Pregnancy Care in Primary Health

Suspected pregnancyPre reading prior to using this power

point:https://www.racgp.org.au/Education/

Curriculum/Pregnancy-care

Comparison of philosophy

Midwife• Holistic Approach• “Social Justice approach”• Work towards Self-health

and Self determination• Partnership Model• The woman ‘births’ her

baby

Medical• The mother reaches the end

of pregnancy as healthy or healthier than the outset

• That any physical or psychological defects are detected and treated

• That the mother is delivered of a healthy baby

Role and responsibility of the clinician caring for the pregnant woman in the Primary Health Care setting

• Healthy woman during pregnancy• Healthy outcome for the baby• Detection of any deviations from the normal• Appropriate referral to correctly qualified medical

specialist • Liaise and coordinate care• Advocacy for the woman and her baby• You are NOT expected to manage pregnancy

complications

Approach with caution• Confirmation of pregnancy• Planned or unplanned• Does she wish to continue with the

pregnancy?• Counselling skills essential

Termination of Pregnancy• Reasons• Explain legal position• Discuss other options, adoption?• Full hx / exam including hvs, STI screening and

antenatal bloods• Psych state & counselling• Info sheet, discuss procedure• Contraception• Follow up

Antenatal Screening• Routine 1st A/N screen: FBC, Rubella, Bl Grp, antibody screen, Hep B & C,

VDRL, HIV, MSU• At Risk

– Vit D & Thyroid function test.• USS if unsure of dates between 7-8wks• NIPT, which analyzes cell-free fetal DNA circulating in maternal blood 10-

20wks– Generation Test $395– Harmony Test $450

• NT scan & Maternal Serum (SAMSAS)– Two tests MUST be done on the SAME day– 11wks + 6days – 12wks +6days

• MSSU or LVS STI screening• Amniocentesis (women over 40 + women with high risk screening result

publically funded) or cvs in high risk cases 1% miscarriage risk

Vitamin D and Pregnancy• Serum vitamin D testing is relatively new• During pregnancy, severe maternal vitamin D deficiency has been associated with

biochemical evidence of disordered skeletal homeostasis, congenital rickets, and fractures in the newborn.

• At this time, there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency.

• Recent evidence suggests that vitamin D deficiency is common during pregnancy especially among high-risk groups, including vegetarians, women with limited sun exposure (eg, those who live in cold climates, reside in northern latitudes, or wear sun and winter protective clothing) and ethnic minorities, especially those with darker skin

• Best absorbed from the sun – 20 min walk in sunshine arms and legs exposed

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Vitamin-D-Screening-and-Supplementation-During-Pregnancy

Thyroid Function Tests in Pregnancy

• Currently, there is controversy over whether universal screening or targeting of high-risk individuals is more appropriate

• Pregnancy has a profound impact on the thyroid gland and thyroid function since the thyroid may encounter changes to hormones and size during pregnancy.

• Excessive iodine can paradoxically cause fetal hypothyroidism and very high doses of iodine should be avoided

• Many foods are already fortified with iodine http://www.racgp.org.au/afp/2012/august/thyroid-disease-in-the-perinatal-period/

MSU• Asymptomatic bacteriuria 2%-10% (NICE

2003) can cause pyleonephritis and preterm labour

• Urine dipstick unreliable only detects 50% of cases (NICE guidelines 2003)

Chlamydia Urine Screening should be offered to high risk women

• Under 25yrs• Unmarried women• History of STD• New/multiple partners• No history of barrier contraception• Women in communities with high rates1st trimester and 3rd trimester (Kirkham et al

2005)

Medical Assessment• Cardio vascular check & BMI• Previous medical history• Review of medications• Previous Obstetric history• Social Supports• Risk assessment for ongoing care, assessment

for further referral

Medical History• Current medical illnesses• Past medical Illnesses• Current medications, *folic acid• Allergies• Smoke/alcohol/drugs• Family history

Social history• Support network• Work• Cultural Awareness

Assessment Family Violence

• Within the last year have you been hit, slapped or hurt in any way by your partner/ex partner

• Are you afraid of your partner/ ex partner• Are you safe to go home when you leave here• Would you like any assistance?• Screen when partners/family NOT present• (MOH guidelines 2007)

Physical Examination• Ht/Wt BMI• CVS including BP• Abdominal Exam ?fundus ?FH• No evidence to support breast exam• No evidence to support V/E or smear taking• No evidence to support HVS• (Latter 2 increased risk of miscarriage &

infection ‘Cochrane review’)

The Opportunity for Education• Alcohol & drug use during pregnancy• Diet and exercise• Options of care

– Be mindful of own beliefs around pregnancy, labour and birth– Darwin Homebirth Service– Community Midwife program– Midwifery Group practice (Indigenous women)– Private Obstetric services– Public system– GP shared care– GP/Midwife shared care

• Women need to have a referral letter sent to the hospital• All women will have AT LEAST one obstetric review appointment on level 8 at

RDH.

Further Tests• 18-20wks Morphology scan please make written

request for cervical length estimation• 28wks- FBC, ?Ferritin if Hb < 105g/dL, Antibodies,

1st Anti D Rh neg (NICE 2003). OGTT test• 34 wks ?kick chart (debateable point), 2nd dose

Anti D Rh neg (NICE 2003)• 32wks Scan if previous was placenta low lying• 36wks- FBC for those on iron, Antibodies Rh neg,

check presentation, ?ECV for breech

Schedule of Antenatal Visits• Uncomplicated

pregnancy 10 visits • 1st-before 12wks• 14weeks• 20 weeks• 26wks• 30wks• 34wks

• 36wks• 38wks• 39wks• 40wks• 41wks CTG and refer for

obs consult

• (NICE guidelines 2003) & Australian Federal Guidelines

Complications of Early PregnancyNausea and Vomiting• Nausea 70%-80% (Medalie 1957; Whitehead

1992; Gadsby 1993)• Vomiting 50% (Whitehead 1992; Gadsby 1993)• 17% just in the mornings• 13% beyond 20wks gestation• 35% lost time at work

Early pregnancy causes of nausea• Rising HCG levels thought to stimulate thyroid

activity. Goodwin et al (1992)• Thyrotoxicosis. Chong and Johnston (1997)• Deficiency B6 and Zinc• Multiple pregnancy• Molar pregnancy• Hypogycaemia• Decreased serotonin levels

Psychosocial causes of nausea• Stress• Anxiety• Fear• Unwanted/unplanned pregnancy• Relationship difficulties

Possible Treatments• Acknowledge problem• Frequent small meals• Vit B6, ginger, acupuncture, acupressure• Medications (metoclopramide,

prochlorperazine) little is known of their teratogenic effects

Monitor• Urine for Ketones• U&E for dehydration if severe vomiting

Refer and admit if signs of hyperemesis gravidarum

• Early scan to exclude molar pregnancy

Pain and Bleeding 1st trimester• Bloods for HCG and progesterone levels

– A very debateable point– HCG levels are so variable they are inconclusive and increase anxiety in

the woman– Progesterone levels are pretty meaningless

• Scan – Probably the only conclusive test possible– Some scanning services save ‘emergency’ appointments – Can refer to early pregnancy clinic at RDH

• Anti D for Rh neg women• History and location of pain• Under 8wks possible ectopic

Possible causes of bleeding in early pregnancy

• A developing fetus that is incompatible with life – Threatened or complete miscarriage

• Cervical erosion or cervicitis• Infection• Ectopic pregnancy• Implantation bleeding• Blighted Ovum• Postcoital bleeding• Trauma to the vagina

Complications of late pregnancy• UTI/pyelonephritis – MSU – Antibiotics• Abdominal Pain ?muscular ?more serious• Bleeding- ?how much, ?placental position• Headaches - ?New, ?migraine, ?hormonal• Carpal Tunnel syndrome – due to fluid

retention• Anaemia

Hypertension in pregnancySOMANZ Guidelines

• Gestational Hypertension

• Pre eclampsia

• Eclampsia

• Chronic hypertension– Essential– Secondary– White coat

Gestational Hypertension• A blood pressure >140/90 mmHg after 20wks

gestation• Without features of pre eclampsia• Near term associated with little or no increase

risk of adverse pregnancy outcome• May progress to pre eclampsia when it occurs

in early pregnancy

Pre EclampsiaA MULTI SYSTEM disorder unique to humans

• Raised blood pressure 140/90 or above

• Renal Involvement– Proteinuria >/equal to

30mg/mmol– Serum creatinine >90umol/L– Oliguria <80mL/4hr– Urate is not diagnostic

• Haematological involvement– Thrombocytopenia– Haemolysis– Disseminated intravascular

coagulation

• Liver involvement– Raised ALT– Severe upper right quadrant

pain/epigastric pain• Neurological involvement

– Convulsions (eclampsia)– Hyperreflexia with sustained

clonus– Persistent new headache– Persistent new visual

disturbances– Stroke

• Fetal growth restriction

Cholestasis • Itching especially soles of feet and palms of hands• Rash• Check Bilirubin & Bile Salts• Bile Salt results take 2 wks • Needs urgent obstetric referral and assessment

for ongoing care• Can cause Still birth due to the build up of bile

salts

Gestational Diabetes• 2%-9% pregnancies (NICE 2003) increasing due to maternal

obesity• RANZCOG recommend OGTT screening for all pregnant

women at 28wks • Human Placental Lactogen produced by the placenta at

28wks has the purpose of increasing maternal serum glucose levels to ensure the fetus gains weight. The insulin receptor (IR) is a transmembrane receptor that is activated by insulin. HPL ‘switches off’ the insulin receptors as does obesity. When too many insulin receptors are switched off too much glucose circulates creating gestational diabetes.

Consequences of gestational diabetes

• Maternal circulating glucose is too high• Too much glucose is available to the growing fetus• The fetus gains too much weight

– Leading to possibility of birth complications• Newborn baby is born in a hyperinsulaemic state

– Leading to dangerously low blood sugars in the immediate neonatal period

• Maternal complication of hypertension during pregnancy• Risks associated with caesarean section and

instrumental birth

Cultural Considerations During Pregnancy

Many groups of women have special cultural issues during pregnancy. There is a need to be ‘woman centered’ and ‘woman led’ during ALL consultations.Pregnancy is a complex life event that occurs in the majority of the time to fit healthy women.Pregnancy is NOT an illness to be ‘treated’.However respect MUST always be extended to the Aboriginal and Torres Strait Islander women of Australia.

Key characteristics of culturally competent care

• Physical environment and infrastructure• Specific Aboriginal and/or Torres Strait Islander program• Aboriginal and Torres Strait Islander workforce• Continuity of care and carer• Collaborating with Aboriginal Community Controlled Health Organisations and other

agencies• Communication, information sharing and transfer of care• Staff attitudes and respect• Cultural education programs• Relationships• Informed choice and right of refusal• Tools to measure cultural competence• Culture specific guidelines• Culturally appropriate and effective health promotion and behaviour change activities• Engaging consumers and clinical governance.

Aboriginal and Torres Strait Islander women of Australia.

• Originally the Aboriginal population was split into 250 individual "nations", many of which were in alliance with one another, and within each nation there existed separate, often related "clans", from as few as 5 or 6 to as many as 30 or 40. Each "nation" had its own language, and a few had several.

There is no ‘one’ set of rules to be applied to every Aboriginal woman of Australia

Birthing Symbolism• A pregnancy is often conceived following ‘A Dreaming’ • A child is often symbolized by a Totemic spirit• As the pregnancy becomes visible it is ‘women’s business’• It is considered rude or indiscreet to be referred to by the men• Older women protect the pregnant woman rub her skin with oils, teach her what to eat, and prepare

her for the birth• The pregnant woman mustn’t eat bandicoot, turtle, goanna because these might make the baby ‘slow’• A birthing pit is prepared with stones stacked on either side• She is prepared to birth in an upright position• The women watching over her gather fire items, water, food, special herbs and leaves and they sing• The rest of the tribe are in another camp the men usually watch over the other children• The father is taken to a place far away, older men loosen his clothing, tie a hair belt around his waist and

he lies back with the belts support with his legs wide open, he assists his wife to give birth with his energy. His breathing simulates labour. He transmits his energy to his birthing wife.

• The women assisting the birth bury the placenta, sing a song of completion• The umbilical cord already detached from the woman is not tied off for another week• The cord hangs around the woman’s neck until the baby is crawling• The baby is named after the father’s skin group, ancestors, country, his mothers country and birthplace.• The baby is taken back to camp and is offered to all of his kin• A celebratory djumba, song or dance ceremony is performed by all kinsfolk as a celebration of new life

Birthing Ceremony• The baby is checked over for signs of his Gi,

the totemic spirit of the animal or plant whose spirit entered him

• When the baby is two months old he/she is named after his/her Totem in a smoking ceremony

Smoking Ceremony• Rocks are heated in a camp fire• Particular leaves are collected from local trees

and algae is collected from the Wunggud waterhole from which the baby’s spirit came

• Wunggud is the Earth snake from which all of earth’s power and substance stems

• The baby is held and turned in the aromatic smoke and so enters his/her totem spirit and country.

Naming • His kinsmen name him in song and in chant• He/she must serve his/her totem for the rest

of their lives• The baby is joined with nature during this

ceremony• He/She is joined with ancestral history of the

land, the people, experience and heritage

The baby in the neonatal period• The newborn is constantly held in someone’s arms• A small tassel of the soft tail of the possum is tied around

the waist for sensory stimulation for the skin and vision• The baby is in constant touch from human contact• The baby is constantly stimulated by adult contact• The baby is never separated from the earth• Only when the baby can crawl or walk is he/she in touch

with the ground until then they are carried by someone• Women are responsible for the management of babies

and small children

References• "Department Of Health | National Antenatal Care Guidelines". Health.gov.au. N.p., 2017. Web. 28 Feb.

2017.• 2017, Prenatal screening and diagnosis of chromosomal and genetic conditions (C-Obs 59) Amended May

2016.pdf, RANZCOG. https://www.ranzcog.edu.au/RANZCOG_SITE/media/DOCMAN-ARCHIVE/Prenatal%20screening%20and%20diagnosis%20of%20chromosomal%20and%20genetic%20conditions%20%20(C-Obs%2059)%20Amended%20May%202016.pdf accessed 28th February, 2017

• "RACGP - Pregnancy Care, Pregnancy, Pregnant,Birth,Maternity". Racgp.org.au. N.p., 2017. Web. 28 Feb. 2017.

• "SOMANZ - Guidelines". Somanz.org. N.p., 2017. Web. 28 Feb. 2017.• Bell, Hannah Rachel. Men's Business, Women's Business. 1st ed. Rochester, Vt.: Inner Traditions, 1998.

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