Perinatal Care Manual3rd EditionMINISTRY OF HEALTH MALAYSIA


CONTENT PAGEContentsPageHow To Use This Manual2Objectives Perinatal Care:3* Section 1 - Pre Pregnancy Care5* Section 2 - Antenatal Care37* Section 3 - Intrapartum Care97* Section 4 - Postpartum Care135* Section 5 - Neonatal Care163Abbreviations235Members of The Working Group238*Detailed content page is available at the beginning of each section.1

HOW TO USE THIS MANUALThis manual is not intended to replace standard textbooks used for teaching.It is to be kept at hand at your work place which can be referred for guidance. Themanual consist of five sections: pre pregnancy, antenatal, intrapartum, postpartumand neonatal care.Section One – Pre Pregnancy Care Focuses on specific group of women in the reproductive age group with counselingon appropriate medical care to optimize pregnancy outcomes. It includes riskassessment check list and management of various conditions. In future editionsthe manual will include all women in reproductive age.Section Two – Antenatal Care Describes activities and screening services for each trimester. It explains how todiagnose and manage common conditions, which can be identified during routineexamination of the mother. It provides standard operating procedures for quickreference in the management of common complications and high risk cases.Section Three – Intrapartum Care Understanding the process of normal labour and delivery allows optimal care forthe mother and timely recognition and intervention of abnormal events.Section Four – Postpartum Care Provides information for appropriate care, reassurance and early recognition ofpostpartum problems.Section Five – Neonatal Care Outlines the comprehensive approach to neonatal care. Flow charts and checklistsare available to aid health care workers to provide quality care and to initiate andfacilitate referrals when necessary.2

OBJECTIVESGeneral objective:To develop a comprehensive training manual and reference for general use by healthcare provider who are enstrusted with the care of mothers and their newborns.Specific objectives:1. To serve as a guide containing the basic knowledge and skills required in the carefor women beginning at pre-pregnancy and extending to the neonatal period.2. To provide management of certain common conditions which occur during thedifferent stages of pregnancy and neonatal period.3. To serve as a guide for primary health care providers to meet the expected standardof care in the delivery of the respective services in an endeavor to improve maternaland neonatal outcomes and reduce morbidity and mortality.3

Section 1Pre Pregnancy Care

CONTENT PAGEContents1.1 Introduction1.2 Rationale1.3 Objectives1.4 Target Groups1.5 Entry Points1.6 Place of Pre-Pregnancy Care Services1.7 Setting-Up of a Pre-Pregnancy Care Clinic1.8 Flow Process1.9 Major Activities During a Pre-Pregnancy Visit Include:1.10 Standard Operating Procedure (SOP)1.11 Suggestions for IncorporationAppendicesAppendix 1: Setting Up of a Pre Pregnancy Care ClinicAppendix 2: Flow Chart of Pre-Pregnancy Care at Primary Care LevelAppendix 3: Pre Pregnancy Risk FactorsAppendix 4: Pre-Pregnancy Health EducationAppendix 5: Pre-Pregnancy CounsellingStandard Operating ProceduresSOP1 - Pre-existing Chronic Medical IllnessSOP2 - ThalassemiaSOP3 - History of Congenital AnomaliesSOP4 - Previous Surgical HistorySOP5 - Recurrent AbortionsSOP6 - History of Unexplained Perinatal DeathSOP7 - Medication/Substance AbuseSOP8 - Sexually Transmitted Illness (STI)SOP9 - 233355

1.1 INTRODUCTIONEvery mother has the right to expect her baby to be born‘aliveand healthy just as every baby has the right to aliving and healthy mother.’Making pregnancy safer is an important component of maternal and child health(MCH) services. As our nation develops, the profile of a woman embarking uponpregnancy changes. A greater number of them are being categorized as highrisk pregnancies. Early intervention and treatment can reduce the incidence ofmaternal and neonatal complications in these women.The couple or women in reproductive age in good physical and psychologicalhealth, living in a good socio-economic environment, will benefit both the motherand child. As such, pre-pregnancy care and consultation can assist the coupleand women in reproductive age to choose the appropriate time to conceive andthus reduce the risk of complications to the mother and baby. Definition:A set of intervention that aim to identify and modify biomedical, behavioural,and social risks to a woman’s health or pregnancy outcome through preventionand management, emphasizing those factors that must be acted on beforeconception or early in pregnancy to have maximal impact.Samuel FP, Kay J, Christopher P, et al. The National Summit on PreconceptionCare: A Summary of concepts and Recommendations. Maternal al ChildHealth J (2006) 10:S197-S1.2 RATIONALEIn making pregnancy safer, policies are primarily focused on optimizingantenatal and intra partum care. Currently pre-pregnancy care is only limited topremarital counseling courses, HIV screening, Thalassemia screening programand screening for other medical conditions.Evidence suggests that appropriate pre-pregnancy care has improved pregnancyoutcomes. The increase in the number of high risk pregnancies requires readilyavailable formalized pre-pregnancy care services. As such, pre-pregnancy careshould be formalized into our health care services.6

1.3 OBJECTIVESGeneral:To provide couples, men and women in reproductive age group with an avenueto achieve a safe and successful pregnancy.Specific:i. To screen and counsel future mothers appropriately for early intervention andtreatment, aimed to reduce maternal and perinatal morbidity and mortality.ii. To enable prospective parents and women in reproductive age group to planfor pregnancy through: Provision of appropriate and adequate information. Health promotion and education Counselingiii. To emphasize the practice of healthy life style and initiative in makingpregnancy safer to prospective parents and family members.1.4 TARGET GROUPSGeneral:i. Prospective couples intending to get marriedii. Women who are married, planning a pregnancyiii. Women in reproductive age group (15–44 years of age; WHO definition onWomen’s Health Fact Sheet 334 Nov 2009)Specific:i. Women above 35 years old without medical illness, planning a pregnancyii. Clients with obesityiii. Clients with medical illnessesiv. Clients with previous miscarriages/stillbirths/early neonatal death.v. Clients with inherited abnormalitiesvi. Clients with babies who have inherited abnormalitiesvii. Clients with congenital structural abnormalitiesviii. Clients with babies with congenital structural abnormalitiesix. Clients with family history of genetic disorders1.5 ENTRY POINTSi.Outpatient Department (OPD) Wellness Clinic Premarital HIV Screening Program Thalassemia Screening Program Adolescent Clinic Referral from General Practitioners/private medical centers Community Outreach Program7

Klinik 1 MalaysiaNon Communicable Disease ClinicMaternal and Child Health Services (MCH Services) Family Planning Services Child Health Services Postnatal ServicesSpecialist Clinic Cardiology Clinic Nephrology Clinic General Medicine Clinic Paediatric Clinic Obstetrics & Gynaecological Clinic Other specialist clinicHospital In patient (All Disciplines)Ambulatory Care CentreOthersLPPKN (Lembaga Penduduk & Pembangunan Keluarga Negara)/RSAT(Rumah Sakit Angkatan Tentera)/PLKN (Program Latihan Khidmat Negara)/FPA (Family Planning Association)/Federation of Reproductive HealthAssociation of Malaysia (FRHAM previously known as FFPAM – Federationof Family Planning Association Malaysia)/University Hospitals/GeneralPractitioners/Private Medical Centers PLACE OF PRE-PREGNANCY CARE SERVICES O&GSpecialist Clinic - coordinator/provider of pre-pregnancy care servicesat hospital level, preferably under the supervision of Maternal Fetal MedicineSpecialist. Other specialist clinics (medical/surgical/psychiatric etc.) should also activelyinvolved in providing pre-pregnancy care services. Health Clinic – at primary care level. Pre-pregnancy care will be integrated intocurrent (MCH/OPD) services, headed by Family Medicine Specialists/Medical& Health Officer (FMS/M&HO). Outpatient services at district hospitals Hospital without specialist (visiting O&G Specialists and other specialists ofother discipline)1.7 SETTING-UP OF A PRE-PREGNANCY CARE CLINIC (Refer Appendix 1)1.8 FLOW PROCESS (Refer Appendix 2)1.9 MAJOR ACTIVITIES DURING A PRE-PREGNANCY VISIT INCLUDE:i.8Screening for risk factors History taking Physical examination Clinical laboratory tests

ii. Identification of pre-pregnancy risk factors (Appendix 3)iii. Appropriate management according to identified risk factorsiv. Referral to pre-pregnancy care clinic Health education Counseling Investigations Appropriate treatment and management Appropriate referral1.10 STANDARD OPERATING PROCEDURE (SOP)Standard operating procedure is designed to assist health care providersin managing the patient. The conditions are selected based on risk factorspresent.SOP1 - Pre-existing chronic medical illnessSOP2 - ThalassemiaSOP3 - History of congenital anomaliesSOP4 - Previous surgical historySOP5 - Recurrent miscarriageSOP6 - History of unexplained perinatal deathSOP7 - Medication/substance abuseSOP8 - Sexually transmitted illnessSOP9 - Subfertility1.11 SUGGESTIONS FOR the curriculum of the following courses Under graduate medical course Post graduate training in all specialties Midwifery course Community nurse training program Assistant Medical Officer training program Diploma & Degree In Nursing/Public Health NursingThalassaemia screening programPremarital courses/marriage registry officeBreast feeding courseNCD (Non Communicable Disease) Courses and Training ProgramHigh Risk Pregnancy and Family Planning Course9

APPENDIX 1SETTING UP OF A PRE PREGNANCY CARE CLINIC1. Scope of activities Screening Diagnosis Therapeutics Referrals Counseling (Refer Appendix 6) Supplementation Health education Focus Group Discussion2. Infrastructure Examination room (ensure privacy) Counseling room (ensure privacy) Laboratory Support Health Education Room3. Clinic Schedule As appropriate for the centre Integrated/dedicated4. Human Resources As appropriate for the center Obstetrician & Gynecologists Other specialists Staff Nurses/Community Nurses trained in PPC Assistant Medical Officers Family Medicine Specialists Medical Officer Staff Nurses With Midwifery Nurses Educator example Diabetic Educator/Bronchial Asthma Educator Nutritionists/Dieticians Counselor5. Training Paramedics Doctors Counselors10

APPENDIX 2FLOW CHART OF PRE-PREGNANCY CARE AT PRIMARY CARE LEVELWalk-in or referral caseEntry of patients (refer to1.5 for full list):1. Maternal and childhealth services Family Planning Child Health Services Postnatal ServicesScreening and history taking using prepregnancy screening format(Paramedics)NoAny risk factor?Yes(Appendix 3)Give advice/healtheducation (Appendix 4)(Paramedics)YesRequestcounseling2. Out patient Services Wellness Services Premarital Screening ThalassemiaScreening Adolescent Services Referral from GP/NGORefer MO/FMSPre-pregnancy caremanagement(MO/ FMS)3. Specialist Clinic Physician Cardiology Nephrology Pediatric Other specialist clinicConduct furtherinvestigations(MO/FMS)Any risk factor?No(Appendix 3)NoYesRefer pre-pregnancyservice tosecondary/tertiarylevel (Specialists /Consultants)1. History taking2. Physical examination3. Diagnosis and confirmpossible risk4. Counseling5. InvestigationEnd11

APPENDIX 3PRE PREGNANCY RISK FACTORSGeneral Risk factors1. Age Women less than 18 years old: Teenage pregnancies are associated with poormaternal and fetal outcome. Women above 35 years old: Advanced maternal age is associated with higherprevalence of medical illnesses and fetal chromosomal abnormalities.2. Lifestyle Smoking, alcoholism and substance abuse: These may have teratogenic effectresulting in fetal abnormalities and growth restriction High risk sexual behavior: Increases the risk of maternal and fetal infection. Obesity/underweight: Metabolic disorders have a detrimental effect duringpregnancy both on the fetus and mother. It may also affect mode of delivery. Pets: Some household pets such as cats and birds maybe associated withinfections (example Toxoplasmosis, Psittacosis and Bird flu). Infections orexposure of these allergens to mothers with bronchial asthma can affect apregnant mother and may result in poor fetal outcome.3. Specific Risk Factorsi. Obstetric history Recurrent miscarriage Intrauterine death Previous abnormal baby Early neonatal death History of bleeding in pregnancy (ectopic, APH, massive PPH 1.5L orrequiring blood transfusion) Instrumental delivery Big baby (4kg and above) Poorly spaced pregnancy ABO incompatibility/Rhesus group Small baby (2.5kg or less) Grand multipara (Para 5 and above) Preterm delivery Previous history of retained placenta 3rd/4th degree of perineal tearii. Medical History (Chronic medical illnesses) Hypertension Heart disease Diabetes mellitus Thyroid disease Epilepsy12

Bronchial asthmaConnective tissue diseases such as SLERenal disordersCommunicable Diseases (example TB, HIV, Malaria)AnemiaBlood disordersMalignancyOther medical conditionsiii. Medications (Refer to table 1.1 in Appendix 5)iv. Surgical history Caesarean section Uterine surgery Pelvic surgery Bowel surgery Transplant surgery (example liver & renal) Other abdominal surgeryv. Family history Consanguinity Familial or genetic disorders Congenital structural abnormalitiesvi. Social history: Domestic violence Stress at work Stress in relationship Occupational hazard Lower socioeconomic status Marginalized group Single mothersvii. Vaccination Active/Passive immunization--Rubella--Hepatitis B--Chicken pox13

APPENDIX 4PRE-PREGNANCY HEALTH EDUCATION1. Towards a Healthy and happy familyA healthy married couple is the basic foundation for a happy family. Factors whichinfluence the health of an individual, family and the community include: Lifestyle Genetics Familial factors Environmental factors2. Practicing a healthy Lifestyle2.1 Balanced dietA diet which contains all the necessary nutrients inthe right proportions according to caloric needs andright proportion based on the food pyramid. Ensureadequate fluid intake.2.2 Social interactionsHusband and wife must be supportive and activelyparticipate in enhancing each other’s health.Couples should practice mutual respect and consentfor a satisfying and equitable sexual relationship.2.3 Good daily living habitsAll men and women in reproductive age shouldhave healthy lifestyle; avoid unhealthy habits likesmoking, consuming alcohol and other types of drugabuse.2.4 RelaxationRegular exercise decreases stress and lowers therisk of heart disease, stroke and hypertension.2.5 Adequate rest and sleepSeven hours of sleep a day in order to stay healthy.3. Genetic factorsCouple, men and women with: Consanguineous marriage (example autosomal recessive disorders) Previous child with genetic disorders (example Thalassemia) Family history of genetic disorders (example autosomal recessive disorders) Women at risk for genetic disorders at a particular age group (example Down’sSyndrome) Male disorders (example X-linked disorders – Duchene Muscular Dystrophy,Haemophilia) Unexplained/uninvestigated fetal loss should be counseled for possible geneticproblems.14

4. Family PlanningIt is encouraged for couples to plan their pregnancy in order to contributepositively to the eventual maternal and fetal outcome.Health care provider should be consulted and be able to provide informationregarding the appropriate and effective contraceptive method.5. Birth and pregnancy Physical maturity and age of the motherThe appropriate age for a woman to get pregnant is at the legal age 18 andabove. Women above 35 years are at higher risk of pregnancy complication. Preventing infectionsMen and women in reproductive age group are advised about infections suchas sexually transmitted diseases as well as lifestyle diseases which can affectreproductive potential and the unborn child. Hepatitis B, varicella and Rubellavaccinations may be advised to all women who are not immune. Antenatal health careCouples who are planning to start a family should be in optimal health. Apregnant woman and her partner should attend antenatal clinic before 12weeks of amenorrhea. SupplementationFolic acid supplementation should be emphasized to all women at least 3months prior to a pregnancy. Appropriate iron and folic acid supplementationshould be advised by health care provider after screening for thalassemia. BreastfeedingBreast milk is the best food for the newborn as it contains all the necessarynutrients, in the right proportions, for the optimum health and growth of thenewborn. Exclusive breast feeding for first 6 months of the newborn andencourage to continue for 2 years. ChildbirthEach pregnant woman must be advised on the appropriate place of delivery. Child careEvery child must be immunized according to the recommended schedule.6. Screening PAP Smear according to national guideline STI (sexually transmitted infection) screening as indicated. Clinical Breast Examination. Diabetes and hypertension screening should be offered at least annually.15

APPENDIX 5PRE-PREGNANCY COUNSELLINGA recommendation for pre-pregnancy counseling should be given to all men andwomen with risk of pregnancy complications. Such counseling can reduce theincidence of maternal and fetal mortality and morbidity.Objectives of pre-pregnancy counseling include:1. Conducting an initial assessment a full history (personal, social, medical, surgical, past obstetric, psychiatric andfamily history) general physical examination identification of appropriate screening tests if necessary2. Allaying or reducing anxietyIt is necessary to reduce anxiety in women with bad obstetric history exampleprevious unsuccessful pregnancies or major obstetric complications.Counseling should include: The effect of pre-existing disorder on pregnancy and pregnancy on the disorder. The likelihood of possible recurrence of previous complications and how thismay possibly be reduced (e.g. intrauterine or neonatal death, hypertension,deep vein thrombosis, miscarriage or preterm labour, mechanical problems oflabour or delivery).3. Providing genetic informationThe risk of familial or other handicapping disorder in a future child – expert advicefrom clinical geneticist/pediatrician will usually be needed, but factual preliminaryguidance should be available in a pre-pregnancy clinic.4. Determining fitness for pregnancyPregnancy should be deferred and contraception be offered to allow furtherevaluation and management of known disorders or new findings (example anemia,heart disease, diabetes and hypertension). Treatment and optimization of medicaland surgical disorders may be required. Reproductive issues should be managedappropriately.Health care providers who interact with men and women of childbearing age shouldunderstand the potential benefits of pre-pregnancy counseling thus preparing thehealth care providers to approach the pregnancy evaluation in a thorough manner.5. Follow up intervals Minimum of 2 years or till further management16

Factors Affecting Pregnancy1. Social behaviorCommon social behaviors affecting pregnancy:Smoking-Alcohol-Cocaine-Miscarriage, low birth weight, placenta previa, placenta abruption,infant respiratory tract infection, sudden infant death syndrome,impaired fertilityMiscarriage, fetal alcohol syndrome, placenta abruption, fetalintrauterine growth restriction, low birth weight, central nervoussystem abnormalitiesAbortion, premature birth, placental abruption, IUGR, congenitalanomalies, neonatal CNS dysfunctionLow birth weight, IUGRCaffeineAny form of substance abuse can affect pregnancy and its outcome.2. MedicationA potential preventable group of disorders are drug induced anomalies. Medicationsduring pregnancy should be avoided as far as possible.Table 1.1: Effects of medications on PregnancyAGENTSEFFECTSAnti-convulsionsIncidence of congenital malformations in children bornto epileptic mothers is about 6%. This appears to belargely due to teratogenic effects of anticonvulsant.Combining drugs increases the incidence of congenitaldefects.Sodium ValproateIncrease risk of neural tube defect to about 1/1000pregnanciesLithium CarbonateIncrease in cardiovascular abnormalityWarfarinVarious congenital malformations includingabnormalities of the CNS and the nose and bonyepiphysesAlcoholLow birth weight, microcephaly, congenital heartdisease and mental retardationAndrogensTeratogenesis in first trimester, virilisation of femalefetusAtropineFetal tachycardiaBeta –blockersIUGRDiazepamRespiratory depressionCyclophosphamideTeratogenesis in first trimesterDiureticsIUGR17

AGENTSEFFECTSDiethyl-stilboesterolGenital anomalies, female may develop clear cellcarcinoma of the vagina many years later, maleinfertilityMethadoneMaternal symptoms of withdrawal inducing fetalcompromise, abruption.Fetal complications are smaller-than-normal head size,low birth weight, IUGR, pre term delivery, unspecifiedstructural anomalies and fetal withdrawal syndrome.Methothrexate Neural Tube DefectsMethothrexateNeural Tube DefectsPhenytoinEmbryopathy includes dysmorphic facial features,microcephaly and motor and intellectual retardation.TetracyclineTooth enamel hypoplasia and liaAngiotension Converting EnzymeInhibitor and angiotensionreceptor blockerOligohydramnios, bony malformation, prolongedhypotension, renal failure3. Nutritional StatusNutritional deficiency in woman of reproductive age affects not only the generalhealth condition but also the fertility capacity. Folic acid supplementation isessential to prevent neural tube defect.4. Medical historyPre-existing medical conditions may adversely affect mother and fetus. Prepregnancy intervention is important in counseling regarding risk and in optimizingmedical management.18

Table 1.2: Medical illnesses Affecting PregnancyILLNESSRISKDiabetes MellitusFetus :multiple congenitalmalformations (VSD, NTD,skeletal malformation)fetal macrosomiaMother:Pre-eclampsia, urinarytract infection, candidiasis,sepsisThyroid disease: HypothyroidFetus:Abortion, IUGR, fetal goiterand cretinism.PRE PREGNANCY INTERVENTIONFor poorly controlled DiabetesMellitus, insulin should be initiatedearly before pregnancy. Bloodglucose and HbA1c monitoringand control should be done priorto embark on a pregnancy. Folicacid supplementations. Screeningdiabetes complications at leastannually. Appropriate managementof complications and co-morbidconditions. Referral to appropriatesecondary or tertiary centers whenindicated.Maternal Thyroid hormonereplacement.Mother:Impaired fertility andhypothyroid complications HyperthyroidismFetus:Thyrotoxicosis, IUGRAnti-thyroid therapyMother:Thyroid storm,hypertensionDeep venousthrombosisFetus:Fetal warfarin syndromeWarfarin interacts with oralcontraceptive pills.Mother: Bleeding complications,osteoporosis withprolonged heparintherapyProphylactic therapy with LMWH ispreferred to conventional heparin orwarfarin therapy. Heparin inducedPlanned pregnancy with advise fromhealth care providersthrombocytopenia19

ILLNESSSeizure disorderRISKFetus:Congenital heart disease,Cleft lip and palate,skeletal, CNS,gastrointestinal,genitourinaryabnormalities, increasedrisk of epilepsy.PRE PREGNANCY INTERVENTIONTry to minimize or stop medicationprior to pregnancy ideally allowpregnancy after 18 months fit free.Folic acid supplement. Safety of thenewer of anti-epileptic is not known.Mother:40% risk of increasedseizuresChronicHypertensionFetus:Placenta abruption, IUGRMother:Stroke, renal failure,cardiac failure, cardiacfailure, pre-eclampsiaRenal diseaseFetus:Stillbirth, 2nd trimesterabortion, neonatal death,IUGR, premature labor anddelivery.Mother:Increase in Hypertension,pre-eclampsia, decrease inrenal function20ECG at least annually.Aim BP below 140/90.Avoid angiotensin convertingenzyme (ACE) inhibitors, angiotensinreceptor blocker, anti-lipid agents anddiuretics.May need to consider aspirin from 12weeks onwards.Assess kidney function and bloodpressure.Pregnancy reasonably safe if renalfunction is normal.Target BP less than 140/90Advice against pregnancy for severerenal insufficiency.For specific renal disorders refernephrologist or physician.Low dose aspirin should be given infirst trimester.

ILLNESSHeart disease inpregnancyMechanicalProsthetic HeartValvesRISKPRE PREGNANCY INTERVENTIONFetus:5-10% Increase incidenceof congenital heartdisease in the fetus ofmother with congenitalheart disease.Higher risk of IUGR incyanotic heart diseaseSymptomatic mother should be seenby a cardiologist/physician.Mother with mechanical valve changeto LMWH.Mother:Primary PulmonaryHypertension andEisenmenger Syndromehave high risk of maternalmortality and should avoidpregnancy.Increased risk ofpulmonary embolism,stroke and SBE morecommon in prostatic valve.Contraception continued untiloptimization of the heart condition.Specific disorders should be managedby the cardiologistFetus:Fetal warfarin syndromeLowest dose of warfarin to achievetherapeutic level. Counseling onoutcome and management. Ideallynot to convert to heparin. Consultspecialists and combine care beforeembarking in a pregnancy.Mother:Valve thrombosisDetail scan for fetal anomaly duringpregnancy.Serial growth scans.21

Table 1.3: Infectious Diseases commonly affecting pregnancy(based on indication and risk behavior)INFECTION22PRE PREGNANCY MANAGEMENTRubellaRubella vaccination in women not immunized, avoidpregnancy for at least 3 months after immunizationToxoplasma gondiiGood food hygiene and avoid eating under cookedmeat/food (example sushi)Chlamydia, gonorrhea, humanpapilloma virus, syphilisAppropriate treatment of STI. Refer to dermatologicalclinic appropriately. Consider HPV vaccination forsuitable women.Hepatitis BCounseling/screening for Hepatitis B surface antigen,consider vaccination.HIVOffer universal screening, counsel risk oftransmission, offer ARV therapy.


24 Disease severity Complications Co morbidities Blood pressureHypertensioncontrol andoptimzationand optimization Disease severity Complications Co morbidities Glycemic controlstenosis and otherconditions) FBS HbA1c Lipid profile Renal profile LFT Microalbuminuria urine protein Funduscopy ECG BP FBS Lipid profile Renal profile Microalbuminuria Urine protein ECG CXR (if indicated) BP Ultrasound Kidney,ureter & bladder (Look for renal artery UncomplicatedHPT Hypertensionwith TOD HPT with TOF Young HPTTOF Uncomplicated Diabetes withTOD Diabetes with1Pre-existing Chronic Medical IllnessLaboratoryAssessmentinvestigation andClassificationphysical examination::Diabetes MellitusRisk FactorsProcedure numberName of conditionaccording tohypertension CPG Family planning PPC counseling Refer to appropriatedisciplines Managementcomplications and comorbid conditions Refer to appropriatedisciplines Managementaccording to DM CPG Family planning PPC counseling Screening forManagementSTANDARD OPERATING ologistLevel of personnelCare PlanHealth Clinic/Hospitalwith/without specialistHospital with/withoutspecialist /HealthClinicsLevel of care

25 FBS Lipid profile Renal profile Microalbuminuria 24hrs urine protein eGFR MDRD Ultrasound KUB ECG CXR (if indicated) BP CKD StagingRenal Disease(CKD 1 – 5with or withoutproteinuria) Renal diseasewith co morbidity Assessment forother concurrentmedical conditionsother medicalconditions FBS Lipid profile ECG CXR (if indicated) Echocardiography Renal Profile Exercise Stress Test BP NYHA FunctionalClassification Heart diseasewith co morbidity Concurrent with(Hospital Care)according to HeartDisease CPG Family planning PPC counseling Refer to appropriatedisciplines NYHA Class 1 & 2 Primary Care NYHA 3 & 4 –Hospital Care ManagementManagement CKD Stage 1 & 2 Refer to appropriate(Primary Care)disciplines CKD 3 – 5 Management(Hospital Care)according to CKD CPGRenalDisease Family planningwith co morbidity PPC counselingwith comorbidities NYHA Class 1&2 NYHA Class 3&4 Heart diseasewith complication Heart disease1Pre-existing Chronic Medical IllnessLaboratoryAssessmentinvestigation andClassificationphysical examination::Heart DiseaseRisk FactorsProcedure numberName of cian/CardiologistLevel of personnelCare PlanHealth Clinic/Hospitalwith or withoutspecialistHealth Clinic/Hospitalwith or withoutspecialistLevel of care

26 Severity ofBronchialAsthmaBA accordingto guidelines(example GINAguidelines) BA with recurrentadmissions BA with comorbidityhyperthyroidsymptoms Thyroid diseasewith complications Thyroid diseasewith co morbidity Stability of thyroiddisease ontreatment Hypothyroid andManagement PEFR Control/fairlycontrol/poorly Spirometrycontrol Asthma Control TestAssessment BA with comorbidity CXR (if indicated)according to CPG orother guideline Family planning PPC counseling Refer to appropriatedisciplines Management FBG Complicated/ Refer to appropriateuncomplicateddisciplines as Lipid profile TSH/freeT4/free Thyroid disease indicatedFree T3with co morbidity Managementaccording to thyroid ECGdisease CPG or other BPguidelines FBC thyroid ultrasound If Family planningindicated PPC counsel

Section Two – Antenatal Care Describes activities and screening services for each trimester. It explains how to diagnose and manage common conditions, which can be identified during routine examination of the mother. It provides standard operating procedures for quick reference in the management of common complications and high risk cases.