Pre-ante-post natal care (60 min presentation, 60 mins case studies) GPs will need to provide first trimester

care for all public patients (and the majority of private patients). The Three Centres Consensus Guidelines on. Antenatal Care, October 2001. Evidence based antenatal guidelines recommends women are seen 3 times in first trimester. Prenatal Care Clinical Assessment - history and examination to identify any conditions that may be of relevant to the forthcoming pregnancy and need to be managed prior to pregnancy.

History GTPAL, personal/family/genetic history, risk factors age, complications in previous pregnancies, multiparity, tobacco/alcohol/drug use or teratogenic medications, multiple foetuses in previous pregnancy, unplanned pregnancies, short stature, high or low weight, social issues (low socioeconomic status, domestic violence). Examination Cardiovascular, respiratory, abdominal, pelvic. Obs (BP, HR, Wt). Investigation Bloods: FBC, BSL, blood group including rhesus status and antibodies, viral screening (Hep B/C sAg, rubella, varicella, HIV), sickle cell and thalassaemia in at risk groups (non western European or aboriginal). Urine: UMCS and chlamydia PCR. Pap smear if indicated. Healthy Pregnancy Advice MAIDDENS MEDICATIONS that are safe to use during pregnancy. ADULT IMMUNISATIONS .. check immune status if history uncertain. Vaccinations (except influenza) contraindicated once pregnant. DRUGS (including alcohol and tobacco) .. cessation counselling. DENTAL CARE .. hormonal changes in pregnancy predispose to periodontal disease which is associated with low birth weight and prematurity. Early pregnancy dental check, early treatment of any problems, oral hygiene education, avoidance of sugary foods/drinks. EXERCISE NUTRITION .. supplements include folate for Neural Tube Defects from beginning of pregnancy (preferably before). SUPPLEMENTS .. iron is only element for which dietary intake is definitely not enough during pregnancy, but folate also recommended as oNTD prophylaxis from 12/52 pre-conception .. multivitamin like Blackmore's Conceive Well Gold is one option. Give practical advice on where to go and when in early pregnancy.

Antenatal Care: care provided to improve the health of the pregnant woman and her baby by

monitoring the progress of the pregnancy and detecting and managing any problems. 1st Visit (timing varies)

Prepare OrangePregnancy Record. Provides a useful prompt and checklist to assist with comprehensive assessment. GPNNT's pregnancy information kit for women in first pregnancy. SAMSAS information sheet and request forms. Estimate GA/EDC Gestational Age? Determine gestational age (on history if previously regular periods and sure of first day LMP, or otherwise by ultrasound at 8-12 weeks). Estimated Date of Confinement? Whatever the GA, determine estimated date of confinement by calculator, wheel or Nageles Rule (1st day LMP + 7d 3 3/12 eg LMP 1 April = EDD 6 Jan). History ObsGyn: GTPAL (gravida, term, preterm<37/40, abortions<20/40 para, live young), year, sex, weight, gestational age, length of labour, mode of delivery, complications, uterine surgery (myomectomy, D&C, cone biopsy). Antenatal Assessment Questionnaire, Edinburgh Depression Score, Antenatal Risk Questionnaire, Smokefree Pregnancy Intervention and Intervention. General: Medical/Surgical. Family and Social History, Drugs (prescription, OTC, recreational), Allergies Examination Examine: Check for conditions relevant to pregnancy. All systems (abdominal, pelvic, consider Pap if none within 24mo, breast, respiratory, cardiovascular), baseline BP and wt. Investigation Booking Bloods: Confirm pregnancy with quantitative B-HcG and correlate with calculated EDC. Order FBC, iron studies (ferritin), red cell folate, B12, BSL, blood group, rhesus status and antibodies. Bearing in mind TORCHES infections: trepinostika screening assay for syphilis, Hep B, Hep C (if IVDU), HIV, rubella, varicella IgG (if no history of chicken pox). Consider testing for haemoglobinopathies (Hb electrophoresis), sickle cell and thalassaemia (non-Western European, aboriginal), Mantoux test, vitamin D (if risk factors present). Urine: UA then UMCS if leukocytes/nitrites (In pregnancy bacteriuria 5%, UTI 2530%, risk of premature labour). PCR/culture for gonorrhoea and chlamydia. PAP smear if none in last 2yrs. DoHA National Cervical Screening Program recommends cervical screening should be offered to all women presenting for antenatal care who have not had a Pap smear in the past two years. RANZCOG advises women should be reassured there is no evidence that Pap smears cause any problems with pregnancy, though they may cause spotting [8]. Consider dating scan (ideally at about 8 weeks .. may be unnecessary if regular periods and sure of LMP). Transvaginal if <8/40 (Quantitative B-HcG <6500), transabdominal thereafter. As well as EDD (to within 3-5/7), 1st Trimester USS checks foetal size, number, location, heartbeat. Also checks size and condition of

gestational sac, condition of uterus, ovaries. Some women (especially if low risk) wait for 2nd Trimester morphology scan. Advise: CONCEEPTUSS CARE OPTIONS: Antenatal and birthing options (No midwifery managed birthing centres in NT). Assess suitability/interest in private, public, GP shared care. All public referrals should initially be to first antenatal clinic. Discuss and refer for antenatal classes. NUTRITION: Diet: Eat >300kcal, including foods rich in folate and iron, plus multivitamin from 2nd trimester if normal diet inadequate but definitely <1 multivitamin a day (including folate for oNTDs from beginning of pregnancy, calcium, and iron especially in 2nd and 3rd Trimester). Discuss what foods to avoid (Salmonellosis can cause miscarriage and is found in raw vegies like bean sprouts, raw eggs and undercooked/cold meats like salami, sashimi, cold chicken/turkey, peeled prawns / Listeriosis can cause miscarriage, stillbirth, prematurity and is found in leftovers, unwashed/preprepared vegies/salads, soft cheeses and soft serve ice cream, processed meats, cold chicken, pate, stuffing; Toxoplasmosis can cause foetal blindness or brain damage, is found in cat faeces and can be picked up by eating unwashed fruit/veg, handling infected cats or kitty litter, gardening, drinking unprocessed goat's milk) Foods to Eat or Avoid When Pregnant: foodauthority.nsw.gov.au COITUS: OK except if high risk for abortion, preterm labour or in placenta praevia. Avoid breast stimulation in high-risk patients near term. Coitus can precipitate labour 2 to prostaglandins in semen. EXERCISE: Can do moderate exercise (strength improves posture/tone an reduces pain). Avoid aggressive training. EMPLOYMENT: Avoid heavy work, have rest breaks, avoid stress (which is associated with preterm labour and IURG). PHARMACEUTICALS: Discuss potential teratogens (OTC/herbal/prescription medications, alcohol, tobacco ... etc). Counsel on cessation of smoking, alcohol, illicit drugs (refer to detox services), restriction of caffeine. Prescription medications categorised by TGA (categories only apply in recommended doses and routes): Cat A: large evidence base in humans, no AEs seen in foetus/neonate; Cat B1: limited evidence base in humans, no AEs seen, also no AEs in animal studies; Cat B2: same as B1 but only limited animal studies; Cat B3: same as B2 but animal studies do show foetal damage; Cat C: drugs causing pharmacological AEs but no malformations (AEs may be reversible); Cat D: observed, suspected or potential cause of irreversible malformations and may also have pharmacological AEs; Cat X: high risk of causing malformations and should not be used in pregnancy or where pregnancy possible. Avoid aspirin/ibuprofen after 30/40 as they can cause foetal heart valve defects. Avoid topical treatments for candidiasis (check BSL). Avoid retinoids for acne. Avoid Ural (high sodium content). Most antibiotics OK (not folate antagonists, tetracyclics).

 TRAVEL: No contraindication, but travel-related stress carries some risk preterm labour. ULTRASOUND and SERUM SCREENING: Dating scan at around 8 weeks. Genetic counselling. Discuss 1st Trimester screening for Down's, 2nd Trimester screening for oNTD, 18-20wk morphology scan, and timing of routine visits. Refer 1st trimester screening for Trisomy 18 and 21: nuchal translucency and bloods including PAPP-A, AFP, hCG, UE3 (unconjugated oestradiol 3), DIA (dimeric inhibin A). Coordinated by SAMSAS (Note: does not include testing for open neural tube defects, which are tested for in 2nd trimester). Give patient SAMSAS pre-test information sheet. Two request forms required, one SAMSAS pathology form with patient's Medicare number recorded and one for imaging, specifying nuchal translucency for risk of foetal abnormality, cc SAMSAS. SAMSAS will coordinate the results with the ultrasound practice and you will receive a single report giving the risks calculated for the pregnancy. Scan at 11w3d - 13w6d [optimal gestation 11w3d 12w]. Bloods at 9w - 13w6d [optimal gestation 10 12w]. Easiest for patient to have ultrasound at NT Imaging then walk across to RDH pathology (foyer of main hospital block) for bloods at 12w. Post-test information sheets are provided with all reports issued by SAMSAS on pregnancies found at increased risk of fetal abnormality. Further Investigation CVS at 10-12w if indicated and MSS/NTS performed early enough to allow. Ordered by obstetrician (Dr O'Callaghan). Risk of abortion 0.51%, a bit higher than amniocentesis.

Follow-up Visits: Monthly during 1st and 2nd trimesters, fortnightly from 29 36w, then weekly (how much of this done by GP depends on mode of care: private, public or shared).

Estimate GA/EDC GA/EDC. History Foetal movement, bleeding, leaking, cramping. Maternal wellbeing, BP, etc Examination Abdomen: Leopold manouevre (lie, position, presentation): four manoeuvres .. fundal grip of upper abdomen (to determine if head up or down), umbilical grip (one hand bracing, the palm of the other performing deep palpation to determine back on which side), Pawlick's single handed lower abdominal grip usually replaced by two handed palpation as more comfortable (gives reciprocal information to fundal grip and indicates if foetal head engaged), pelvic grip (similar to umbilical grip, trying to

locate the foetal brow on opposite side to back which indicates head well-flexed or foetal occiput indicating head extended). Fundal height: within 2cm of gestational age from 20-37w .. at pubic symphysis at ahout 12w at umbilicus at 20w at sternum at 37w.. If findings abnormal recheck dates and think of diabetes mellitus (maternal-foetal), poly/oligo-hydramnios, multiple gestation, abnormal karyotype, IUGR, foetal anomaly, abnormal lie. Maternal obs: especially BP and Wt. Foetal wt increases at .45kg/mo first 20w then . 45kg/wk second 20w. Maternal wt averages 11-15kg (40% products of conception). Foetal Heart Sounds: >12wks using doppler (if available). Investigation Urinalysis (? glucose, protein). Timed Investigations, Treatments 1420+6/40 Second Semester Maternal Serum Screening [optimal at 16w] Coordinated via SAMSAS. 80-100% sensitive. Tests for oNTDs +/- trisomies. Part of integrated screening, used in combination with or replacement of the 1st Trimester Screen. Request oNTD only if trisomy screen done in 1st trimester [serum AFP only]. Full triple screen for trisomies 21, 18 or oNTDs [serum AFP, bHCG, unconjugated oestrogen all required]. Interpretation: T21: low AFP, high BHCG, low uE3 / T18: low AFP, low BHCG, low uE3. Amniocentesis indicated in high risk patients. Note gestational age crucial in interpretation, and further investigation may be needed in high risk patients as other defects are not detected. 1540/40 Amniocentesis If indicated by MSS/NTS. Risk of abortion 0.5-1% (usually requested by obstetrician). Available at the public hospital from 15/40 or consider private referral to Drs O'Callaghan or Miller. Morphology Scan Recommendations on exact timing may vary. Note: only change EDD if scan findings >10 days different to menstrual dates. 28 Week Screen and anti-D Treatment Antibody check for Rh- women or those known to have atypical antibodies. (For Rh+ women only check antibodies once at booking and not again at 28 or 36 weeks). Give Antenatal prophylaxis for Prevention of Rhesus Alloimmunisation (Anti-D, Rhogam) to Rh- mums without antibodies at 28 and 34/40. 50g oral GTT. Also Repeat FBC. Placental Localisation Scan Placental localisation scan if low lying at time of morphology scan.

1820/40

28/40

30/40

34/40 36/40

Second dose of Rhogam to Rh- women without antibodies. Rhesus and GBS Screening Rh ABx screen in Rh- mums. GBS screen (low vaginal swab). FBC

Advise (CONCEEPTUS, plus ..) Signs of labour: period-like cramps, diarrhoea, backache, show, gush/trickle of fluid, regular/painful contractions [7]. When to attend delivery suite: Once contractions 5 minutes apart (or when regular/painful contractions occur if living a long distance from hospital), if waters break or vaginal bleeding occur, or if no longer comfortable being at home. If unsure, call delivery suite and speak to midwife. Braxton-Hicks contractions may be confused with labour, occurring from about 20/40 [7]. Breastfeeding advice. Refer If foetal growth slower than expected. Late term if presentation abnormal presentation.

Postnatal Care (06 weeks): In Australia, mainly done by GPs 90% of GPs do them, 95% of women attend for them (on average presenting 7.7 times in the first 6 months postpartum). The literature doesn't show any benefit to 6-week check. Similarly, there is little evidence on timing and content. But the postpartum period is a time of tremendous change, emotional upheaval and increased health problems with 94% of women having more than 1 health problem during the postpartum period 50% of new mums would like more help [4]. General practitioners are in an ideal position to provide proactive postpartum care, but many are not confident in this area [5]. Checks are often set up to fail, with women booking a routine consultation, presenting with or without baby, with 100 questions and due for a Pap smear. Many women come away from their postnatal health check unsatisfied, feeling that examination was unfocussed and the relevant issues not addressed [5]. Guidelines recommend assessing physical, emotional, social wellbeing of mum and bub.

Daily checks for first 5 days (usually in hospital), then weekly for baby and as needed for mum till 6-week check. Use recall system to ensure appropriate follow up. Preparation for the Check During antenatal period, recommend mother make long appointment for 2-4 weeks postpartum. Mother should be advised to bring baby, dad (if possible), discharge summary, pregnancy record, list of questions she wants to discuss (might include: breastfeeding issues, support networks, contraception and pain management). Notify Medicare of the birth.

6-Week Postnatal Check (usually done at 68 weeks, and sometimes as late as 12 weeks, but it may be worth considering earlier timing even though evidence lacking) Review birth summary from RDH. Assess Mum: Debrief by asking about labour and birth, complications, treatments needed, recovery. Specifically ask about vaginal blood loss, perineal/LSCS pain, tiredness, backache, urinary symptoms, bowel movements, rectal bleeding, breast/nipple tenderness, sleep patterns and mood. Ask how mother feels about baby , how baby is feeding, settling and responding. History should focus on identifying the following common maternal complaints: 1. Vaginal or rectal blood loss, bowel movements (postpartum vaginal lochia flow varies, generally persisting for 48 weeks with red blood loss for the first 212 days secondary PPH caused by retained products, endometritis, uterine atony, haematoma, coagulopathy). 2. Urinary symptoms (? stress incontinence ? nerve damage to urinary bladder) 3. Pain: backache, symphyseal or perineal pain, LSCS wound pain, vaginal heaviness/pain, dyspareunia .. after pains caused by oxytocin secretion, especially during breastfeeding. Reassurance and paracetamol 4. Breastfeeding difficulties (refer if any problem), mastitis and/or breast engorgement. Expressing and storing. Difficulties making, storing formula. 5. Exhaustion 6. Postnatal (Kegel's pelvic floor) exercises. 7. Postnatal depression: ask about mum's sleep pattern, mood. Ask how mother feels about baby (how feeding, settling, responding). Use Edinburgh Postnatal Depression Scale. 8. Family/social support: has mum been to early childhood centre? 9. Financial difficulties? Assist to link mother up with social services. Also be alert to the possible presence of the following: 1. Relationship and/or sexual difficulties (sex can usually be recommenced from 4-6 weeks postpartum, but libido often reduced due to low oestrogen levels during breastfeeding, body image problems, fear of pregnancy) 2. Contraception or return of fertility 3. Wound infection 4. Haemorrhoids 5. Anaemia 6. Endometritis 7. Thyroid disorders 8. Complications of pregnancy related conditions 9. Frequent URTIs Examination, look for: 1. Signs of anaemia 2. BP (investigate if hypertensive >3/12 postpartum) 3. Breasts, nipples, breastfeeding position 4. Wound infection (perineum, LSCS) 5. Thyroid 6. Uterine fundus (within 3cm from 24/40) 7. Routine bimanual examination for uterine involution not recommended, but may be done if persistent bleeding is a problem.

 Investigations, consider the following: 1. FBC & iron studies (iron supplements if anaemic) 2. Coags and ultrasound uterus if excessive bleeding and risk factor like family history, pre-eclampsia. If mum well, conservative approach with Augmentin DF and metronidazole. If febrile, IV antibiotics and curettage may be needed 3. TSH (and thyroid autoantibodies if abnormal) 4. BSL (and oral GTT if gestational diabetes or birth weight >4kg) 5. MSU: UTI (can exacerbate incontinence), protein, glucose 6. Rhesus antibodies if Rh7. Pap smear and HPV screening if due (>6-8 weeks postpartum to allow inflammation to subside after parturition) 8. Vaginal/perineal swabs probably not useful in diagnosing infection as bacteria usually commensal Treatment 1. Anaemia management: iron supplements 2. MMR if rubella antibodies low 3. Vitamin D (if deficient during pregnancy) .. 0.45mL Pentavit a day for baby, then seek Paeds advice when weaning 4. NVD pain management: ice packs, baths (no salt), paracetamol, diclofenac 50mg TDS for perineal pain, dietary fibre. Codeine can cause constipation. Drain haematoma. 5. LSCS pain management: paracetamol, diclofenac, codeine, tramadol for first 2 weeks. 6. Fatigue management: adequate dietary/fluid intake, regular rest periods, explore social support options (gettng a nanny for early evening, partner using holiday entitlements to work 2-3 days a week, parental support with older kids), explore issues causing anxiety or stress. Maternal and child health nurse may be able to provide support, surveillance, advice. 7. Sexual difficulties: lubricants and vaginal oestrogen can be used for dyspareunia. 8. Contraception: only combined OCP absolutely contraindicated during breastfeeding (interferes with lactation) and relatively contraindicated if pregnancy related hypertension .. if not breastfeeding, wait till 3 weeks to reduce VTE risk. Lactational amenorrhoea 97% effective as long as fully demand breastfeeding and amenorrhoeic, remembering ovulation can occur before menses resume. POPs not registered for use during breastfeeding in Australia, but can be used from 6 weeks postpartum. Implanon/MDP OK from 48h but generally withheld till 6 weeks, can cause irregular bleeding. IUCD at 4-6 weeks to avoid expulsion (may be inserted at 6-week check). Can cause irregular bleeding. Diaphragms need to be refitted at 6 weeks. Condoms OK. Other options are tubal ligation (at time of LCSC with consent), vasectomy. Assess baby (outside scope of this presentation):

NT Maternity Hospitals Alice Springs Hospital Gap Rd, Alice Springs, 0870 ph: 08 8951 7621Public hospital: public, private and birth centre. Baby Friendly Health Initiative accredited Darwin Private HospitalRocklands Drive, Tiwi NT 0810 ph: 08 8920 6011Private

hospital: private care only. Gove District HospitalMatthew Flinders Way, Nhulunbuy, 0880 ph: 08 8987 0211 Public hospital: public care only. Baby Friendly Health Initiative accredited Katherine HospitalGorge Rd, Katherine, 0850 ph: 08 8973 9211Public hospital: public care only. Baby Friendly Health Initiative accredited Royal Darwin HospitalRocklands Dr, Tiwi, 0810 ph: 08 8922 8888Public hospital: public care only. Baby Friendly Health Initiative accredited Tennant Creek HospitalSchmidt St, Tennant Creek, 0860 ph: 08 8962 4399Public hospital: public and private

NT Antenatal Classes Childbirth Education Association Darwin Shop 6, Nightcliff Community Ctr, 18 Bauhinia St, Nightcliff, 0810 ph: (08) 8948 3043 Darwin Private Antenatal Classes covering: Karama and surrounds ph: 0405 536 794 Innerlife: Alawa ph: (08) 8941 2229 References: 1. GP Care in Pregnancy Guide: GPNNT http://www.gpnnt.org.au/client_images/301998.pdf 2. ATLAS Antenatal and Postnatal Care: NT Dept of Housing and Families 3. Physical Examination, Questions and Discussion: Birth.com.au 4. The Postpartum Visit, Why wait 6 weeks? AFP, Ewa Piejko 5. The role of the general practitioner in postnatal care: an early intervention study: Jane Maree Gunn, Dept of Public Health and Community Medicine, University of Melbourne 1997 PhD thesis 6. Pregnancy and Food Safety, Foods to Eat or Avoid When Pregnant: foodauthority.nsw.gov.au 7. Pregnancy, Stages of Labour: Better Health Channel http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/pregnancy_stages_of_labour? open 8. Policy for cervcal screening during pregnancy: National Cervical Screening Program, DoHA http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/screeningpregnancy-policy 9. Creasy Resnik High Risk MFM