPERATIN* PRO EDURE Proce9%re n%&+er 1 '

43

Na&e o2 con9ition 1 Ri'B 2actor'

6edication 7 (ubstance ,buse Sign' an9 Sy&$to&' La+ in(e'tigation an9 2in9ing' Diagno'tic criteria an9 9i22erentia" 9iagno'i' are P"an Manage&ent Le(e" o2 $er'onne" Le(e" o2 care

(ubstances abuse )eg. ben;odia;epine 7 opiates 7 stimulants 7 recreational drugs*

4hin8 lethargic8 drug withdrawal s!mptoms8 needle mar/s8 pallor

Drine for drugs HI> screening >5RC Hepatitis screening

(ubstance abuse 7 addiction

Positive lab findings for s!mptomatic patients refer to Hospital ,s!mptomatic< %ounseling ,dvise on famil! planning ,dvise on ris/ of complications of pregnanc! Offer methadone replacement therap! Refer :uit smo/ing clinic

.6( 7 6O Ph!sician 7 ps!chiatrist

H%7 Hospital with or without specialist

(mo/ing

.6( 7 6O 7 Respirator ! Ph!sician

H%7 Hospital with or without specialist

STANDARD OPERATIN* PRO EDURE Proce9%re n%&+er 1 Na&e o2 con9ition 1 + (e-ual 4ransmitted Infection )(4I*
44

Ri'B 2actor'

Sign' an9 Sy&$to&' ,s!mptomatic (!mptommati c

La+ in(e'tigation an9 $#y'ica" eDa&ination M.E% MC.4 MHE>7H%> M%5" 7 %5+ ratio M>5RC B other (4I screening MRenal profile M.CP MRenal profile Mph!sical e-amination for opportunistic infections 7 ,I5( defining comple-

are P"an "a''i2ication Manage&ent 9HO clinical classification criteria of severit! Le(e" o2 $er'onne" 6O 7 .6( 7 I5 Ph!sician 7 Ph!sician Le(e" o2 care H% 7 Hospital with or without specialis t

HI> Positive ,I5(

,R4 as indicated in accordance to the %P# O%P 7 Implant 7 I6 5epo 7 %ondoms E4C %ounseling for safe se-ual practices

Ri'B 2actor'

Sign' an9 Sy&$to&'

La+ in(e'tigation an9 $#y'ica" eDa&ination 2in9ing'

Diagno'tic criteria an9 9i22erentia" 9iagno'i' "a''i2ication

are P"an Manage&ent Hea"t# care Pro(i9er Le(e" o2 are

Hepatitis E positive Health! carrier %hronic

,s!mptomatic 7 s!mptomatic )eg. nausea8 d!spepsia8 loss appetite*

C.4 Hepatitis E antibod! Hepatitis E e antigen 7 antibod!

Raised Civer 1n;!mes )I 3JD@C* 3 refer gastroenterologi st

%ontinue 6O 7 medical follow up .6( 7 )surveillance* Ph!sician 7 gastroenter Refer to ologist

H% 7 Hospital with or without specialis

45

hepatitis

Hepatitis % screening ,lpha fetoprotein D(# HE(

Civer en;!mes normal 3 .7u at primar! care

gastroenterologis t 7 ph!sician 6anagement in with %P# accordance .amil! planning )hormonal 7 barrier method* Offer vaccination

(!philis #onorrhea %hlam!dia Herpes (imple4o-oplasma

,s!mptomatic (!mptomatic<

R1.1R 4O guideline (4I wor/ out

6(, @,

,dvise on regular follow up and treatment of the (4I. .amil! planning )hormonal 7 barrier method* %ompl! to medication. (afe se-ual practices 1arl! boo/ing

>aginal discharge >ulval ulcer >iral warts Pruritus

6O 7 .6( 7 #D6 specialist 7 OB# specialist

H% 7 Hospital with or without specialis t

STANDARD OPERATIN* PRO EDURE Proce9%re n%&+er Na&e o2 $roce9%re 1 1 2 (ubfertilit!

46

Ri'B 2actor'

Sign' an9 Sy&$to&'

La+ in(e'tigation an9 2in9ing'

Diagno'tic criteria an9 9i22erentia" 9iagno'i' .ailure to conceive despite normal uninterrupted coital activit!

are P"an Manage&ent #eneral counseling Refer to Infertilit! %linic Le(e" o2 $er'onne" .6( 7 OB# (pecialist Le(e" o2 care H% 7 Hospital

(ubfertilit!

,s!mptomatic P%O( 7 signs of metabolic s!ndrome

.(H CH (erum Prolactin (eminal .luid for anal!sis 4h!roid function test >5RC 521 Progesterone

47

A""REVIATIONS
ED(1 %H% %P# .E% .6( .(H Hb H% HI> ID#R C.4 CH 6O @45 OB# O#44 (@ 4OR%H1( D.161 >5RC >(5 Elood urea B serum electrol!tes %ommunit! health clinic %linical Practice #uidelines .ull Elood %ount .amil! 6edicine (pecialist .ollicular (timulating hormone Haemoglobin Health clinic Human Immunodefienc! >irus Intrauterine #rowth Retardation Civer .unction 4est Cuteinising hormone 6edical officer @eural 4ube defect Obstetrician B #!naecologist Oral glucose tolerance test (taff nurse 4o-oplasmosis8Rubella8%!tomegalovirus8Herpes simp/e-8(!philis Drine .ull 1-amination and 6icroscopic 1-amination >eneral 5isease Research Caborator! 4est. >entricular (eptal 5efect

MEM"ERS OF THE #OR$ING GROUPS

48

PRE7PRE*NAN 4 Dr J. Ra(ic#an9ran 8Aet%a; Dr. Sri Wa#y% Ta#er Dr. S%Barno Sa%9 Dr. Ra&e'# )aira(an Matron AEiEa# Ari22in Matron Noor Aini Aari&on ANTENATAL INTRAPARTUM POSTNATAL NEONATAL

49