ANTENATAL

CARE
Dr Junita Aris
Segamat
17 Nov 2012

1
 2 June 28, 2013

PERINATAL CARE MANUAL

DIVISION OF FAMILY HEALTH DEVELOPMENT

MINISTRY OF HEALTH MALAYSIA
2004 (1st edition)
2009 (2nd edition)
 3 June 28, 2013

Antenatal visit - AIM

 Early antenatal care (1st trimester)
 to identify and manage women with medical
complications
 to screen woman for risks factors that may have
bearing on the progress of the pregnancy and its
outcome
 to encouraged involvement of the spouse or
family (possibly once or twice)
 provide emotional support in time of need for the
expectant mother. It also helps in areas pertaining
to compliance and advice for the mother.
 to identify the mothers‟ needs and wants and to
discuss the plan for delivery.
 4 June 28, 2013

Frequency of visits
Recommended schedule for normal,
uncomplicated pregnancy (white tagged):
Primigravida (weeks) Multigravida (weeks)

12 12
18 20
24 28
28 32
32 36
36 38
37 40
38
39 Reference : NICE Guideline
40 (published March 2008)
 5 June 28, 2013

Booking visit

 The first visit is most important

 should be done as soon as possible
(preferably by 12 weeks POA).
 MDG 4 Indicator: New antenatal register
between 0 -12 weeks POG. TARGET 70%
 Even if the first visit may be late in her
pregnancy it is still regarded as the
booking visit.
 6 June 28, 2013

The “PINK BOOK”

 7 June 28, 2013

History taking
• Detailed menstrual history
 - Last menstrual period (LMP)*
 - Regularity of cycles
 - Contraceptive usage
 * If patient‟s period is irregular or stopped
contraceptive pills less than 6 months of
LMP or unsure of date, refer for dating by
ultrasound.
 HISTORY TAKING

Medical Surgic Family

Social Obstetric
al

*Previous *Diabetes
*Occupati *Hypertension
*Allergies
on Pregnanc *Heart
*Blood Disease
*Previou *Smoking y
s *Renal
Transfusion *Alcohol *Pre-term disease
Operati *Education labour
*Medical *Psychiatric
on al *Previous
problems *PTB
Infections Level LSCS, *Multiple
IUD/END Pregnancy

END =Early Neonatal Death

PTB = Pul. Tuberculosis
 9 June 28, 2013

Medical history
 - Allergies
 - Blood transfusion
 - Medical problems
 - Infections
Family history:
 - Diabetes mellitus
 - Multiple pregnancy
Socio-economic background
 - Occupation of both the woman and her partner
 - Smoking, drugs and alcohol consumption
 - Education level
Past obstetric history
 - Previous miscarriage or termination of pregnancy
 - Intrauterine growth restriction and preterm labour
 - Previous LSCS
 - Intrauterine death
 - Early neonatal death
 10 June 28, 2013

PHYSICAL ASSESSMENT
General examination
 - Height
 - Weight
 - Pallor, cyanosis & clubbing
 - Oral hygiene
 - Oedema
 - Varicose veins
 - The mother‟s gait – any bony deformity of
pelvis
 11 June 28, 2013

Blood pressure
Thyroid enlargement & signs of
hypo/hyperthyroidism
Breast
Cardiovascular system
Spine – kyphosis/scoliosis
Abdomen
 Scars of previous operation
 Palpation – uterine size/other masses
Vaginal examination – when indicated
 12 June 28, 2013

Investigations
Urinalysis : protein (albumin); sugar (glucostix);
urine biochemistry (when indicated)
Blood:
 Haemoglobin
 ABO and Rhesus group
 Syphilis(VDRL) – if positive perform TPHA and
refer for treatment
 HIV (Rapid test) – if positive proceed with
Western Blot test for confirmation
 BFMP
 Hepatitis B (HBs Ag) antigen
 13 June 28, 2013

ROUTINE MEDICAL
EXAMINATION BY MO
 RME 1 @ booking
 RME 2 @ 36/52
Pegawai Perubatan perlu mengenalpasti
kes- kes yang sesuai untuk bersalin di rumah
atau di Pusat Bersalin Alternatif (Rujuk
Senarai Semak)
 14 June 28, 2013

Heart rate
Thyroid
 15 June 28, 2013

Ultrasound scan
 At booking: for dating. Strongly
recommended during booking visit if
facilities are available.
 At 20/52 for fetal anomaly
 At 28/52 for placenta localization if earlier
suspected to be low lying
 At 36/52 for estimated birth
weight, AFI, presentation
 16 June 28, 2013

Management
 Folic acid supplementation: (Hematinics
supplement > 12 weeks)
 Nutritional advice
 Health education e.g smoking cessation
 Give information on the antenatal
screening test i.e benefits and limitations
 17 June 28, 2013

Subsequent visits
Ask relevant symptoms if present
 Anaemia, IE, hypo/ hyper, asthma, UTI,
 Weight and blood pressure
 Urine for protein and glucose
 Symphysio-fundal height – to be plotted on
SFH chart to alert the observer to possible
growth retardation
 Assess the lie and presentation of the fetus
after 32 weeks.
 18 June 28, 2013

Subsequent visits
 High
grade fever in pregnant mothers – refer
O&G for opinion.
 19 June 28, 2013

Screening for risk factors

 Checklist should be assessed and documented.
The care plan should be based on the protocol
given. (Appendix 1)
Senarai semak ini perlu digunakan seperti berikut :
(a) Kali pertama semasa booking
(b) Kali kedua semasa kandungan 13-20 minggu
(c) Kali ketiga semasa kandungan 21-28 minggu
(d) Kali keempat semasa kandungan 29-32
minggu
(e) Kali kelima semasa kandungan 33-36 minggu
 20 June 28, 2013

PENJAGAAN ANTENATAL &

SISTEM KOD WARNA
Berdasarkan “tahap penjagaan” menurut keperluan
pengendalian klinikal

Merah : Kemasukan segera ke Hospital

Kuning : Rujukan segera untuk pengendalian di Klinik Pakar

O&G Hospital/Pakar Kesihatan (dalam masa 48 jam)

Hijau : Pengendalian di Klinik Kesihatan oleh Pegawai

Perubatan & Kesihatan

Putih : Penjagaan oleh Jururawat Kesihatan / Masyarakat di

Klinik Kesihatan dan Klinik Desa

(sekiranya tiada terdapat faktor risiko yang disenaraikan

berikan kod warna putih).
21 June 28, 2013
RED
22 June 28, 2013

1. Eklampsia

2. Preeklampsia (tekanan darah tinggi dengan urin

albumin) atau dengan kehaidran symptom atau BP
> 160/110 mmHg

3. Sakit jantung semasa mengandung dengan

tanda-tanda dan gejala (sesak nafas, berdebar-
debar)

4. Sesak nafas ketika melakukan aktiviti ringan

(aktiviti seperti sapu sampah, cuci pinggan)

5. Bagi ibu yang diabetic yang tidak terkawal

dengan kehadiran urin keton (≥1+)
 23 June 28, 2013

RED
6. Pendarahan antepartum (termasuk keguguran)

7. Denyutan jantung janin yang abnormal

• FHR ≤110/min pada dan selepas 26/52
• FHR > 160/min selepas 34/52 (denyutan jantung
mungkin tinggi jika pramatang)

8. Anemia dengan symptom pada mana- mana

gestasi

9. Kontraksi rahim pramatang

10. Keluar air likuor tanpa kontraksi

11. Serangan asma yang teruk

 24 June 28, 2013

PLAN - RED
1. Stabilisasi jika perlu seperti kes:
- Antepartum Hemorrhage
- Eklampsia
- Serangan asma yang akut

2. IM Dexamethasone 12 mg stat dos bagi kes:

- Kontraksi pramatang
- Keluar air ketuban pramatang
- Pendarahan antenatal sebelum 36 minggu

3. Urusan penghantaran pesakit hendaklah

menggunakan ambulan sama ada dari Klinik
Kesihatan atau “Flying Squad”
 25 June 28, 2013

A. Bagi kes 22 minggu ke

atas:-

a) Maklumkan kepada anggota di Bilik

Bersalin (Labour Room) mengenai kes yang
dirujuk
b) Kes yang tiba di hospital hendaklah
dimaklumkan pada Pegawai Perubatan /
Pakar yang bertugas
c) Butir-butir rujukan hendaklah
didokumentasikan dalam kad KIK 1/96A
 26 June 28, 2013

B. Bagi kes kurang 22

minggu:-
1. Rujukan kemasukan kes ke wad Ginekologi
2. Kes yang tiba di hospital hendaklah dimaklumkan
pada Pegawai Perubtan / Pakar yang bertugas
3. Butir-butir rujukan hendaklah didokumentasikan
dalam Kad KIK 1/96A
4. Pengendalian akan dilakukan oleh hospital
mengikut protocol hospital masing-masing
5. Pesakit yang stabil akan dirujukan kembali ke Klinik
Kesihatan berserta:-
a. Pelan tindakan disediakan oleh pihak hospital
(discharge summary)
b. Ringkasan pengendalian kes disertakan di dalam
kad KIK 1A/96
 27 June 28, 2013

YELLOW
1. Ibu HIV positif
2. Ibu Hepatitis B positif
3 Tekanan darah tinggi > 140/90 - <160/110
mmHg dengan urin albumin negative
4 Ibu diabetic
5 Pergerakan janin kurang semasa
kandungan ≥ 32 minggu
6 Kandungan melebihi 7 hari dari EDD
7 Ibu dengan masalah perubatan yang
8 memerlukan rawatan bersama dengan
hospital
8. Ibu yang terlibat dalam isu Mediko-legal
9. Ibu tunggal dan Ibu remaja
 28 June 28, 2013

PLAN - YELLOW
 Dirujuk ke hospital berhampiran dalam masa
48 jam
Prosedur rujukan:
1. Dapatkan temujanji dari Pakar O & G / FMS
2. Sertakan surat rujukan serta dokumenkan ke
dalam kad KIK IA/96 apabila merujuk
3. Kes yang dirujuk akan didendalikan mengikut
protocol hospital masing-masing
4. Kes yang stabil boleh dirujuk kembali ke Klinik
Kesihatan bersama dengan pelan
pengendalian kes dari hospital tersebut.
 29 June 28, 2013

GREEN (*Penilaian sekali sahaja )

Nota : Ibu mesti diperiksa oleh Pegawai
Perubatan dalam tempoh 2 minggu dari tarikh
booking
1 *Rh negative
2 *Berat badan ibu sebelum mengandung
atau ketika booking <45kg
3 *Masalah perubatan semasa (termasuk
psikiarik dan kecacatan fizikal)
4 *Pembedahan ginekologi yang lalu
5 *Ketagihan dadah/merokok
6 *LNMP yang tidak pasti
7 *3 kali riwayat keguguran yang berturutan
 30 June 28, 2013

GREEN
8. Riwayat obstetric yang lalu :
i) Pembedahan caesarean
ii) Riwayat lalu PIH/Eklampsia/Diabetes
iii) Kematian Perinatal
iv) Mempunyai sejarah bayi dengan berat lahir
kurang daripada 2.5kg atau lebih daripada 4kg
v) Koyak perineum 3rd degree
vi) Lekat uri
vii) Pendarahan selepas bersalin
viii) Kelahiran instrumental
ix) Sakit bersalin lama

9 Kandungan lebih dari satu

10 Tekanan darah tinggi (140/90 mmHg) tanpa urin albumin
 31 June 28, 2013

GREEN
11 Haemoglobin kurang dari 11g%
12 Gula dalam air kencing 2kali
13 Air kencing mempunyai albumin ≥1+
14 Pertambahan berat badan yang mendadak
melebihi 2 kg dalam seminggu
15 Berat badan melebihi 80 kg semasa “booking”
16 Tinggi rahim (SFH) kecil atau besar dari tarikh
jangka masa
17 Menyongsang/oblique/melintang dengan tidak
ada tanda sakit bersalin pada 36 minggu
kehamilan
18 Kepala bayi tinggi (Head not engaged) semasa
cukup bulan (37 minggu) bagi primigravida)
 32 June 28, 2013

PLAN - GREEN
1. Kes dirujuk kepada Pegawai Perubatan
2. Pegawai Perubatan tersebut akan mengendali
dan membuat keputusan samada
- Pengendalian berterusan oleh Pegawai Perubatan
- Pengendalian oleh Jururawat Kesihatan di Klinik
Kesihatan
- Pengendalian oleh Jururawat Desa di Klinik Desa
3. Pegawai Perubatan boleh merujuk kes-kes
kepada FMS jika perlu
4. Pelan pengendalian perlu disediakan oleh
Pegawai Perubatan atau FMS
 33 June 28, 2013

 Nurses to refer the patients to be seen by

doctors accordingly
 Doctors may change the coding of the
patients according to current
circumstances.
 34 June 28, 2013

KOD PUTIH
(BERSALIN DI HOSPITAL)

1. Primigravida
2. Ibu berumur kurang 18 tahun atau lebih 40
tahun
2 Gravida 6 dan ke atas
4 Jarak kelahiran kurang dari 2 tahun atau
melebihi 5 tahun
5 Ibu dengan masalah tertentu :
i) Ukuran tinggi kurang dari 145 cm
KOD PUTIH
35 June 28, 2013

(DIBENARKAN BERSALIN DI RUMAH / PUSAT

BERSALIN ALTERNATIF)
• Sekiranya memenuhi syarat-syarat seperti berikut
1 Gravida 2-5
2 Tiada masalah obstetric yang lalu
2 Tiada masalah perubatan yang lalu
4 Tiada komplikasi semasa mengandung
5 Persekitaran rumah ibu yang sesuai
6 Ukuran tinggi lebih dari 145 sm
7 Ibu berumur lebih 18 tahun dan kurang 40 tahun
8 Ibu berkahwin dan mempunyai sokongan keluarga

9 POA >37 minggu atau <41 minggu

10 Anggaran berat bayi > 2 kg dan < 3.5 kg
 36 June 28, 2013

Immunisation
 Anti-tetanus vaccination (ATT)
 Primigravida – at quickening and
repeated 4 weeks later
 Multigravida – a single dose is given in the
third trimester before 37 weeks of
gestation
 37 June 28, 2013

Home visits
 Home visit should be provided for patients
who defaulted follow-up and for high-risk
mothers.
 White tag – at least 3-4 visits
 At booking, at second trimester, at third
trimester, at term if not delivered yet
 High risk pregnancy – more frequent, as
per required
 38 June 28, 2013

PROTOCOL ON HOME VISIT

 Enter the house only after obtaining
permission
 Respect the mother and the family
 Communicate well with the mother in order to
develop rapport
 Describe the objectives of the visit clearly to
the mother
 Avoid making any unfavourable comment or
judgement about the patient and family
 Educate the mother and family about
personal hygiene and better sanitation
sanitation unit) for follow up
 39 June 28, 2013

 If the mother prefers home delivery and

meets all the criteria, the health worker should
check the intended birth site and advise the
mother regarding necessary preparation,
 If the mother requires delivery at a hospital or
Alternative Birthing Centre, she should be
advised with regards to the facility and its
locality
 A history and physical examination can be
done after you have developed a rapport
with the mother. First ascertain the progress of
the pregnancy and the well being of the
mother. The antenatal book should be
updated.
 40 June 28, 2013

Problems with home visit

1. Mother not at home.
2. Staff not allowed to come in the house
3. Limited time
4. Weather
5. Transport
6. Wrong address
7. Wrong phone number

So what do you do?

 41 June 28, 2013

FETAL MONITORING AND

SURVEILLANCE
Fetal monitoring during the antepartum
period consists of tests for:
A. Fetal growth
B. Fetal well being
 42 June 28, 2013

A. Fetal growth
 Symphysio-fundal height (SFH):
tape measurement should be performed routinely from
22 weeks onwards in all pregnancies
Discrepancy SFH and POA of +/- 3cm
re-evaluated with regards to the
1. accuracy of the LNMP AND
2. REFERRED FOR AN ULTRASOUND. This can be an
early indicator of impaired fetal growth.
 Maternal weight gain:
should be a progressive increase in weight of
approximately 10 – 12.5 kg (25% of her non-pregnant
weight) throughout the pregnancy. Generally the
weight gain should be about
0.5 kg /month for the first 20 weeks and
0.5 kg/week from 20 weeks onwards.
 43 June 28, 2013

Ultrasound
 Ultrasound scanning for dating is reliable if
the parameters are taken before 24
weeks.
 For fetal growth assessment, serial scan
should be done every 2 – 3 weeks.
SYMPHYSIO-FUNDAL HEIGHT(SFH)
UTERINE SIZE BY WEEK
 46 June 28, 2013

Uterus larger than dates Uterus smaller than dates

Wrong dates Wrong dates

Polyhydramnios Oligoydramnios
Multiple pregnancy Intrauterine growth
retardation
Big baby

# Ultrasound scanning for dating is reliable if the parameters

are taken before 24 weeks.

# For fetal growth assessment, serial scan should be done every

2 – 3 weeks.
 47 June 28, 2013

B. Fetal monitoring
Fetal heart auscultation:
Pinards Fetoscope. Should be routinely
practiced from 24 weeks onward using a
If Daptone is available, fetal heart can be
detected as early as 14 weeks.

CTG
should be performed in cases where there is
high risk of fetal compromise such as
decrease fetal movement, hypertension,
diabetes, IUGR or postdates.
 48 June 28, 2013

Fetal Kick Chart

 Over the past 30 years, fetal movement
counts have been recommended to
women in the second half of pregnancy
as a way of monitoring fetal wellbeing
and providing an early warning of fetal
distress.
 49 June 28, 2013

Fetal Kick Chart

 Fetal kick chart is an indirect tool for
monitoring of fetal wellbeing.
 All mothers should be given the fetal
movement chart (Cardiff „count-to-ten‟)
for recording of fetal movements from 28
weeks gestation onwards and should be
told to report to any health facility if
movements are less than 10 in 12 hours.
 This observation should be done at
regular intervals everyday.
50 June 28, 2013
HEALTH
EDUCATION
 52 June 28, 2013

Health education topics to be given to

every antenatal mothers during clinic
session :
No. Topics (ANTENATAL)
1 Jagaan antenatal
2 Kepentingan datang awal ke klinik semasa mengandung.
3 Persediaan psikologi semasa mengandung
4 Masalah ringan semasa hamil dan cara mengatasinya
5 Pemakanan antenatal & postnatal
6 Kepentingan & cara yang betul pengambilan vitamin
7 Jagaan payu dara
8 10 topik dalam penyusuan susu ibu
9 Senaman antenatal & postnatal
53 June 28, 2013
 54 June 28, 2013

No. Topics
10 Aktiviti seksual semasa hamil
11 Carta pengerakkan janin
12 Persiapan bersalin
13 Kepentingan pengetahuan kelahiran
14 Tanda – tanda bersalin
Proses kelahiran
Perancang Keluarga
 55 June 28, 2013

(Keadaan luar biasa semasa

mengandung)

No. Topics
1 Pre eclampsia (darah tinggi semasa mengandung)
2 Tanda – tanda impending eclampsia
3 Diabetes semasa mengandung
4 Anaemia semasa mengandung
5 Pendarahan semasa mengandung
6 Masalah perubatan
 56 June 28, 2013

Postnatal Topics
No. Topic (Postnatal)
1 Jagaan postnatal
2 Jagaan episiotomy
3 Jagaan bayi baru lahir
4 Neonatal jaundis
5 Perancang Keluarga
6 Pap Smear
FLOW CHART A/N Register ACTION
CHECK UP Client

Return Case
NEW CASE/TRANSFER IN /Referrals
- Preferable < 12/52 POA
- Register in KIB 101 ( Subsequent visits )

PJK
KJK
History Taking JKA
JT
JM
INVESTIGATIONS
* Tracing of blood result &
document.

Physical Examination
- FKC @ POA 28/52
 RISK IDENTIFICATION &
TAGGING ACTION
( Inclusive of QAP FP Tagging for HRM @
POA 36/52

HEALTH EDUCATION
(Inclusive QAP FP)
Haematinic compliance
PJK
KJK
JKA
YES REFER NO
DOCTO JT
R JM
Unsure LMP
RME
All HRM
** Routine
examination @ POA
34 onwards
 IMMUNISATION ACTION
PRIMI - @ quickening & Repeat 4/52 later
MULTIP – single dose in the 3rd trimester < 37/52
ABORTION CASE – NO ATT to be given

DOCUMENTATION
- KIB 101 including total number of visits
- Transfer out cases – ensure clinics PJK
concerned
receive case
KJK
JKA
ANTENATAL CLASSES JT
( Base on local setting only done in big
clinics ) JM

HOME VISIT
Make appointment for visit.
( For HIGH RISK Cases, defaulters )

Hom
e
MANAGEMENT OF COMMON DISORDERS IN
PREGNANCY

 Anaemia in Pregnancy
 Gestational Diabetes Mellitus
 Vaginal Bleeding in pregnancy
- Antepartum Haemorrhage (ACUTE OBSTETRIC
EMERGENCY AND LIFE THREATENING CONDITION)
 Group B Streptococal infection in pregnancy ( Preterm
labour or rupture of membranes for more than 18 hrs.)
 HIV ( CPG HIV )
 PIH ( Training Manual Mx of PIH )
 Heart Disease in pregnancy ( CPG and training Manual
on Mx. Of heart disease)
 62 June 28, 2013

THANK YOU