Overview Antenatal Care (ANC)

Dr. Kusuma Andriana SpOG

Antenatal Care: Overview

Essential Health Sector Interventions for Safe Motherhood

SAFE MOTHERHOOD
Essential Obstetric Care

Clean/safe Delivery

BASIC HEALTH SERVICES EQUITY EMOTIONAL AND PSYCHOLOGICAL SUPPORT

Postpartum Care

Family Planning

Antenatal Care

Postabortion

Definisi
Optimalisasi kes fisik + mental

Kehamilan

Persalinan

Nifas

Laktasi

Kes. ibu Kesejahteran janin Abnormalitas

Cukup bulan Partus aman Trauma minim

Normal

ASI eksklusif

ANC Efektif bila .

Provider terampil ANC berkelanjutan Mempersiapkan persalinan dan tahu potensi komplikasi Promosi kes & cegah peny Tetanus toxoid, nutrisi, rokok & alcohol dll Deteksi dan Tx peny HIV, syphilis, tuberculosis, other co-existing medical diseases (e.g., hypertension, diabetes) Deteksi dini dan manaj komplikasi

Goal-Directed Interventions Give a Framework for Effective ANC

Disease detection Counseling and health promotion Birth preparedness Complication readiness

Why Disease Detection and Not Risk Assess

Pendekatan risiko TIDAK EFISIEN & EFEKTIF unt menurunkan MMR :

Risk factors tdk memprediksi komplikasi : sering tak berhub dg penyebab komlpikasi What do you do once you identify risks? What about low risk? Maternal mortality pd populoasi berisiko Risk factors

relatif terjadi pd populasi yg sama , Bukan indikator yg baik

Sebag besar bumil berisiko tdk timbul komplikasi , sebaliknya bukil tanoa risiko justru terjadi komplikasi

Fortney 1995; Yuster 1995.

Goal-Directed Components of ANC: Disease Detection

Look for problems requiring additional care

Condition Malnutrition Signs of infection Signs of pre-eclampsia Signs of anemia Breast disease Fetal distress/demise Sexually transmitted diseases

Parameter Skin, general appearance, night blindness, goiter Temperature, dysuria Blood pressure, edema, proteinuria, reflexes Hemoglobin, conjunctiva/palms/ tongue pallor Breast exam Babys movements, fundal height, babys heart beat Pelvic and speculum exam

Goal-Directed Components of ANC: Counseling and Health Promotion

Tujuannya untuk
Nutrition and micronutrients Rest and avoidance of heavy physical work Danger signals of complications and disease/illness Family planning Breastfeeding Malaria prophylaxis Tobacco and alcohol use

Goal-Directed Components of ANC: Birth Preparedness

Rencanakan :
Prepare the necessary items for birth Identify a skilled attendant and arrange for presence at birth Identify appropriate site for birth, and how to get there Identify support people, including who will accompany the woman and who will take care of the family

Establish a financing plan/scheme

Goal-Directed Components of ANC: Complication Readiness

15% of all pregnant women develop a life-threatening complication requiring obstetric care

Rencanakan dana Decision maker ??? Bgm transportasi Blood donation

Take Home Message

Antenatal care includes goal-directed interventions Skilled attendant Preparation for birth and complications Health promotion Detection of complications

DEFINISI

Gestational Age : usia hamil mulai HPHT Developmental age : usia hamil mulai fertilisasi Trim 1 : 0 14 mgg Trim 2 : 14 28 mgg Trim3 : 28 lahir Embrio : fertilisasi 8 mgg Fetus : 8 mgg lahir Previable : sbl 24 mgg Preterm : 24 - 37 mgg Term : 37 42 mgg

PELAKSANAAN

Nas minim 4 x Ideal : 1x /bl sd UK 28 mgg 2 mgg an UK 28 - 36 mgg 1 x /mgg UK > 36 mgg Standar minimal 7
Timbang BB TFU TD Imunisasi TT Tes PMS Tablet besi Temu wicara

: 1kg/bl : naik : Normal : Ya : Indikasi : Ya : Ya

TIMBANG BADAN

Metabolic changes, accompanied by fetal growth, result in an increase in weight of around 25% of the non-pregnant weight.

Approximately 12.5 kg in the average woman.

TIMBANG BADAN
Per(+) bervariasi antar perempuan per (+) nyata pada trim II 0.5 kg/mgg Mendekati aterm BB sedikit Per (+) ok

TFU
UK Tinggi Fundus

12 minggu
16 minggu 20 minggu 22 27 mgg

20 cm (+ 2 cm)

Diatas simfisis pubis

Pertengahan simfis- umbilikus Setinggi umbilikus

UK (cm) (+ 2 cm)

28 minggu
29 35 mgg 36 minggu

28 cm (+ 2 cm)

Pertengahan umbilikus px

UK (cm) (+ 2 cm) 36 cm (+ 2 cm) Setinggi proc.Xiphoideus

40 minggu

32 cm (+ 2 cm)

2 jari dibawah proc. Xiphoideus

GEJALA DAN TANDA

TEKANAN DARAH INDIKATOR

DIASTOLIK

MERUPAKAN

MENGUKUR TAHANAN PERIFER TIDAK TERPENGARUH KEADAAN EMOSI

DIAGNOSIS HIPERTENSI BILA TEKANAN DIASTOLIK 90 mmHg PADA DUA KALI PENGUKURAN BERJARAK 1 JAM HIPERTENSI DALAM KEHAMILAN

HIPERTENSI KARENA KEHAMILAN HIPERTENSI KRONIK

PENILAIAN KLINIK

KEJANG RIWAYAT KEJANG DEMAM (-) KAKU KUDUK (-)

DEMAM NYERI KEPALA KAKU KUDUK (+) DISORIENTASI TRISMUS SPASME OTOT MUKA NYERI KEPALA GANGGUAN PENGLIHATAN MUNTAH RIWAYAT GEJALA SERUPA

EPILEPSI MALARIA SEREBRAL MENINGITIS ENSEFALITIS TETANUS

TEKANAN DARAH NORMAL

MIGRAINE

TEKANAN DARAH MENINGKAT

( 140/90 mmHg)
NYERI KEPALA GANGGUAN PENGLIHATAN HIPERREFLEKSIA PROTEINURIA KOMA

PENILAIAN KLINIK
HAMIL < 20 MG
HIPERTENSI KRONIK SUPERIMPOSED PREECLAMPSIA

KEJANG + HAMIL > 20 MG

EKLAMPSIA
HIPERTENSI

KEJANG

PREEKLAMPSIA RINGAN PREEKLAMPSIA BERAT

IMUNISASI TT

1 bl sebelum menikah TT 1 : UK 16 mgg TT 2 : UK 20 mgg Booster : bila kehamilan berikutnya > 5 th

TES PMS

Untuk menilai adanya PMS Dilakukan wawancara + pemeriksaan penunjang bila diperlukan

Asymptomatic bacteriuria
Pregnant women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth.

Asymptomatic bacterial vaginosis

Pregnant women should not be offered routine screening for bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes.

Chlamydia trachomatis
Pregnant women should not be offered routine screening for asymptomatic chlamydia because there is insufficient evidence on its effectiveness and cost effectiveness.

Cytomegalovirus
The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered.

Hepatitis B virus
Serological screening for hepatitis B virus should be offered to pregnant women So that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child-transmission.

Hepatitis C virus
Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence on its effectiveness and cost effectiveness.

HIV infection
Pregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection.

Rubella
Rubella-susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies.

Streptococcus group B
Pregnant women should not be offered routine antenatal screening for group B streptococcus (GBS) because evidence of its clinical effectiveness and cost effectiveness remains uncertain.

Syphilis
Screening for syphilis should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and fetus.

Toxoplasmosis
Routine antenatal serological screening for toxoplasmosis should not be offered because the harms of screening may outweigh the potential benefits.

Toxoplasmosis
Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection, such as: 1. Washing hands before handling food 2. Thoroughly washing all fruit and vegetables, before eating C 3. Thoroughly cooking raw meats 4. Wearing gloves and thoroughly washing hands after handling soil and gardening 5. Avoiding cat faeces in cat litter or in soil.

Tablet Besi
Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mothers or fetuss health and may have unpleasant maternal side effects.

TEMU WICARA (ANAMNESA)

Riwayat Kehamilan Ini
-

Riwayat Obstetri Lalu

-

Usia ibu HPHT Perdarahan pervaginam Keputihan Mual dan muntah Obat-obatan atau jamu Masalah lain

Jumlah kehamilan Jumlah persalinan cukup bulan, atau prematur Jumlah anak hidup Jumlah abortus Riw. Hipertensi Berat bayi < 2,5 kg atau > 4 kg Masalah saat hamil, persalinan dan nifas

ANAMNESA

Riwayat penyakit sebelumnya

Anamnesa yang teliti tanya !!!

JANGAN tunggu ibu yang bercerita

Riwayat Sosial ekonomi

Status perkawinan Kebiasaan rokok, alkohol Pekerjaan Pendidikan dll

PEMERIKSAAN FISIK

UMUM Vital Sign Pemeriksaan luar setiap kunjungan TFU, BJA, Leopold Pemeriksaan genitalia
Bila ada indikasi Dari luar, VT TIDAK DILAKUKAN UNTUK TENTUKAN HAMIL +/

Lab : DL, UL, GDA

Konseling (Health Promotion)

Gizi AKtifitas normal Perubahan fisiologis Hub suami istri Rencana ANC Pantau janin 10 gerak/12 jam Tanda-tanda bahaya Rencana partus Kebersihan Keterlibatan keluarga Suami SIAGA, Tab dll

GIZI

Kenaikan BB 1 2 kg/ bl Kalori : (+) 300 kcal/hr dari kebutuhan awal Vitamin
As. Folat Zat besi Calcium

: 400 g/hr : 30 mg/hr elemental : 1200 mg/hr

Folic acid

Dietary supplementation with folic acid, before conception and up to 12 weeks gestation, reduces the risk of having a baby with neural tube defects (anencephaly& spina bifida).

The

recommended dose is

400 micrograms per day.

Vitamin A

Vitamin A supplementation (intake greater than 700 micrograms) might be teratogenic and therefore it should be avoided.

Liver

and liver products may also contain high levels of vitamin A, consumption of these products should also be avoided. C

Vitamin D
There

is insufficient evidence to evaluate the effectiveness of vitamin D in pregnancy. In the absence of evidence of benefit, vitamin D supplementation should not be offered routinely to pregnant women.

MUAL & MUNTAH

Terjadi 50 % pd T1 Berat hipermesis gravidarum Management MM ringan :

Hindari makanan berlemak Makan sedikit tapis ering Minum the jahe

Management MM berat
Hentikan suplemen Antihistamin Prometazine Metoclopramide

AKTIFITAS FISIK

Tidak perlu dibatasi Hindari posisi OR supinasi yg lama pada T2 dan T3 Stop bila kelelahan (++), sesak) Kontraindikasi :
IUGR Vag bleeding Incompetenc Cx Faktor risiko partus prematur KPD HT dlam kehamilan

Exercise in pregnancy
Beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes.

Sexual intercourse in pregnancy

Sexual intercourse in pregnancy is not known to be associated with any adverse outcomes.

Air travel during pregnancy

Pregnant

women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis. Wearing correctly fitted compression stockings is effective at reducing the risk.

Car travel during pregnancy

Pregnant women should be informed about the correct use of seat belts (that is, threepoint seatbelts above and below the bump, not over it).

Traveling abroad during pregnancy If pregnant women are planning to travel abroad, they should discuss considerations such as flying, vaccinations and travel insurance.

GPP

GUIDE LINE ANC & POST PARTUM CARE