Introduction to...

Carol Lim Maternal Fetal Medicine Consultant Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang 6 July 2013 17th Malaysian Family Medicine Scientific Conference 2013

Introduction to SOSCG
What Why (by) Who (for) Whom Where (setting) When (started) How

6 July 2013

What

SOSCG S O S C G

Sabah Obstetric Shared Care Guidelines

SOSCG !

Yum!

Why

Objectives
To streamline the management of obstetric patients between O&G department and health clinics, in an effort to provide efficient and costeffective obstetric health service.

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Objectives (cont)
To complement existing relevant departmental, regional or national protocol / Clinical Practice Guidelines /Standard Operating Procedures, and to supplement*/prepare where it was inadequately covered /not available.
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*Viral Hepatitis B in Pregnancy *Single Mother *Morbidly Adherent Placenta *HIV viral level

In short
To better manage obstetric patient in shared care manner
Towards MDG5
an after thought!

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By who

Developed by
Family Medicine Specialists O&G - Of Kota Kinabalu & Sabah Womens & Childrens Hospital (Likas Hospital) - Plus other FMS/O&G on needs basis - Consultation with other experts - Initially targeting West Sabah (West Coast, Kudat & Interior Divisions), later include East Sabah (Sandakan & Tawau Divisions)
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The SOSCG-ians

Dr Carol Lim Dr Lee Wai Khew

Dr Christine Lee (O&G) Dr Fauzia Abdul Majid (FMS) Dr George Matthew (FMS) Dr Hoong Farn Weng Michael (O&G) Dr Ng Wen Lee (FMS) Dr Rumihati Abdul Hamid (FMS) Dr Teh Chin Mey (FMS) Dr Vijayan Valayatham (O&G) Dr Zaiton Yahaya (FMS) Dr Lavitha Sivapathem (O&G) Dr Teh Beng Hock (O&G)

?!! SOSCG-ians

Whom

Users
The nurses in Klinik Kesihatan Medical & Health Officers (M&HO) O&G Medical Officers (MO)

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Where

Settings for the use of SOSCG

Health Clinics Dept of O&G in Specialist Hospital O&G Clinic in Non-Specialist Hospital
(with modification, local adaptation)
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How, Who & When

The Beginning
Since 2008 group got together to plan out the format & SOPs Till now 20 guidelines: Sep 2009 8 guidelines; May 2010 5 guidelines; Mar 2011 4 guidelines; Oct 2011 3 new guidelines.
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Focus on:
Antenatal (+ Prenatal) issues
(intrapartum LR protocol)

Clinical & operational Adapted to local settings

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 Roll out guidelines batch by batch as we were ready to issue Feedback obtained to improve on contents Road show & training workshop once entire series were ready Translation in to Bahasa Malaysia Publication

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Format
Two main components: Guidelines Appendices Emphasis on: Common antenatal problems Medical Eligibility Criteria (MEC) Flowcharts, algorithm Other relevant documents
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Format of Contents:
Phases - Seven phases

Plan of action - Special clinics, investigations, etc

Remark - Reminder on values, definition, etc
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Format of Contents:
Seven phases: 1)Pre-pregnancy 2)At diagnosis (of the condition) in pregnancy 3)Subsequent antenatal follow up 4)Delivery plan 5)Delivery 6)Postpartum 7)Upon discharge from hospital
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Topics
Medical Conditions: 1. Anemia 2. Known case of Thalassemia Carrier 3. Dm, GDM on Insulin 4. GDM on Diet Control 5. Chronic Ht 6. PIH / PE
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Topics (cont)
Medical Conditions (cont): 7. Heart disease 8. Hyperthyroidism complicating pregnancy 9. Hypothyroidiam complicating pregnancy 10.Epilepsy 11.Bronchial asthma
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Topics (cont)
Infectious diseases: 12.Retroviral Disease 13.Viral Hepatitis B 14.Urinary Tract Infection in Pregnancy

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Topics (cont)
Pregnancy / patient factor: 15.Breech / Malpresentation 16.Multiple pregnancy 17.Placenta Previa 18.Previous Scars 19.Risk for macrosomia / shoulder dystocia 20.Single mother, teenage pregnancy
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Example: (1) Anemia

Phase 1. At diagnosis Plan of Action Asymptomatic -Hb 8 g/dL, irrespective of gestational age follow-up at health clinic -Hb < 8 g/dL, POA < 36 weeks follow-up at health clinic -Hb < 8 g/dL, POA > 36 weeks refer to O&G Dept, to be seen within 1 week Symptomatic of anaemia, irrespective of gestational age & Hb level refer to O&G for hospital admission Remark If confirmed thalassaemia carrier, screen husband as well If husband confirmed thalassaemia carrier, see SOSCG guideline Known Case of Thalassaemia Carrier

and more

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Example: (1) Anemia

Phase
2. Subsequent antenatal followup 3.Delivery plan

Plan of Action
Monitor Hb level at health clinic Monthly fetal growth monitoring by health clinic Keep Hb > 8 g/dL Generally may allow postdates, unless specified otherwise

Remark

4. Delivery

Hospital delivery PPH prophylaxis

Discuss options of contraception with patient / couple Refer Appendix Medical Eligibility Criteria for Contraceptive Use

5. Postpartum

6. Upon discharge Routine discharge procedure from hospital

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(2) Known Case of Thalaassemia Carrier

Phase Plan of Action Remark

1. Prepregnancy

If both couple are thalassaemia carriers, refer to FMS / O&G (Prepregnancy Clinic) for counselling, including information regarding prenatal diagnosis

DNA molecular analysis of the couple is a prerequisite for prenatal diagnosis

2. At booking

Dating scan Screen husband for thalassaemia status (if not done yet) If both couple are thalassaemia carriers, refer to FMS / O&G (Prepregnancy Clinic) for counselling, including information regarding prenatal diagnosis Refer to MFM Clinic immediately for couple requesting prenatal diagnosis

Prenatal diagnosis of fetal thalassaemia status can be achieved by CVS or amniocentesis

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(2) Known Case of Thalaassemia Carrier

Phase Plan of Action Remark

3. Subsequent antenatal follow up

Refer to MFM Clinic for detailed Iron supplement for scan appointment at 18-22 weeks thalassaemia minor if both couple are -thalassaemia without coexisting iron carriers deficiency anaemia Monitor Hb level (IDA) can cause iron Check serum ferritin & TIBC overload & has adverse before giving iron supplement systemic effect Tab. Folate should be given Low ferritin & high throughout pregnancy TIBC suggests coexisting IDA

4.Delivery plan Keep Hb > 7 g/dL Generally may allow postdates, unless specified otherwise 5.Delivery Hospital delivery PPH prophylaxis
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(2) Known Case of Thalaassemia Carrier

Phase Plan of Action Remark

6.Postpartum Babies (at risk of being thalassaemia major or carrier) to be referred to M&HO in health clinic at 6 months for cascade screening Discuss options of contraception with patient / couple 7. Upon discharge from hospital Routine discharge procedure Pre-pregnancy Clinic appointment at 3/12 postnatal (if future pregnancy possible) if both couple are thalassaemia carriers

Refer Appendix Medical Eligibility Criteria for Contraceptive Use

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Appendices examples:
High risk discharge notification CS Summary MEC for respective conditions

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Strategies towards MDG5

SOSCG Improve clinical management Facilitates referral - clear, established SOP for Referral System & Communication Clinical Risk Management - SOSCG a platform for discussion & for damage control
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Other strategies for MDG5

Uterine Tamponade Technique (Bakri Post Partum Balloon) Obstetric Life Saving Skills Course (OLSSC) Obstetric Emergency Retrieval team Pre-Pregnancy Clinic hospital & health clinic Family Planning (hospital)
4 May 2012 SOSCG Roadshow 29

Impact of SOSCG
Nurse empowerment Maternal deaths in Sabah - lesser number of clinic / booked patients:
2008: 48% of maternal deaths were clinic cases 2012: 38.2% of maternal deaths were clinic cases

Opportunity to bring up issues Platform for clinical risk management

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Challenges
Networking between health & hospital Establish a system of cooperation to maintain standard of care SOP user friendly Improve communication SOSCG - a working model for other state / region?
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The best preparation for good work tomorrow is to do good work today.
-Elbert Hubbard

Thank you
carolkklim@yahoo.com