WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital CLINICAL GUIDELINES Section B: Obstetrics and Midwifery Guidelines

ANTEPARTUM CARE

1.1 Ante partum clinic visits

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Authorised by: OGCCU Review Team: OGCCU 1.1.4 Subsequent visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia

1.1.4 Subsequent visits

AIM
1. 2. 3. To monitor the progress of the pregnancy. To detect any abnormalities that may have arisen since the previous visit. To initiate treatment where indicated.

PROCEDURE
1 Frequency of antenatal visits See Clinical Guidelines, Section B 1.1.2.4

ADDITIONAL INFORMATION

The frequency of the antenatal visits is adjusted according to fetal and maternal wellbeing. Refer to individualised guidelines for specialised clinics and their schedule for antenatal visits.

2 2.1

Maternal Assessment Weight Monitor the womans weight at each visit if at the booking visit she has an: increased Body Mass Index (BMI) decreased BMI There is no benefit to repeated weighing of women who have a normal weight at the booking visit and who have no nutritional 1 concerns. Increased BMI in pregnancy is associated with increased risk of hypertensive disorders, gestational diabetes, increased caesarean sections, and the neonate is at risk for more neonatal admissions to intensive care, birth 2 defects and prematurity. Obesity is also linked to increased anaesthetic complications, prolonged labour, failed induction of labour, thromboembolic events 3 and wound infections. Women with a BMI below 20kg/m are at risk of fetal growth restriction and perinatal 1 mortality.
2

Refer to the dietician as appropriate.

DPMS Ref: 5247

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 1 of 7

PROCEDURE
2.2 Urinalysis Document the regent urinalysis test result at each visit for: 2.3 protein glucose

ADDITIONAL INFORMATION

Testing may indicate pre-eclampsia, urinary tract infection, renal abnormalities, or 4 diabetes in pregnancy.

Blood Pressure (BP) Assess the BP each visit. See Clinical Guidelines, Section B 1.6.1 Measuring blood pressure. If a woman is attending the low risk midwives clinic the midwife should consult with the womans obstetric team during office hours, or contact the MFAU registrar after-hours regarding management of abnormal BPs.

2.4

Oedema assessment Identify and document oedema including the site and degree. 50-80% of women experience oedema in pregnancy which is due to increased tissue fluid. If the BP and urinalysis is normal, 5 reassure the woman.

2.5

Vaginal Discharge Note at each visit: if any vaginal bleeding has occurred since the last visit signs of vaginal infection signs of premature rupture of membranes Women should be informed than increased vaginal discharge is a normal physiological change in pregnancy, however if they experience an itch, soreness, offensive smell or pain with voiding they should inform the 7 midwife or doctor.

2.6

Assess for abnormal symptoms Assess if the woman has any abnormal health symptoms e.g. headaches epigastric pain vomiting visual disturbances. These symptoms may be associated with pre-eclampsia and further investigations or 1 evaluation may be required.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

1.1.4 Subsequent Visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 2 of 7

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

PROCEDURE
2.7 Abdominal Palpation Assess the fetal growth at each visit by: Measurement of symphysis-pubis to fundal height. This should always be documented in cm The measurements are to be documented in cm at every scheduled antenatal visit.

ADDITIONAL INFORMATION

Estimated growth by clinical palpation. Consult with the obstetric team if discrepancies in fetal growth is suspected. Assess amniotic fluid volume. Palpate for presentation from 36 weeks 1 gestation.

Evidence of the value of the symphysisfundal measurement height is limited, but the practice should not abandoned until larger 8 studies are done.

Abnormal presentation is discussed with the obstetric team and a management plan is formulated.

2.8

Medication Compliance Confirm the woman is taking recommended medications i.e. she is taking the appropriate dosage and at the correct time. Ensure the absence of side-effects. Change or adjustment of medications is documented on the MR222 Antenatal Record. Financial restrains or side-effects may cause a woman to cease her medications.

3 3.1

Fetal Assessment Fetal activity Monitor the history of fetal activity at each visit. Discuss management with the obstetric team if the woman has noticed a change in pattern or frequency of fetal movements. There is not enough evidence to recommend or not recommend counting fetal movements by the mother as an effective assessment 9 tool for fetal well-being. Routine formal fetal7, 10 movement counting should not be offered.

3.2

Fetal heart rate (FHR) auscultation Offer FHR auscultation at each visit. Routine listening of the FHR provides confirmation of a live fetus, but does not give a predictive value. However, if the woman would like auscultation of the FHR it may 7 provide reassurance.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

1.1.4 Subsequent Visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 3 of 7

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

PROCEDURE
4 4.1 Blood tests Blood group and antibody screen See: Clinical Guideline, Section A 1.1.9 Blood group and antibody screening during pregnancy. Clinical Guideline, Section A 1.9.3 Rh Immunoglobin (formerly Anti-D).

ADDITIONAL INFORMATION

All Rh (D) negative women are recommended to have prophylactic Rh Immunoglobin at 28-30 weeks and 34-36 weeks gestation.

4.2

Full blood picture (FBP) Repeat FBP at: 28 weeks gestation 36 weeks gestation as required. All women with anaemia, treated for anaemia, with low ferritin levels or at an increase risk of haeshould have repeat FBP repeated at 36 weeks gestation. The most common form of anaemia in pregnancy is iron deficiency. Order iron studies as required. Assess risk factors for anaemia e.g. history for haemoglobinopathies, dietary restrictions, 11 multiple pregnancy, and hyperemesis.

Repeat sexually transmitted infection (STI) screening Repeat screening is recommended for women at high risk for blood-borne viruses and STIs in the third trimester. Repeat screening should include: HIV serology Hepatitis C serology Hepatitis B serology Chlamydia screening Gonorrhoea screening All women living in STI endemic areas of Western Australia (WA) i.e. the Kimberley, Pilbara and Goldfields should have: Repeat testing for HIV and syphilis serology between 28 and 36 weeks 12 gestation Repeat testing for chlamydia and 12 gonorrhoea at 36 weeks.

See Department of Health Western Australia Guidelines for Managing Sexually Transmitted Infections.

Women treated for syphilis in the current pregnancy should be advised the RPR status will be monitored frequently in subsequent 12 pregnancies. Treatment for syphilis is considered adequate in pregnancy if it is completed at least 30 days prior to birth, and there is a documented four-fold drop in RPR 13 titre. Women with clinical hepatitis B should be 12 retested at the time of admission for birth.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

1.1.4 Subsequent Visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 4 of 7

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

PROCEDURE
6 Diabetes screening in pregnancy Screening is recommended for all pregnant 14 women.

ADDITIONAL INFORMATION

See Clinical Guidelines Section B 3.1.1 Screening for Diabetes in pregnancy. for screening advice: before 24 weeks gestation between 24-28 weeks gestation between 29-32 weeks gestation.

Ultrasound Arrange a repeat ultrasound for placental location if a woman has a low lying placenta in the second trimester. Women from the country may have the ultrasound ordered later in the third trimester to coincide with an antenatal visit.

Psychological assessment Repeat the Edinburgh Postnatal Depression Scale after 32 weeks gestation.

Family and Domestic Violence (FDV) screening Repeat the FDV screening tool in the third trimester if the woman is alone. See Clinical Guideline Section B 1.1.7 Screening for Family and Domestic Violence.

10

Screening for Group B Streptococcus (GBS) Screening for GBS is recommended for 15 women between 35-36 weeks. See Clinical Guidelines Section B 1.4.1 Group B Streptococcal Disease

11

Tobacco smoking assessment Assess smoking habits each visit for women who smoke or have ceased in pregnancy. Offer interventions/strategies to cease smoking or prevent resumption of smoking. See Clinical Guidelines Section B 1.1.8 Nicotine dependence assessment and intervention.

12

Parent education Provide ongoing pregnancy education including: discharge planning pain relief options auditory screening for the neonate Newborn Screening Test Consent for Vitamin K and Hepatitis B vaccination Visiting Midwifery Service Child Health Services Education may include both verbal and available written brochures.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

1.1.4 Subsequent Visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 5 of 7

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

PROCEDURE
Breastfeeding including the KEMH Breastfeeding Centre services, and community resources Family Planning Sudden Infant Death Syndrome and Co-Sleeping Use of capsules and car seats Community resources Birth plans GP follow-up Post-partum screening tests e.g. PAP smears Health issues e.g. hepatitis, vitamin D deficiency

ADDITIONAL INFORMATION

references
1. 2. Kean LH, Chan KL. Routine antenatal management at the booking clinic. Obstetrics, Gynaecology and Reproductive Medicine. 2007;17(3):69-73. Callaway LK, Prins JB, Chang AM, McIntyre HD. The prevalence and impact of overwight and obesity in an Australian obstetric population. The Medical Journal of Australia. 2006;184(2):56-9. Mahimeister LR. Best Practices in Perinatal Nursing. Improving Outcomes for Obese and Morbidly Obese Women During Intrapartum and Postpartum Periods. Journal of Perinatology and Neonatal Nursing. 2007;21(2):85-8. Simm A. Maternal Diseases in pregnancy. In: Sullivan A, Kean L, Cryer A, editors. Midwife's Guide to Antenatal Investigations. London: Churchill Livingstone; 2006. p. 45-67. Sheperd J, Rowen C, Powell E. Confirming Pregnancy and Care of the Pregnant Woman. In: Henderson C, MacDonald S, editors. Mayes' Midwifery A textbook for Midwives. London: Bailliere Tindall; 2004. p. 235-87. Bamigboye AA, Smyth RMD. Interventions for varicose veins and leg oedema in pregnancy. The Cochrane Database of Systematic reviews. 2010(1). National Collaborating Centre for Women's and Children's Health. Antenatal care. Routine care for the healthy pregnant woman. 293. London: NICE; 2008. Neilson JP. Symphysis-fundal height measurement in pregnancy. The Cochrane Database of Systematic reviews. 2009(1). Mangesi L, Hofmey Gj. Fetal movement counting for assessment of fetal wellbeing. The Cochrane Database of Systematic reviews. 2010(1). Freen JF, Heazell AEP, Holm Tveit JV, et al. Fetal Movement Assessment. Seminars in Perinatology. 2008;32:243-6. Strong J. Haematology in pregnancy. In: Sullivan A, Kean L, Cryer A, editors. Midwife's Guide to Antenatal Investigations. London: Churchill Livingstone; 2006. p. 45-67.
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6. 7. 8. 9. 10. 11.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

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Department of Health Western Australia. Antenatal testing for sexually transmissible infections and blood-borne viruses. Operational Directive No OD0064/07. 2007. Department of Health Western Australia. Guidelines for Managing Sexually Transmitted Infections. Syphilis During Pregnancy. http://silverbookhealthwagovau/Defaultasp?PublicationID=1. 2011. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Prepregnancy Counselling and routine Antenatal Assessment in the absence of pregnancy complications. College Statement C-Obs 3. 2009. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Screening and Treatment for Group B Streptococcus in Pregnancy. College Statement CObs 19. 2009.

Date Issued: October 2001 Date Revised: November 2013 Review Date: November 2016 Written by:/Authorised by: OGCCU Review Team: OGCCU DPMS Ref: 5247

1.1.4 Subsequent Visits Section B Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 7 of 7

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual