ANTENATAL CARE

Presented by: DM Obsgyn FK UNSYIAH RSUDZA March, 2013

Scope of Problem

Maternal Health 180200 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 pregnancyrelated complication

Global Causes of Maternal Mortality

Hemorrhage 24.8% 19.8 7.9 Obstructed Labor 6.9% Unsafe Abortion 12.9% Other Direct Causes 7.9% Indirect Causes 19.8% Infection 14.9% 24.8 Eclampsia 12.9%

12.9 6.9 12.9

14.9

But WHY Do These Women Die?

THREE DELAYS MODEL

Delay in decision to seek care Delay in reaching care

Lack of understanding of complications Acceptance of maternal death Low status of women Socio-cultural barriers to seeking care

Delay in receiving care

Supplies, personnel Poorly trained personnel with punitive attitude Finances

Mountains, islands, rivers poor organization

Interventions: Antenatal Care

ANC clinics started in US, Australia, Scotland (19101915) New concept - screening healthy women for signs of disease By 1930s large number (1200) ANC clinics opened in UK No reduction in maternal mortality However, widely used as a maternal mortality reduction strategy in 1980s and early 1990s
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 CARE
Antenatal Care program terencana oleh tenaga kesehatan 1. observasi 2. edukasi Ibu Hamil Kehamilan aman 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
Depkes RI (2001)

Ibu Hamil

Suami

Keluarga

Masyarakat

Aims Of Antenatal Care

To 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

 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.

Tujuan ANC

Classification Of Antenatal Care

Shared Care

Hospital Maternity Team

General Practitioner (GP) Community Midwives

Advice, Reassurance & Education

Reassurance & explanation on pregnancy symptoms:
1. 2. 3. 4. 5. 6. 7. 8. 9. Nausea Heartburn Constipation Shortness Of Breath Dizziness Swelling Back-ache Abdominal Discomfort Headaches

Confirmation of the pregnancy

Symptom of the pregnancy
Breast tenderness Amenorrhea
Nausea
Urinary

Frequency

Pregnancy test

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

Dating Pregnancy

Confirms the pregnancy and accurately dates it.

Dating Pregnancy
A. Menstrual EDD B. Dating by ultrasound
Benefits 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

Past Medial History Past Obstetric History Booking History Previous Gynaecological History Family History Social History

Booking Examination
Cardiovascular

Full Breast Examination Full Physical Examination

Respiratory Systems

Full Pelvic Examination

Abdominal

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

4 weekly appointments from 20 weeks until 32 weeks
fortnightly visits 32 weeks to 36 weeks

weekly 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.

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, preeclampsia 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 symphysisfundal 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.

What Is Safe Motherhood?

A womans ability to have a SAFE and healthy pregnancy and childbirth.

Every Pregnancy Is at Risk

TERIMA KASIH