PEMERIKSAAN ANTENATAL

Tujuan ANCMempromosikan dan menjaga kesehatan fisik, mental dan sosial ibu dan bayi dengan memberikan pendidikan mengenai nutrisi, kebersihan pribadi and proses kelahiran Mendeteksi dan menatalaksana komplikasi-komplikasi yang terjadi selama kehamilan, baik medis, pembedahan atau obstetrikMengembangkan rencana kesiapan persalinan dan kesiapan menghadapi komplikasiMembantu mempersiapkan ibu untuk dapat menyusui dengan sukses, menjalani masa nifas normal, dan menjaga anaknya secara fisik, psikologi dan sosial

Apakah ANC yang Efektif Itu ?Suatu asuhan yang berasal dari tenaga terlatih dan asuhan terus-menerusPersiapan untuk kelahiran dan potensi terjadinya komplikasiMempromosikan kesehatan dan mencegah penyakitTetanus toxoid, suplemen nutrisi, tembakau dan penggunaan alkohol, dsb. Mendeteksi adanya penyakit dan cara pengobatannyaHIV, syphilis, tuberculosis, dan penyakit lain yang berhubungan dengannya (e.g., hipertensi, diabetes) Deteksi dini dan penatalaksanaan komplikasi

Komponen-Komponen ANC Terarah ke-Sasaran : Pendeteksian PenyakitMencari permasalahan yang memerlukan asuhan tambahan

Parameter

Kondisi

Kulit, kenampakan umum, rabun senja (night blindness), goiter

Malnutrisi

Suhu, disuria

Tanda-tanda infeksi

Tekanan darah, edema, proteinuria, Refleks

Tanda-tanda pre-eklamsia

Hemoglobin, konjungtiva/telapak/lidah pucat

Tanda-tanda anemia

Pemeriksaan payudara

Penyakit payudara

Gerakan bayi, tinggi fundus, detak jantung bayi

Gawat janin/demise

Pemeriksaan Pelvik dan speculum

Penyakit Menular Seksual

Komponen ANC Terarah ke-Sasaran:Kesiapan Menghadapi KomplikasiMembuat suatu rencana/skema keuangan Membuat rencana untuk mengambil keputusan Mengatur suatu sistem transportasiMembuat suatu rencana mengenai donor darah15% wanita hamil mengalami komplikasi yang membahayakan jiwanya dan menghendaki adanya asuhan obstetrik

PROSEDURAnamnesisPemeriksaan FisikUSGLaboratorium

Kunjungan pertamaAnamnese lengkap / status kesehatan/ data dasar.Faktor resiko dan riwayat persalinan buruk.Hal yang berkaitan dengan kehamilan ini.Bimbingan menyeluruh mengenai kesehatan ibu dan perkembangan janin.Membangun kepercayaan ibu dan keluarga.

PemeriksaanLaboratorium: Pemeriksaan darah, meliputi: Hematologi dasar (CBC, RH, Ferritin, sediaan hapus) serta pemeriksaan urin. Wajib dilakukan di awal kehamilan dan jika memungkinkan, diulang pada usia 32 minggu, kecuali Rh.

Antenatal terfokusNUTRISIHASIL AKHIRLUARAN IBULUARAN ANAK

6 TTIMBANGTEKANAN DARAHTINGGI FUNDUS UTERITABLET BESITETANUS TOXOIDTEMU WICARA / TANYA

TAKSIRAN TANGGAL PERSALINANSIKLUS HAIDTANGGAL + 7BULAN -3TAHUN -129-januari-2007

TRIMESTER ITrimester Ia.Pemastian kehamilanb.Pemastian intrauterin - hidupc.Pemastian kehamilan tunggal/multipeld.Pemastian usia kehamilane.Pemastian faktor risiko dan mereduksi kebiasaan hidup yang merugikan kehamilanf.Persiapan dan pemeliharaan payudarag.Penapisan Thalasemia, Hepatitis B, Rhesus (bila mungkin)h. Pemeriksaan TORCHS (bila mungkin)

Trimester II

a. Penapisan defek bumbung saraf (Neuro Tube Defect)b.Penapisan defek jantungc.Evaluasi pertumbuhan janind.Evaluasi toleransi maternale.Penapisan servikovaginitisf.Penapisan infeksi jalan kencing (UTI)g.Penapisan diabetes melitus (DM) pada 24-30 minggu

Trimester III

a.Evaluasi pertumbuhan janinb.Evaluasi toleransi maternalc.Evaluasi rute persalinan/kelahirand.Evaluasi fasilitas kelahiran/perawatan neonatale.Membahas rencana kontrasepsi pascapersalinan

SYMPHYSEAL FUNDAL HEIGHTBAG.ATASSYMPHISISFUNDUS

Vena Cava Syndrome

Laboratorium, Hematologi DasarMis: G1 hamil 8 minggu, Hb 12,1 gr%

Laboratorium, Hematologi dasar

Hb12,1RBC4,58 jutaMCV71,8MCH25,2MCHC35Ferritin8,7

Laboratorium, Urine.Identifikasi ISKMudah dilakukan, lebih murah daripada tes darahMeliputi pemeriksaan makroskopis dan mikroskopis

Laboratorium, UrineUrinalisa, dijumpai sedimen urine:1. Sel leukosit: sering karena kontaminan vaginal, ISK, jika ada indikasi lain2. Sel darah merah: trauma ginjal, penyakit ginjal sistemik.3. Bakteri- Tidak hamil: 100.000 koloni/ ml= infeksi- Hamil: 10.000 koloni/ mL= infeksi.

PEMERIKSAAN: USGStandar pemeriksaan USG trimester I:1. Memastikan kehamilan dalam kandungan2. Menentukan usia kehamilan3. Mendeteksi tanda-tanda kehidupan4. Deteksi kelainan mudigah5. Deteksi kehamilan kembar6. Dugaan kelainan kromosom7. Evaluasi adnexa8. Membantu tindakan intervensi.

-PARAMETER UNTUK MENENTUKAN USIA KEHAMILAN-Usia kehamilan < 7 minggu : GS-Usia kehamilan 7 12 minggu : CRL -Usia kehamilan 12 15 minggu : CRL dan BPD -Usia kehamilan 15 28 minggu : BPD, FL.-Usia kehamilan > 28 minggu: BPD, FL, AC, HC, Jarak Orbita dll

Ultrasound pada kehamilan

Gambar: Citra anensefalus pada usia gestasi 13 minggu, yang menunjukkan tak ada kalvarium, tampak sedikit jaringan otak (serebrovaskulosa) diatas orbita

TRIMESTER KEDUAPemeriksaan USG:Pemeriksaan terhadap tanda kehidupan, jumlah janin, presentasi janin, aktivitas janin.Pemeriksaan terhadap volume air ketubanPemeriksaan terhadap plasenta dan tali pusatPenentuan usia kehamilanMenghitung berat janin.Pemeriksaan anatomi janin

PEMERIKSAAN DUH VAGINABV merupakan penyebab yang sering dari keluarnya cairan vaginaMenurut Goldman & Hatch (2000), dijumpai 3 juta kasus BV pada wanita, di mana 800.000 di antaranya terjadi pada kehamilan.Prevalensi BV: 25%-50% di antara wanita yang tidak hamil, dan 10%-35% di antara wanita hamil.

DIAGNOSA BVKriteria AmselPeningkatan derajat keasaman vagina (>4,5)Bau amis dengan KOHDijumpai clue cells (20% di antara seluruh sel)Discharge Vagina yang homogenSelain untuk diagnosis BV, perlu juga dilakukan pemeriksaan Trichomoniasis, Candidiasis, Sifilis, juka dicurigai.

Diabetes mellitus GESTASIResiko tinggi DMG:Umur lebih dari 30 tahunObesitasMemiliki riwayat keluarga DMPernah menderita DMG sebelumnyaPernah melahirkan anak >4000 gramAdanya riwayat KJDKAdanya glukosuria.

Pada resiko tinggi, pemeriksaan dimulai pada saat ANC pertamaUsia kehamilan 24-28 minggu.

DMG berkaitan dengan abortus dan kelahiran aterm, dengan KJDK, makrosomia, kematian perinatal, dll.Dengan penatalaksanaan DMG yang semakin baik, komplikasi perinatal akan lebih ditentukan oleh keadaan normoglikemi sebelum dan selama hamil.

PEMERIKSAAN KROMOSOMIndikasi: Riwayat, usia ibu, keluarga, thalasemia

Masalah: Prevalensi 1-2 % bayi baru lahir akan menderita cacat mayor.

Klinis: Hidrmanion, oligohidramnion, PJT, kelainan.

TEKNIK DIAGNOSA PRENATALAmniosintesisChorionic Villi SamplingPercutaneous Umbilical Blood SamplingFetal Skin SamplingUSG

PJTMerupakan Janin dengan berat badan kurang atau sama dengan 10 persentil, atau lingkaran perut kurang atau sama dengan 5 persentil atau FL/AC >24Etiologi: Gangguan perfusi plasenta, kelainan kromosom, faktor lingkungan, dan infeksi.Prevalensi: Penelitian 4 senter di Indonesia kira 4,4 %

SCREENING PJTPada populasi umum dengan cara mengukur TFU sejak 20 minggu sampai aterm. Jika perbedaan >3 cm, perlu dilakukan USG.Suspected PJT jika dijumpai satu atau lebih tanda di bawah ini:1. TFU < 3 cm dari standar.2. BB < 5 kg pada UK 24 minggu atau < 8 kg pada ibu UK 32 minggu.3. EBW < 10 persentil4. HC/AC >15. AFI < 5 cm6. Sebelum UK 34 minggu, plasenta grade III7. Ibu merasa gerakan janin berkurang.

RekomendasiKunjungan ANC yang mempunyai tujuan yang jelas oleh petugas kesehatan terampilBerfokus kepada kualitas kunjungan daripada kuantitas kunjunganPenyuluhan kesehatan/Konseling terencana disetiap kunjungan.

THANKYOUYA!!!!!

*Objectives of ANC:Promote and maintain the physical, mental and social well-being of both the mother and baby by providing education on danger signals, nutrition, rest, sleep and personal hygiene PLUS the environment of the pregnancy and birth; Keeping normal normalDetect and manage complications, whether medical, surgical or obstetric: current problems, not predictionsDevelop birth preparedness plan: who attends, where, communication/transportation, birth attendant, who accompanies, necessary items (blanket/towels, clean plastic cover, clean razor blade, clean settingDevelop complication readiness plan: where, who accompanies, who stays with children, who makes decisions if primary decision-maker not available, potential blood donor, finances, transportation, communicationHelp prepare the mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially*ProviderThe issue of who could or should provide antenatal care continues to be widely discussed, despite the extensive implementation of Midwife managed programs or antenatal care led by providers other than Obstetrician/Gynecologists. The WHO Department of Reproductive Health and Research found that clinical effectiveness of Midwife/General Practitioner managed care is similar to that of Obstetrician/ Gynecologist led shared care. In addition, they found that lower salary costs and enhanced women's satisfaction can be attained by Midwives' clinics (Giles, 1992; Tucker, 1996; Turnbull, 1996). The most important lesson from this is that the set of competencies necessary to provide antenatal care is more important than the specific cadre of healthcare provider caring for a woman during her pregnancy.In addition, while womens response to the midwives' clinic were positive, continuity of care and of care provider was a significant factor enhancing women's satisfaction and building confidence. Care providers should, therefore, seek to facilitate a system of care provision that fosters continuity of both the provider and the care received. Screening and Detection of existing diseases and treatment which will have a direct impact on the pregnancy, childbirth, or perinatal outcome: HIV, Syphilis, Tuberculosis, Hypertension, Diabetes* Goal-directed care:In many countries, the antenatal exam is divided into stations - history, blood pressure, height and weight, urine testing, abdominal palpation and fetal heart tones, etc. - with the woman moving from station to station until her antenatal exam card is filled in for the visit. When information is gathered in this way, there is a risk that the information gathered is analyzed in isolation rather than integrated. Goal-directed care, on the other hand, involves gathering information in such a way that certain complications are either detected or ruled out. The table shows how information can be gathered in a goal-directed way.Collecting information in this way forces the provider to look critically at all of the parameters that are being checked, and deciding if they mean that the womans pregnancy is evolving normally or that she is experiencing a complication that needs to be managed. The quality of antenatal care can be improved by having goal-directed care, not only because providers are processing the information they gather, but also because this way of gathering information facilitates clinical decision making.*We know that 40% of pregnant women will develop some form of a pregnancy-related complication, that 15% of all pregnant women develop a life-threatening complication requiring obstetric care, and that 1-2% of these women will die (UNICEF, 1996). Evidence has shown that it is nearly impossible to predict which women will have a complication, so it is extremely important to work with all women to recognize complications and to establish a plan of action in case they arise. This should save many womens lives and ensure that they arrive earlier at points in the healthcare system where they can receive appropriate and competent care.A pregnant woman also needs to develop a plan for emergency transportation with the family in case she develops a complication and needs to seek care. It is important to discuss how families/couples make decisions about when to seek care and where to go. When only one person is responsible for making decision, it is important to establish an alternate plan for decision-making if there is an emergency when the chief decision-maker is absent. The husband or the mother-in-law may be the primary decision-maker and should make a plan for decision-making.The family should be encouraged to save money or learn how to access community emergency funds so that the necessary funds will be available in the case of an emergency. In too many cases, women either dont seek care or dont receive care because they dont have the necessary funds.A major problem in many facilities is that although a facility may be able to provide a blood transfusion, there is a chronic lack of blood. Another problem, of course, is a supply of safe blood to be transfused. Women are at a high risk of developing blood-borne infections because they are exposed to pregnancy and potential complications leading to loss of blood. For these two reasons, it is extremely important that the woman designate blood donors that can be available should the need arise either during pregnancy, labor, birth, or in the immediate postpartum period.**Skilled provider Review in Cochrane data base of 3 randomized controlled trials of routine antenatal care provided by midwives compared with shared care led by obstetricians found all 3 similar in terms of clinical efficacy and perception of care (womens satisfaction.) Midwife managed care as opposed to obstetrical led care has similar or in some instances more favourable outcomes (also reduction in cost)

Number recommended by WHO for routine care (no complications) is four1st visit before 4 mo (as early as possible in pregnancy)2nd visit 6-7 mo3rd visit 8 mo4th visit 9 moFollow-up visit for complications[WHO Technical Working Group on ANC]