1. GOOD ANTENATAL
CARE
& HOW CAN WE
IMPROVE POSTNATAL
CARE…

2. ANTENATAL CARE

3. WHY IS IT IMPORTANT??
 ANTENATAL CARE is one of the 4 pillars of
safe motherhood
-Family planning
-Safe & Clean Delivery
-Essential Obstetric care

4. EVIDENCES…
 Inadequate antenatal visits are associated
with increased neonatal mortality in the
present or without high risk pregnancy (Chen
2007)
 Marginal increase in neonatal death in the
reduced antenatal visit (Dowstell T 2010)

5. SUMMARY FROM CEMD REPORT 2006-2008
 Principal cause of maternal deaths are obstetric
embolism, medical disorders in pregnancy,
PPH & hypertensive disorder
 The risk of maternal death was higher in
woman aged >40 years & in mothers who had
>6 childrens
 Deaths due to associated medical illness are
rising
 Maternal death tagged with the green code
increased from 26.6% in 2006 to 32.3% in 2008

6. AIMS….
1. Screening for risk factors
2. Treating existing conditions & complications
3. Providing information to patients
4. Offer intervention

7. 1. SCREENING FOR RISK
FACTORS
 Pregnancy is an
normal process
 Assessing pregnant
woman to identify
any risks factor

8.  Ministry of Health has introduced colour
coding for the level of obstetric care
COLOUR
CODING
RISK & LEVEL OF CARE
WHITE Low risk- level of care by PHN/ JM in clinics
GREEN Level of care- MO in health clinic- shared care with
nurses under supervision of MO
YELLOW Urgent referral to Hospital with O&G specialist/ FMS in
clinic, shared care possible
RED Urgent admission to the hospital

9.  Antenatal patient coded GREEN or YELLOW
can be seen by health nursing staff as part of
shared antenatal care
 Antenatal patients who are coded RED and
are admitted to the hospital should have the
colour coded changed appropriately by the
doctors managing the patient upon discharge
if she has not delivered yet

10. ?? LOGISTIC PROBLEMS
 Antenatal patients who are coded
YELLOW or GREEN but lives in an
inaccessible area of Sarawak or
who are unable to see MO/FMS or
Specialist should:
1. Advise to stay with relative near
MCH with DR or a hospital for the
duration of her pregnancy
2. Advise to stay in the nearest
“halfway” accomodations which
are available in some clinics in the
state
3. Nurses in remote clinics without
DR should refer the patient via
radio/ phone line to MO/FMS or
Specialist

11. 2. TREATING EXISTING
CONDITIONS AND
COMPLICATIONS
 COMMON
PROBLEM
Nausea and
vomitting
Heart burn
Constipation
Haemorrhoids
Varicose vein
Vaginal discharge

12. COMMON COMPLICATIONS
 MATERNAL
- PIH/ PE
- GDM
- APH
- VTE
 FETUS
- SGA
- IUGR
- Macrosomia

13. SCREENING….
 BLOOD TESTS
ANAEMIA
RHESUS AND
BLOOD GROUPING
HIV
VDRL
BFMP
**For all patients

14.  SCREENING?
GDM
HEPATITIS B/C
THALLASEMIA
ANOMALY SCAN
?DOWN SYNDROME
SCREENING
**In those high risk
patients

15. VTE SCORING….
 According to
SARAWAK VTE RISK
ASSESSMENT
 AIMS  To reduce
maternal mortality
from venous
thromboembolism
 Scoring should be
done for every patient
and must be
documented inside
antenatal card

16. ROUTINE MEDICAL
EXAMINATION..
 To be done by MO in the
1st booking and also 3rd
trimester
 To examine patient from
head to toe to detect any
problem, so that early
referral can be made and
management can be done
appropriately
# NOT ONLY HEART &

17. 3. PROVIDING INFORMATION
 Provide and giving information
- regarding pregnancy status, fetal status
- Safe deliveries, labour & birth, post natal
care
- Breast feeding
 Provide additional care
- nutrition & diet, supplement, life style
modifications

18. LIFESTYLE…
 NUTRITION
-Normal diet
-Fibre intake
-Folic acid supplement
-Ferrous fumarate
-Calcium supplement
 EXERCISE
-safe
 SEXUAL
INTERCOURSE
-avoid if PP/PPROM
 ALCOHOL
-Fetal alcohol
syndrome
-IUGR
 SMOKING/ DRUGS
-IUGR

19.  Offer intervention that should have known
benefits and acceptable to pregnant woman (but
need to ensure the availability of the facilities
before offering any intervention)

20. FOLLOW UP
 Frequency of follow up
depends on risk factors
 Those with high risk
required frequent follow
up
 Level of care depends
on the coding

21. HISTORY & EXAMINATION
AIMS- TO ASSESS MATERNAL & FETAL
STATUS
 BP, urine albumin, urine glucose, weight
 Haemoglobin
 SFH (Symphisiofundal height) and HOF (Height
of fundus)
 EFW (estimated fetal weight)
 Fetal heart rate

22. SIMPHYSIOFUNDAL HEIGHT
(SFH)
 SFH is a measure of the size of the uterus
 It is used to assess fetal growth &
development during pregnancy
 Simple & not expensive

23. It is measured from the top of the mother's uterus
to the top of the mother's pubic bone in
centimeters

24. HOF (height of fundus)
34

25.  Fundal height roughly corresponds to
gestational age in weeks between 16 to 36
weeks for a vertex fetus.
 When a tape measure is unavailable, finger
widths are used to estimate centimeter
(week) deviations from a corresponding
anatomical landmark.
 However, landmark distances from the pubic
symphysis are highly variable depending on
body type.
 In clinical practice, recording the actual fundal
height measurement is standard practice
beginning around 20 weeks gestation

26. 34
At xiphisternum, HOF
either 36 or 40 weeks
- 40 weeks if there is
fullness of flank
- 36 weeks if no
fullness of flank
2 finger breath below
xiphisternum, HOF
either 34 or 38 weeks
- 38 weeks if there is
fullness of flank
- 34 weeks if no
fullness of flank
At umbilicus equal 22
weeks
At symphisis pubis
equal to 12 weeks

28.  Most caregivers will record their patient's fundal
height on every prenatal visit.
 Measuring the fundal height can be an indicator
of proper fetal growth and amniotic fluid
development
 Any discrepancy may require IMMEDIATE
referral to MO or specialist TRO IUGR or
MACROSOMIA
 IUGR is a SERIOUS matter as it will increase
perinatal morbidity and mortality

29. ULTRASOUND…
 ROLE OF ULTRASOUND
 In Sarawak, a total of 2 ultrasound scans is
considered the minimum standard for low risk
antenatal patient
1. Dating scan: usually done in 1st trimester
2. Ultrasound scan somewhere during 3rd trimester
as a general screening for fetal growth, placenta
localisation and liquor assessment

30. FREQUENCY…
 LOW RISK
1. Dating scan at
booking
2. Detail scan at 18-24
weeks (if indicated)
3. Around 28-32 weeks
for growth, liquor &
placenta
 HIGH RISK
1. Dating scan at
booking
2. Detail scan at 18-24
weeks (if indicated)
3. Serial growth scans,
every 2 weeks from
24 weeks
4. At 28-32 weeks for
placenta location
5. At 36 weeks to assess
lie & presentation

31.  WELL DOCUMENTED
 CLEAR plan of management for
1.Antenatal check –up
2.Mode of delivery
3.Timing of delivery
4.Place of delivery
5.Post natal plan for mother &
baby

32. ** INCREASE MATERNAL
MORTALITY
** INCREASE NEONATAL
MORTALITY

33. POSTNATAL CARE

34. KEMENTERIAN KESIHATAN MALAYSIA
GARIS PANDUAN PERAWATAN
IBU POSTNATAL DI HOSPITAL
BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA
&
BAHAGIAN KEJURURAWATAN
KEMENTERIAN KESIHATAN MALAYSIA
APRIL 2013

35. MINISTRY OF HEALTH…..
 Memberi perawatan postnatal yang berterusan kepada
semua ibu postnatal, sesuai dengan polisi perkhidmatan ibu dan
bayi semasa postnatal selain memenuhi hak ibu postnatal.
 Memberi sokongan emosi dan moral kepada ibu postnatal
kerana seringkali mereka yang berada di wad adalah dikalangan
yang mengalami masalah kesihatan.
 Mengesan awal keadaan luar biasa atau komplikasi semasa
postnatal seperti secondary PPH, Puerperal Pyrexia, Puerperal
Sepsis, Puerperal Psychosis dan sebagainya
 Merujuk segera sebarang keabnormalan kepada Pegawai
Perubatan.
 Mengurangkan kejadian morbiditi dan mortaliti dikalangan ibu
postnatal.

36.  Ministry of Health has introduced colour
coding for the level of post-natal care
COLOUR
CODING
RISK & LEVEL OF CARE
RED Early referral to Hospital
YELLOW Refer to MO/ FMS at Health Clinic
WHITE Normal postnatal check up

37. EXAMINATIONS FOR POST NATAL
MOTHER
 VITAL SIGNS
 HYGIENE
 BREAST XM
 HEIGHT OF
FUNDUS
 LOCHIA
 ABILITY TO PASS
URINE
 SX & SIGN OF VTE
 ADEQUATE PAIN
RELIEF
 ADEQUATE SLEEP
 EARLY
AMBULATION
 HEALTH
EDUCATION

38. SCREENING !!!!

39. Pulmonary embolism is
the main cause of
maternal mortality in
Malaysia and
Sarawak

40.  Need to screen for any evidence of VTE (deep
vein thrombosis or pulmonary embolism) as
currently VTE is the main cause of maternal
mortality in Malaysia
 It is preventable cause of maternal death
 The VTE Risk Management programme was
implemented in all MOH hospitals in the state
of Sarawak in July 2013

41. 2. Postnatal blues…
 At each postnatal contact, women should be
asked about their emotional wellbeing, what
family and social support they have and their
usual coping strategies for dealing with day to
day matters.
 Women and their families/partners should be
encouraged to tell their healthcare
professional about any changes in mood,
emotional state and behaviour that are outside
of the woman’s normal pattern.

42. E-NOTIFICATIONS…
 E-NOTIFICATION is one form of communication in
between hospital and health clinic in managing both
high risk antenatal and postnatal mothers
 HIGH RISK patient that will be discharged from
hospital will have E-NOTIFICATION
 Any information pertaining to the patient, plan upon
discharge, treatment or follow up will be e-mail to the
respective clinic to ensure that the patient will not be
lost in follow up and the plan of management will be
continue
 Some time the nurse will be required to do regular
home visit for certain patient

43. INFO…..
 Provide information
1. Nutrition, diet & supplement during post-partum
period
2. Breast feeding
3. General hygiene & perineal hygiene
4. Post-natal exercise
5. Neonatal care
6. Contraception
7. Pap smear

44. CONTRACEPTION
 The right contraception choice improves
effectiveness and compliance
 It promotes planned safer future pregnancies
and prevents unplanned risky pregnancy
 Appropriate counselling is vital for a successful
family planning programme

45.  FAMILY PLANNING IN HIGH RISK MOTHER
REDUCES THE RISK OF MATERNAL
DEATHS!!

46. MDG 5
(Millenium Developmental Goals)
MDG 5: improve maternal health
 Target 5.A. Reduce by three quarters,
between 1990 and 2015, the maternal
mortality ratio
 Target 5.B. Achieve, by 2015, universal
access to reproductive health

47. THANK YOU