SDMS ID: P2010/0314-001 WACSClinProc1.

1/09 Title: Replaces: Description: Target Audience: Key Words:

Antenatal Care
Antenatal Care WACSClinProc 1.1 Nov 2006 Antenatal Care Midwifery and Medical Staff, Queen Victoria Maternity Unit Antenatal care, appointments, screening, ultrasound, referral, gestational age P2010/0311-001 Chlamydia Screening in Pregnancy P2010/0312-001 Vitamin D Deficiency in Pregnancy P2010/ 0490-001 Group B Streptococcus P2010/0305-001Rh D Immunoglobulin (Anti-D)

Policy Supported:

Purpose: Pregnancy is a n ormal physiological process and any intervention offered should have known benefits and be acceptable to pregnant women. Woman centred care Women will be offered antenatal care that is evidence based. Women will be pr ovided with the information to enable them to make informed choices regarding their care. Women should be informed about the purpose of any screening test before it is performed. The right to decline or accept a test should be clear. All women should be offered antenatal classes. Antenatal care options Women will be classified as high or low risk for their antenatal care. Women requiring high risk care will be r equired to attend the Antenatal Clinic (ANC) under the care of an obstetrician. Low risk women will be offered shared care with their general practitioner (GP), midwifery or team midwifery care. Hand Held Record/Documentation All women will be provided a hand held antenatal record that they will be required to bring to each antenatal appointment and any admissions to hospital, including birth. For those who choose share care with their GP, both the GP and ANC will keep an antenatal record. The woman is required to attend the GP/ANC appointments as per guidelines. G ood communication between GP and ANC is essential to ensure continuity of care.

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Antenatal Schedule of Appointments Gestation 6 to 8 weeks GP to confirm pregnancy. Referral to named consultant at the ANC 10 to 12 weeks First ANC visit to book in Clerical booking in Midwifery booking in: Review past medical and obstetric history Depression screening Calculate pre-pregnancy BMI Advice is given on diet, exercise, smoking, drug and alcohol use. Cessation intervention (eg QUIT) should be offered to all pregnant women who smoke or have recently quit. Identification of Rh negative women for anti D prophylaxis Breastfeeding information and education is given and referral to the lactation consultant or breastfeeding workshop made. Information on antenatal classes. Antenatal Screening: Routine antenatal screening bloods (Rh, group, antibodies, FBC, Rubella, RPR, HIV, Hepatitis B, Hepatitis C and vitamin D assay) should be of fered and arranged if not yet done. Offer chlamydia screening LVS with dry sterile swab Dating scan if required Prenatal diagnosis screening Book 18 week morphology scan Antenatal psychosocial assessment with social worker by referral for women identified as at risk Review by ANC medical staff GP notification attendance and antenatal management plan. 16 , 20, 24, 28, 32 Routine antenatal check 26 weeks FBC, Antibodies and Glucose Challenge Test Referral for Glucose tolerance test if GCT elevated. If a woman is diagnosed as having gestational diabetes her care should continue in the antenatal endocrine clinic in conjunction with the diabetes clinic for education and advice. Recommend iron supplements if Hb <110 and/or consider iron studies. 28 weeks Prophylactic anti D 625 IU for all Rh negative women. 34 weeks Prophylactic anti D 625 IU for all Rh negative women. 36 weeks Routine antenatal check and FBC if Hb < 110 at 26 weeks Antibodies if Rh negative and has not had prophylactic anti D. Screening for: Group B Streptococcus (GBS) via low vaginal/rectal Chlamydia LVS with dry sterile swab 38, 40 weeks Routine antenatal check 41 weeks Consultant lead ANC visit. Discussion/planning for induction of labour.

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Antenatal Screening Blood pressure Should be recorded at every antenatal visit. Should be taken with the women sitting down with the feet supported. M easurements taken after two to three minutes resting in that position. A standard cuff should be used for women with an arm circumference of 33 cm or less. A large cuff is recommended for an ar m circumference greater than 33cm. Hypertension is defined when the systolic blood pressure is 140mmHg and / or diastolic blood pressure (Korotkoff V) is 90 mmHg or there is an increment rise of 30 mmHg systolic or 15mmHg diastolic. Body Mass Index (BMI) BMI should be calculated at the first visit based on pre pregnancy weight. Dietetic advice on healthy weight gain should be given. Women with a BMI >30 are regarded as high risk and will require discussion with registrar/consultant regarding their suitability for midwifery care. RANZCOG Weight Gain Recommendations by Pre-pregnancy BMI Pre-pregnant BMI Optimal Gestational Weight Gain 18.5 13 18 kg 18.5 24.9 11 16 kg 25 29.9 7 11 kg 30 -34.9 4 -11 kg 35 39.9 0 4 kg 40 No weight gain Lose up to 4 kg Urinalysis A mid stream urine (MSU) specimen is recommended at booking in to screen for asymptomatic bacteriuria. R outine urinalysis should be done for women with diabetes, renal disease, documented intrauterine growth restriction (IUGR) or autoimmune disease. When hypertension is suspected due to an elevated blood pressure reading, urinalysis should be performed for the presence of protein. Symphyseal Fundal Height Measurement Is an as sessment of uterine size used as an i ndirect measure of fetal growth. A measurement from the fundal height to the symphysis pubis should be taken at the antenatal visits from 20 weeks. If the fetus appears either small (3cm below expected) or large (3cm above expected) for gestational age then referral to a consultant or registrar is indicated. Ultrasound scan for assessment of fetal growth and AFI should be undertaken if fundal height more than 3cm below expected. GTT may be appropriate if fundal height more than 3cm above expected. Palpation All women in the third trimester should have the uterus palpated to determine fetal lie and presentation. A fetus noted to be other than in a l ongitudinal lie with a c ephalic presentation at 36 weeks gestation or with a mobile presenting part at 40 weeks must be referred to the consultant or registrar. Auscultation of the Fetal Heart Rate (FHR)

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Auscultation of the FHR is of no known clinical benefit. However, it maybe of psychological benefit to mothers. Fetal movement on palpation or reported by the woman will confirm the fetus is alive. Smoking At every antenatal visit the women should be asked about her smoking behaviour. T he benefits of quitting at any stage in pregnancy should be emphasised.
Attachment 1 Attachment 2 Attachment 3 Attachment 4 Attachment 5 Attachment 6 Attachment 7 Terminology Indications for Consultation and Referral at Booking In Estimation of Gestational Age Discrepancies in EDD from Several Ultrasound Scans Standard Screening Indications for Consultation during Pregnancy References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years (January 2012) Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 13 January 2009

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APPENDIX 1 TERMINOLOGY EDD estimated due date. T his replaces EDC as it more accurately reflects the terminology used in 2004. LMP first day (of proper bleeding) of last menstrual period MSD mean (gestational) sac diameter CRL crown-rump length, although this is a misnomer. The measurement is not actually from the crown (part of skull just above the forehead) but from the highest point of the fetal skull. A s such, the measurement is of the maximal straight line length (MSLL) of the fetus. BPD biparietal diameter, measured across the fetal skull through a s ymmetrical plane containing the third ventricle and thalami HC head circumference, measured around the fetal skull at the level of a symmetrical plane containing not only the third ventricle and thalami, but also cavum septum pellucidum anteriorly and tentorial hiatus posteriorly femur length measured along the long axis of the shaft with endpoints placed at the junction of cartilage and bone abdominal circumference measured at a point where the transverse diameter of the liver is greatest. This is technically the most difficult of the 4 body measurements and the one with greatest reported variability.

FL

AC

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APPENDIX 2 Indications for Consultation and Referral at Booking in In accordance with the Australian College of Midwives (ACMI) referral guidelines, the following co-morbidities require review by a r egistrar or specialist consultant. A collaborative approach for high risk women should be adopted, with any additional care requirements documented in the antenatal history along with review times outside of the standard schedule of visits. Women with co-morbidities may require management in consultation with other medical and surgical specialties. Medical Conditions
Anaesthetic difficulties Previous failure or complication ( eg difficult intubation, failed epidural) Malignant hyperthermia or neuromuscular disease Autoimmune disease Cardiovascular disease / hypertension Drug dependence or misuse Use of alcohol and other drugs Medicine use: the effect of the drugs on the pregnant woman and the unborn child, lactation and/or neonate. Information is available from Mothersafe 1 800 647 848 Endocrine Diabetes mellitus, pre existing insulin dependent or non insulin dependent Gestational diabetes Thyroid disease Hypothyroidism Hyperthyroidism Addisons Disease, Cushings Disease or other endocrine disorder requiring treatment Gastro-Intestinal Hepatitis B with positive serology (Hbs-AG+) Hepatitis C Inflammatory bowel disease including ulcerative colitis and Crohns disease Genetic any condition Haematological Thrombo-embolic process any underlying pathology and the presence of a family medical history Coagulation disorders Anaemia at booking irrespective of how treated or whether it responds to treatment. Anaemia defined as Hb < 9g/dL Infectious Diseases HIV infection Rubella Cytomegalovirus Parvo virus infection Varicella / Zoster virus infection Herpes genitalis: primary infection Herpes genitalis: recurrent infection Toxoplasmosis Tuberculosis: active tuberculosis or a history of tuberculosis Syphilis o positive serology and treated o Positive serology and not yet treated o Primary infection If there is a hi story of viral, microbial or parasitic infections whether active or a previous medical history then medical consultation is required. Maternal Age (under 14 and older than 45 years)
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Maternal Weight > 100kg or Body Mass Index <17 and >35 Neurological Epilepsy, without medication or in the past without treatment and no seizures in the last 12 months Epilepsy, with medication or seizure in the last 12 months Subarachnoid haemorrhage, aneurysms Multiple sclerosis AV malformations Myasthenia gravis Spinal cord lesion (para or quadriplegia) Muscular dystrophy or Myotonic dystrophy History of Mental Health Disorders Care during pregnancy and birth will depend on the severity and extent of the mental health disorder Renal Function Disorders Disorder in renal function, with or without dialysis Urinary tract infections Pyelitis Respiratory Disease Asthma mild Asthma moderate (ie oral steroids in the last year and maintenance therapy) Severe lung function disorder System/Connective Tissue Diseases These include rare maternal disorders such as systemic lupus erythematous (SLE), antiphospholipid syndrome (APS), scleroderma, rheumatoid arthritis, periarteritis nodosa, Marfans syndrome, Raynauds disease and other systemic and rare disorders Pelvic floor reconstruction This refers to colpo-suspension following prolapse, fistula and /or previous rupture Cervical Abnormalities Cervical amputation Cervical cone biopsy Cervical surgery with or without subsequent vaginal birth Abnormalities in cervix cytology (diagnostics, follow-up) Uterine Abnormalities Myomectomy / hysterotomy Bicornuate uterus Intra Uterine Contraceptive Device (IUCD) in situ Infertility Treatment Pelvic Deformities (trauma, symphysis rupture, rachitis) Female Genital Circumcision Active Blood Group Incompatibility (Rh, Kell, Duffy, Kidd) ABO-incompatibility Hypertension in the previous pregnancy Pre-eclampsia in the previous pregnancy Eclampsia Recurrent miscarriage (3 or more times) Pre-term birth (<37 weeks) in a previous pregnancy Cervical incompetence (and/or Shirodkar procedure) Placental Abruption Forceps or vacuum extraction Caesarean section Fetal growth disturbance Asphyxia (defined as an APGAR score of <7 at 5 minutes)
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Pre-existing gynaecological disorders

Previous Obstetric History

Perinatal death Child with congenital and / or hereditary disorder Postpartum haemorrhage as a result of Episiotomy Cervical tear Other causes (>1000ml) Manual removal of placenta Placenta accreta 3rd or 4th degree perineal laceration Functional recovery No/poor function recovery Symphysis pubis dysfunction Postpartum depression Postpartum psychosis Grand multiparity defined as parity > 5 Shoulder dystocia

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APPENDIX 3 ESTIMATION OF GESTATIONAL AGE PURPOSE All patients have an agreed EDD determined after their first ultrasound > 6.5 weeks gestation. CALCULATING EDD FROM LMP 1. Certain LMP a. 28 day cycle: add 280 days to first day (of proper bleeding) of last period b. >28 day cycle: add an extra day to EDD for each extra day of cycle c. <28 day cycle: subtract a day from EDD for each day less of cycle d. irregular cycle: use early (20 week) ultrasound 2. Uncertain LMP: use early (20 week) ultrasound 3. Assisted reproduction: use date given by fertility centre or add 266 days to ovulation date. AMENDING LMP EDD AFTER ULTRASOUND SCAN 1. Irregular cycle or uncertain dates: use scan date (earliest available after 6.5w) 2. Regular cycle and certain dates: amend EDD if there is a discrepancy between menstrual EDD and scan of more than the following: a. CRL scan < 14 w 5 days b. BPD,HC,FL,AC 22 w 7 days c. BPD,HC,FL,AC 22 26 w 14 days Pregnant women seen for first time in third trimester. RECORDING AGREED EDD As far as possible, there should be one agreed EDD. Any change to EDD should be clearly documented on the antenatal record with the name of the person making the change also clearly legible. RECORDING EARLY PREGNANCY ULTRASOUND RESULTS Whenever ultrasound results from the first half of pregnancy are written in the antenatal record, the date of the scan together with the gestation and EDD both by dates and by scan should be recorded, as is done in the FWL reports. e.g. scan done 22.8.03, dates = 12+2 (EDD 3.3.04) scan = 10+4 (EDD 15.3.04) PREGNANT WOMEN SEEN FOR THE FIRST TIME IN THIRD TRIMESTER Since scans have accuracy of only +/- 3 weeks at 30/40 and +/- 4 weeks approaching term, determining the EDD for a woman with no antenatal records (especially if dates are uncertain or cycle irregular) seen for the first time in late pregnancy is clearly difficult. The distal femoral epiphysis appears at about 32 weeks and t he proximal tibial at about 35 weeks (slightly earlier in female than male fetuses) and it is worthwhile asking the sonographer to look for these as an ex tra aid for likely maturity. If routine elective caesarean section is required and there are no other problems, it is reasonable in this situation to await early labour before performing it. H owever, amniocentesis for determination of fetal lung maturity might occasionally be warranted.

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APPENDIX 4 DISCREPANCIES IN EDD FROM SEVERAL ULTRASOUND SCANS 1. In general, the earlier the scan, the more reliable with respect to EDD. Therefore the earliest available scan after 6.5w should be used. 2. Since each scan has an acknowledged range of accuracy (see Educational Notes), it is to be expected that women who have several scans in early pregnancy will have slightly different scan EDDs. As long as the discrepancy falls within the accepted range, the EDD should be guided by the earliest scan and the menstrual history. 3. Where a CRL for dating and a CRL for nuchal translucency are done within a week of each other, the latter is preferred since it is especially accurately measured. 4. Once a womans menstrual EDD has been accepted or amended after a first trimester scan, it should not be again amended after the 18-20 week morphology scan unless there are serious misgivings about the accuracy or quality of the original report. 5. Where a significant discrepancy exists between 6-14w CRL and 18-20w morphology scans, the consultant responsible for the womans care should make the final decision regarding best estimate of EDD. 6. An early pregnancy scan EDD must not be changed after scans done in the third trimester. A baby known to be about 34 weeks by early scan but shown to be 31 week size on later scan, must not have its EDD amended. Instead, a diagnosis of SGA should be made. Likewise, if the same baby measures 37 weeks, it is to be considered bigger than average, not more mature. 1. RELIABILITY OF LMP In about 20% (range 10-40%) of women, the EDD as calculated from LMP is more than a week different from that based on ultrasound in the first 20 weeks of pregnancy. In this situation, ultrasound has been shown more accurate in predicting EDD. While discrepancies are more common in women with irregular cycles, those with certain dates and regular cycles can also have an inaccurate EDD, having ovulated / conceived later or earlier than expected. 2. ACCURACY RANGE OF ULTRASOUND MEASUREMENTS 1. MSD 2mm (5w) to 14mm (6w3d): +/- 3 days (not generally used for EDD) 2. CRL 6.5 14 weeks +/- 8% (3d at 6w, 7d at 13w, average 5d) 3. BPD, HC, FL, AC 14 - 20 w +/- 7 days 21 - 26 w +/- 14 days 26 - 32 w +/- 21 days 32 - 42 w +/- 28 days Note that in our procedure we have allowed morphology scans up to 22 weeks a range of +/- 7days. Many of our women have their morphology scan between 20-22 weeks and a uniform allowance for morphology scans at this time is administratively easier.

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APPENDIX 5 STANDARD ANTENATAL SCREENING Routine bloods or ultrasounds will be organised at the 10 week booking in visit. A copy of all routine antenatal pathology will be sent to the womans GP. Routine pathology At booking in: blood group, antibodies, full blood count, rubella immunity, RPR, Hepatitis B, Hepatitis C and Vitamin D assay. A ntenatal screening for Human Immunodeficiency Virus (HIV) should be offered to all women. Women shall receive counselling by a medical practitioner or accredited Health Care Worker prior to a test for Human Immunodeficiency Virus (HIV) being performed. This must be d ocumented in the antenatal records. Screening for Chlamydia should be offered to all women at booking in and repeated at 36 weeks gestation. At 26 weeks gestation: FBC, antibodies and glucose challenge test. At 36 weeks gestation: Group B streptococcus screening by low vaginal swab Chlamydia screening by high vaginal swab using a dry sterile swab FBC if Hb less than 110 at 26 weeks gestation Antibodies if Rh neg and prophylactic Anti D not given Prenatal Diagnosis Counselling is discussed by the consultant/registrar if GP has not already done s o, and if appropriate for gestation. The offer of screening for Down Syndrome and Neural Tube defects should be m ade available to all pregnant women, irrespective of age. Appropriately trained staff must give pre-screening counselling. If after counselling women choose to proceed with screening tests they should have an accurate dating scan, preferably in the first trimester. Maternal Serum Screening can be organised through the South Australian Maternal Serum Antenatal Screening (SAMSAS) Program. Routine Nuchal Translucency currently is not offered at the LGH but can be arranged through the private sector at a cost to the woman. Nuchal translucency is offered between 11weeks 5 days 13weeks 6days to calculate the risk for Down Syndrome and other Chromosomal abnormalities (trisomy 13 and 18). A raised nuchal thickness associated with normal karyotype may indicate other foetal anomalies. 1st Trimester screening is offered between 10-14 weeks and is done in conjunction with nuchal translucency. Maternal Serum Screening is offered between 15 weeks 20 weeks to calculate risk for Neural Tube Defect, Down Syndrome and other chromosomal abnormalities. AFP is offered between 15 weeks and 19 weeks to calculate risk for Neural Tube defects. Women who are found to be at risk will be not ified of their screening result. A n obstetrician or registrar will review women who have an increased risk of Down Syndrome or Neural Tube defects as soon as possible. Chorionic Villus Sampling (CVS) is offered between 11 weeks-13 weeks to test for chromosomal abnormalities such as Down Syndrome and some genetic disorders. Amniocentesis is offered from 14+ weeks, ideally between 15 weeks 16 weeks to test for Down Syndrome, other Chromosomal abnormalities, Neural Tube defects and some genetic disorders. This procedure carries an additional 1% risk of inducing miscarriage. Morphology Ultrasound Scan Should be undertaken between 18 20 gestation.
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APPENDIX 6 INDICATIONS FOR CONSULTATION DURING PREGNANCY As with booking in risk factors, the Australian College of Midwives (ACMI) referral guidelines, detail the following co-morbidities that require review by a R egistrar or Specialist Consultant. A collaborative approach for high risk women should be adopted, with any additional care requirements for ongoing pregnancy and delivery management be documented in the antenatal history. Women may remain on Team if this is appropriate acknowledging the additional benefits that a m odel providing greater continuity has for high risk women.
Uncertain duration of pregnancy by amenorrhoea >20 weeks Laparotomy during pregnancy Cervix cytology CIN Mental health disorders Hyperemesis gravidarum Ectopic pregnancy Antenatal Screening Suspected fetal abnormalities Pre-term rupture of membranes Gestational hypertension Preeclampsia Eclampsia Chronic hypertension Blood group incompatibility Coagulation disorders Recurring vaginal blood loss Placental abruption Size/date discrepancies Post-term pregnancy Threat of or actual pre-term birth Incompetent cervix Symphysis pubis dysfunction Multiple pregnancy Non cephalic presentation at birth Failure of head to engage at full term No prior antenatal care Baby for adoption Fetal death in utero Fibroids Endocrine Diabetes mellitus or gestational diabetes Thyroid disease Addisons disease, Cushings disease or other endocrine disorders Gastroenterology Hepatitis B with positive serology (Hbs-AG+) Hepatitis C Inflammatory bowel disease including ulcerative colitis and Crohns disease Hernia nuclei pulposi (slipped disc) Haematological Thrombosis Coagulation disorders Anaemia at booking or close to term Infectious diseases HIV infection Rubella
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Toxoplasmosis Cytomegalovirus Parvo virus infection Varicella/Zoster virus infection Tuberculosis: an active tuberculosis process Herpes genitalis o Primary infection o If late in pregnancy o Recurrent Syphillis o Positive serology and treated o Positive serology and not yet treated o Primary infection Renal function disorders Urinary tract infections Pyelitis Respiratory Disease Asthma

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ATTACHMENT 7 REFERENCES Australian College of Midwives 2008 National Midwifery Guidelines for Consultation and Referral Online: http://midwives.rentsoft.biz/lib/pdf/Consultation%20and%20Referral%20Guidelines%2020 10.pdf Filly RA and Hadlock FP. Sonographic determination of menstrual age. In Callen PW Ultrasonography in Obstetrics and Gynecology Textbook. 4th edition 2000. Pages 146 170. National Collaborating Centre for Womens and Childrens Health, Antenatal routine care for the healthy pregnant women, clinical guideline October 2003 Online: http://www.nice.org.uk/guidance/index.jsp?action=download&o=40145 Nursing and Midwifery Board of Tasmania 2003 Code of Practise for Midwives 2003. 3 Centres Consensus Guidelines on Antenatal Care, Mercy Hospital for Women, Southern Health and Royal Womens Hospital 2006 Online: http://3centres.com.au/guidelines/ The Royal Australian and New Zealand of Obstetrics & Gynaecologists (RANZCOG) College Statements Antenatal Screening Test, March 2004 Best Practice Guidelines on Antenatal Screening for Down Syndrome and other Foetal Aneuploidy 2004. Diagnosis of Gestational Diabetes November 2002 Breech Deliveries at Term Swabbing for Group B Streptococcus

Guidelines Guidelines for Use of Rh D Immunoglobulin (Anti D) in Obstetrics 2004

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