DR. Ernawati, dr.

SpOG (K)
Dept / SMF Obstetri & Ginekologi
FK UNAIR / RSU Dr Soetomo - RS Universitas Airlangga
SURABAYA
 TUJUAN PELAYANAN OBSTETRI MASA KINI

1. Agar setiap kehamilan merupakan kehamilan yang

dikehendaki,dan berakhir dengan ibu dan janin yang
sehat.
2. Menurunkan kematian ibu & bayi akibat proses
reproduksi

3. Menurunkan gangguan fisik & mental

4. Mengatur jumlah dan jarak kelahiran demi

kesejahteraan keluarga

5. Menganalisa faktor-faktor sosial dan statistik vital

Antenatal care (ANC) : the care provided by
skilled health-care professionals to pregnant
women and adolescent girls in order to ensure
the best health conditions for both mother
and baby during pregnancy.

The components of ANC include:

• risk identification
• prevention and management of pregnancy-
related or concurrent diseases
• health education and health promotion.
Women expect from ANC is to have a “positive pregnancy
experience”

A positive pregnancy experience is defined as:

Nn maintaining physical and sociocultural normality

Nn maintaining a healthy pregnancy for mother and
baby (including preventing and treating risks, illness
and death)
Nn having an effective transition to positive labour
and birth, and
Nn achieving positive motherhood (including
maternal self-esteem, competence and autonomy)
 TUJUAN PEMERIKSAAN
KEHAMILAN

➘ Menentukan hamil / tidak

➘ Menentukan letak janin
➘ Menentukan adanya komplikasi
➘ Menentukan prognosa

Dari hasil pemeriksaan tersebut, dapat

ditentukan :
1. Kehamilan risiko tinggi
2. Kehamilan risiko rendah
Frekwensi :
Þ Setiap bulan pada hamil 8 minggu sampai hamil 28
minggu, dan selanjutnya setiap 2 minggu.
Þ Pada perawatan antenatal moderen, kunjungan awal
terutama sebelum minggu ke 20 ditujukan pada
skrining.
Þ Perawatan antenatal untuk kehamilan risiko tinggi
harus mendapat perhatian khusus.
Pemeriksaan Kehamilan

Versi 2020
Versi 2015

ANC Wajib pada ibu

hamil menjadi 6 kali :
• 2 kali pada trimester
pertama
• 1 kali pada trimester
kedua
• 3 kali pada trimester
ketiga

Pemeriksaan dokter 2x
à trimester 1 dan 3
 aking this as
NC should
Box 5: Comparing ANC schedules
g and content
ed at a new WHO FANC 2016 WHO ANC
which replaces model model
ANC) model.
ANC model, First trimester
were mapped to Visit 1: 8–12 weeks Contact 1: up to 12 weeks
ce supporting
Second trimester
timing of
ions to achieve Contact 2: 20 weeks
Visit 2: 24–26 weeks Contact 3: 26 weeks

Third trimester
nds a minimum Visit 3: 32 weeks Contact 4: 30 weeks
ntact Contact 5: 34 weeks
ester (up to Visit 4: 36–38 weeks Contact 6: 36 weeks
heduled in the Contact 7: 38 weeks
Contact 8: 40 weeks
of gestation)
trimester (at Return for delivery at 41 weeks if not given birth.
his model, the
of “visit”, as
Pemeriksaan Obstetri
Seperti pemeriksaan pasien pada umumnya :
Þ Identitas
Þ Anamnesa.
Þ Pemeriksaan Fisik.

Anamnesa meliputi :
1. Anamnesa kehamilan sekarang.
2. Riwayat kehamilan yang lalu.
3. Riwayat kelainan ginekologik.
4. Riwayat penyakit yang pernah diderita.
5. Riwayat penyakit keluarga.
1. Anamnesa kehamilan yang sedang
berlangsung :
Þ Keluhan utama umumnya terlambat bulan.
Þ HPHT dan lama siklus haid untuk memperkirakan
tanggal persalinan.
Þ Kehamilan keberapa? Lama menikah?
Þ Durasi kehamilan pada manusia 269 hari dari
tanggal konsepsi.
Determination of Gestasional Age

§ Gestational age or menstrual age :

• is the time elapsed since the 1st day of the LMP .
• About 2 weeks before ovulation and fertilization and nearly 3
weeks before implantation of the blastocyst.
• Is used because most women know their last period.
§ Ovulation age : Embryologists describe embryofetal development
in ovulation age, or the time in days or weeks from ovula .
§ Post conceptional age : identic to ovulation age.
§ Clinicians à use menstrual age to calculate GA.
§ Naegele’s Rule ; GA ~ 280 days or 40 weeks.
Keluhan lain :
Þ Mual dan / atau muntah → bila hebat hiper emesis.
Þ Sering kencing.
Þ Malas.
Þ Payudara membesar, tegang dan kadang disertai
nyeri.
Þ Terasa goyang anak (“quickening”) pada kehamilan
> 20 minggu.
2. Riwayat obstetri yang lalu.
Þ Bad Obstetric History ?
Þ Aterm, Spontan, Hidup ?
Þ Komplikasi / Tindakan ?

3. Kelainan ginekologi.
4. Penyakit yang pernah diderita yang mem-
punyai pengaruh pada kehamilan.
5. Riwayat penyakit keluarga yang diturunkan.
Pemeriksaan Klinik pada ANC
Mengukur :
Þ TB dan BB, mengapa ?
Þ Wanita dengan TB < 145 cm kemungkinan besar
panggul sempit.
Þ Wanita dengan “body mass index” < 20 mempunyai
risiko lebih besar untuk terjadinya gangguan
pertumbuhan pada janinnya.
Þ Wanita dg BMI > 30 beresiko komplikasi :
DM Gestasional, Preekalmpsia
Þ Penambahan BB → kurang → gangguan pertumbu-
han janin intra uteri.
berlebihan → oedema.
 Pengukuran Berat Badan
Pelayanan Bidan (Grafik Peningkatan Berat Badan)
Versi 2020 § Melihat peningkatan BB ibu selama kehamilan
berdasarkan Indeks Massa Tubuh (IMT) pra/
awal kehamilan

§ Penambahan BB rata2 mulai uk 20 mgg

Versi 2015 normal

§ Menghitung peningkatan BB pada saat datang
dibandingkan dengan saat pra/ awal kehamilan
Tidak ada
§ Diharapkan kenaikan BB ibu hamil sesuai
KEK dengan rekomendasi IMT pra/awal kehamilan
pada table

Gemuk Obese

Intervensi :
• Wanita Obese ↓↓
BB sebelum hamil
• Menjaga kenaikan
BB selama hamil
tdk melebihi
rekomendasi IOM
Þ BB harus diperiksa pada setiap kunjungan.
Þ Disamping BB, periksa rutin dilakukan untuk :
- Desakan darah.
- Pemeriksaan urin → protein, dan glucosa.
(pada pasien dengan penyakit penyerta/
komplikasi kehamilan : SLE, HT Dalam Kehamilan,
DM )
Pengukuran Tekanan Darah secara Rutin
● Pengukuran tekanan darah harus dilakukan bagi
semua ibu hamil sesuai anjuran WHO
● Meskipun preeklampsia tidak didiagnosis sebelum
usia kehamilan 20 minggu, pengukuran awal
bertujuan untuk menentukan tekanan darah
basal
Table 2
T. Firoz et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 25 (2011) 537–548 543

Unmet need for blood pressure and proteinuria check in select LMIC.33

Country %Unmet need for BP check %Unmet need for proteinuria check
Bangladesh 53.1% 70.5%
Bolivia 24.5% 50.9%
DRC 38.8% 57.8%
India 52.5% 56.8%
Indonesia 13.9% 63.0%
Kenya 22.8% 38.9%
Malawi 28.6% 81.3%
Mozambique 48.7% 73.9%
Nepal 43.8% 77.7%
Zimbabwe 14.0% 39.8%

genPIERS will include, in addition to symptoms and signs, few laboratory tests (e.g. platelet count and
serum creatinine) and will be used at the facility level. The miniPIERS and genPIERS models should aid

MAP = dBP + (SBP- dBP)/3

in case identification, diagnosis, and risk stratification, thereby, accelerating triage and transport from
the community to facilities (miniPIERS) and to institute surveillance at the facility level (genPIERS).
Effective care will avert the adverse maternal and perinatal consequences of pre-eclampsia. In time,
this process of risk stratification will guide use of evidence-based treatment.

Treatment of pre-eclampsia

Antihypertensives
Desakan darah.

Pengukuran desakan darah :

Þ Tidur – miring kiri.
Þ Duduk – diukur pada lengan yang sama.
Þ Pada pengukuran desakan darah, desakan diastole
ditentukan saat suara hilang (Korotkoff lima)
Kepala dan Leher :
Þ Chloasma gravidarum.
Þ Conjunctiva.
Þ Selera

Mulut – Gigi :
Þ Gingival – epulis.

Thyroid :
Þ Pada kehamilan biasanya terdapat sedikit pembe-
saran thyroid.
Jantung dan Paru-paru :
Þ Karena kehamilan normal menimbulkan keadaan
hyperdinamik pada system kardiovaskuler.
Þ Sering terdengar bising (murmur).
Þ Pada paru tidak terjadi perubahan, kecuali bila ada
kelainan.
Payudara :
Þ Payudara menunjukkan perubahan karakteristik :
- Vaskularisasi meningkat.
- Hypertrofi tuberkel Montgomery.
- Hyperpigmentasi areola putting.
Þ Harus diperhatikan akan adanya
inversi puting atau kelainan
patologis payudara.
Abdomen :
Þ Striae gravidarum.

Þ Hiperpigmentasi linea alba.

Þ Hepatosplenomegali ? Pembesaran ginjal ?

Þ Uterus baru teraba setelah umur kehamilan

12 minggu.
Ekstremitas dan Skeletal :
Þ Ekstremitas
- oedema dan varices.
- perbedaan panjang ekstr. Bawah.
Þ Postur
- terjadi perubahan postur pada kehamilan.
- menimbulkan nyeri punggung sp.scias.
Pemeriksaan Pelvis :
Þ Vulva lesi, bekas luka perineum, varices.
Þ Vagina rugae, menjadi lebih prominent, warna livida,
sekresi menjadi lebih banyak.
Þ Cervix membesar dan lunak, warna berubah menjadi
livida.
Hipertrofi kelenjar servik dan
memproduksi lendir pekat yang
menutup canalis servik.

Þ Uterus membesar asimetris

(Piscasek), lunak dan
mudah mengalami kontraksi
(Braxton Hicks).
Asesmen Tulang Panggul :
Þ Bentuk dan ukuran panggul merupakan faktor kritis
pada proses persalinan.
Þ Pengukuran panggul baik secara klinis / radiologis

tidak banyak berguna dalam menentukan ke-

berhasilan persalinan.
Þ Pelvimetri klinik mempunyai nilai prognostic pada
kelainan panggul karena trauma / bawaan.
Palpasi Abdomen :
Þ Pengukuran tinggi fundus uteri.
Þ Bagian fetus baru teraba pada minggu ke 24.

Þ Palpasi Leopold.
CARA PALPASI LEOPOLD I
Tujuan : - mengetahui bagian apa yang berada
di fundus uteri (bokong, kepala ?).
- mengetahui tinggi fundus uteri,
dapat menentukan umur kehamilan.
 LEOPOLD II
Tujuan : - menentukan batas tepi rahim
- menentukan punggung janin
- menentukan letak kepala pada letak lintang
 LEOPOLD III
Tujuan : - mengetahui bagian terendah janin
yang berada diatas symphisis
- mengetahui bagian terendah sudah
masuk / belum ke PAP
 LEOPOLD IV
Tujuan : - sama dengan Leopold III, disini
lebih mempertegas Leopold III
 PALPASI MULLER - KERR
Tujuan : mengetahui adanya disproporsi antara kepala dengan PAP
Þ Auskultasi.
Menggunakan stetoskop Pinard.
TUJUAN : - mendengar detik jantung janin
- menghitung frekuensi d.j.j
- menentukan irama
A L A T : - Stetoskop Pinard
- Doppler sonic
- arloji
TEMPAT : Zona AUVARD
C A R A : 5 detik istirahat 5” 12
5 detik 12
istirahat 5”
5 detik 12
SUARA-SUARA YANG DIDENGAR :
JANIN IBU
* cortonen * bising A. Uterina
* gerakan * bising usus
* bising tali pusat * bising aorta
Þ Dx kehamilan muda :
Kadar βHCG.
USG.
Test lab. Untuk skrining
1. Pemeriksaan hematology → anemia.
2. Golongan darah (ABO dan Rhesus).
3. Skrining infeksi :
* Syphilis
* Hepatitis B
* HIV
* Asymtomatic Bacteriuria (ASB)
Skrining untuk Diabetes Mellitus
DM Pregestasional : pemeriksaan GD sejak awal hamil
Risk population :
Þ History of a pregnancy complicated by gestational
diabetes or impired glucose tolerance.
Þ First – degree relative with diabetes.
Þ Previous unexplained stillbirth.
Þ Previous macrosomic infant with a birthweight in
excess of 4 kg.
Þ Maternal BMI > 35.
Þ Repeated episodes of glycosuria.
DM Gestasional : pemeriksaan TTGO 50 g glukosa tanpa
puasa setelah usia hamil 24 mgg
 Restricting A.10.1: For pregnant women with high daily caffeine intake (more than Context-specific X X X X X X X X
caffeine intake 300 mg per day),k lowering daily caffeine intake during pregnancy recommendation
is recommended to reduce the risk of pregnancy loss and low-birth-
weight neonates.

B. Maternal and fetal assessment"l

Anaemia B.1.1: Full blood count testing is the recommended method for Context-specific X X X
diagnosing anaemia in pregnancy. In settings where full blood recommendation
count testing is not available, on-site haemoglobin testing with a
haemoglobinometer is recommended over the use of the haemoglobin
colour scale as the method for diagnosing anaemia in pregnancy.

Asymptomatic B.1.2: Midstream urine culture is the recommended method for Context-specific X X X
bacteriuria (ASB) diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings recommendation
where urine culture is not available, on-site midstream urine Gram-
staining is recommended over the use of dipstick tests as the method
for diagnosing ASB in pregnancy.

Type of Recommendation Type of Eight scheduled ANC contacts

intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
j. This recommendation supersedes the previous recommendation found in the 2012 WHO publication Guideline: vitamin D supplementation in pregnant women (75).
Intimate partner B.1.3: Clinical enquiry about the possibility of intimate partner Context-specific X X X X X X X X
k. This includes any product, beverage or food containing caffeine (i.e. brewed coffee, tea, cola-type soft drinks, caffeinated energy drinks, chocolate, caffeine tablets).
violence (IPV) violence (IPV) should be strongly considered at antenatal care visits recommendation
l. Evidence on essential ANC activities, such as measuring maternal blood pressure, proteinuria and weight, and checking for fetal heart sounds, was not assessed by the GDG as these activities are considered to be
when assessing conditions that may be caused or complicated by
part of good clinical practice.
IPV in order to improve clinical diagnosis and subsequent care,
where there is the capacity to provide a supportive response
(including referral where appropriate) and where the WHO minimum
requirements are met.m n

Gestational B.1.4: Hyperglycaemia first detected at any time during pregnancy Recommended X X X X X X X X
diabetes mellitus should be classified as either, gestational diabetes mellitus (GDM) or
(GDM) diabetes mellitus in pregnancy, according to WHO 2013 criteria.o

Tobacco use B.1.5: Health-care providers should ask all pregnant women about Recommended X X X X X X X X
their tobacco use (past and present) and exposure to second-hand
smoke as early as possible in the pregnancy and at every antenatal
care visit.p

Substance use B.1.6: Health-care providers should ask all pregnant women about Recommended X X X X X X X X
their use of alcohol and other substances (past and present) as early
as possible in the pregnancy and at every antenatal care visit.q
WHO recommendations on antenatal care for a positive pregnancy experience

Type of Recommendation Type of Eight scheduled ANC contacts

intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Human B.1.7: In high prevalence settings,r provider-initiated testing and Recommended X
immunodeficiency counselling (PITC) for HIV should be considered a routine component
virus (HIV) and of the package of care for pregnant women in all antenatal care
syphilis settings. In low-prevalence settings, PITC can be considered for
pregnant women in antenatal care as a key component of the effort to
eliminate mother-to-child transmission of HIV, and to integrate HIV
testing with syphilis, viral or other key tests, as relevant to the setting,
and to strengthen the underlying maternal and child health systems.s

Tuberculosis (TB) B.1.8: In settings where the tuberculosis (TB) prevalence in the Context-specific X
general population is 100/100 000 population or higher, systematic recommendation
screening for active TB should be considered for pregnant women as
part of antenatal care.t

Daily fetal B.2.1: Daily fetal movement counting, such as with “count-to-ten” kick Context-specific
movement charts, is only recommended in the context of rigorous research. recommendation
counting (research)

Symphysis-fundal B.2.2: Replacing abdominal palpation with symphysis-fundal height Context-specific X X X X X X X X

height (SFH) (SFH) measurement for the assessment of fetal growth is not recommendation
measurement recommended to improve perinatal outcomes. A change from what
is usually practiced (abdominal palpation or SFH measurement) in a
particular setting is not recommended.

Antenatal cardio- B.2.3: Routine antenatal cardiotocographyu is not recommended for Not recommended
tocography pregnant women to improve maternal and perinatal outcomes.

r. High-prevalence settings are defined in the 2015 WHO publication Consolidated guidelines on HIV testing services as settings with greater than 5% HIV prevalence in the population being tested (98). Low-prevalence
settings are those with less than 5% HIV prevalence in the population being tested. In settings with a generalized or concentrated HIV epidemic, retesting of HIV-negative women should be performed in the third
trimester because of the high risk of acquiring HIV infection during pregnancy; please refer to Recommendation B.1.7 for details.
s. Adapted and integrated from the 2015 WHO publication Consolidated guidelines on HIV testing services (98).
t. Adapted and integrated from the 2013 WHO publication Systematic screening for active tuberculosis: principles and recommendations (105).
u. Cardiotocography (CTG) is a continuous recording of the fetal heart rate and uterine contractions obtained via an ultrasound transducer placed on the mother’s abdomen.
Deteksi Kehamilan Resiko Tinggi dengan kartu
Skor Poedji Rochyati
• KELOMPOK RESIKO 1
• 1. a.Terlalu muda hamil I ≤16 Tahun
b. Terlalu tua hamil I ≥35 Tahun
• 2. Terlalu lambat hamil I kawin ≥4 tahun
• 3. Terlalu lama hamil lagi ≥10 Tahun
• 4. Terlalu cepat hamil lagi ≤ 2 Tahun
• 5. Terlalu banyak anak, 4 atau lebih
• 6. Terlalu tua umur ≥ 35 Tahun
• 7. Terlalu pendek ≥145 cm
• 8. Pernah gagal kehamilan
• 9.. Pernah melahirkan dengan a.terikan
tang/vakum b. uri dirogoh c. diberi
infus/transfuse
• 10. Pernah operasi sesar
KELOMPOK RESIKO 2
11. Penyakit pada ibu hamil a. Kurang
Darah b. Malaria, c. TBC Paru d. Payah
Jantung e. Kencing Manis (Diabetes) f.
Penyakit Menular Seksual
12. Bengkak pada muka / tungkai dan
tekanan darah tinggi.
13. Hamil kembar
14. Hydramnion
15. Bayi mati dalam kandungan
16. Kehamilan lebih bulan
17. Letak sungsang
18. Letak Lintang
KELOMPOK RESIKO 3
19. Perdarahan dalam kehamilan ini
20 Preeklampsia/kejang-kejang
Alat Skrining Ibu Hamil

Kartu skor Poedji Rochyati mempunyai fungsi:

•- Skrining antenatal / deteksi dini factor risiko pada ibu hamil
Risiko Tinggi
•- Pemantauan dan pengendalian ibu hamil selama kehamilan
•- Pencatatan kondisi ibu selama kehamilan, persalinan, nifas
mengenai ibu / bayi
•- Pedoman untuk memberikan penyuluhan
•- Validasi data kehamilan, persalinan, nifas dan perencanaan
KB.

Sistem SKOR
Cara Pemberian SKOR:
•Ø Skor 2: Kehamilan Risiko Rendah (KRR) Untuk umur dan
paritas pada semua ibu hamil sebagai skor awal
•Ø Skor 4: Kehamilan Risiko Tinggi (KRT) Untuk tiap faktor
risiko
•Ø Skor 8: Kehamilan Risiko Sangat Tinggi (KRST)
Berdasarkan jumlah skor kehamilan dibagi tiga kelompok:

1. Kehamilan Risiko Rendah (KRR) dengan jumlah skor 2

Kehamilan tanpa masalah / faktor risiko, fisiologis dan
kemungkinan besar diikuti oleh persalinan normal
dengan ibu dan bayi hidup sehat.
2. Kehamilan Risiko Tinggi (KRT) dengan jumlah skor 6-
10 : Kehamilan dengan satu atau lebih faktor risiko,
baik dari pihak ibu maupun janinnya yang memberi
dampak kurang menguntungkan baik bagi ibu maupun
janinnya, memiliki risiko kegawatan tetapi tidak
darurat.
3. Kehamilan Risiko Sangat Tinggi (KRST) dengan jumlah
skor ≥ 12
Batasan Faktor Risiko / Masalah

A. Ada Potensi Gawat Obstetri / APGO (kehamilan yang

perlu diwaspadai) à kelompok resiko 1

B. Ada Gawat Obstetri / AGO (tanda bahaya pada saat

kehamilan, persalinan, dan nifas) à kelompok resiko 2

C. Ada Gawat Darurat Obstetri / AGDO (Ada ancaman

nyawa ibu dan bayi) à kelompok resiko 3
4. Test untuk skrining anomali janin.
* Anomali mayor biasanya terdeteksi dengan USG.
Trim 1 : 11-13 mgg à Nuchal translucency (NT)

Trim 2 : 22-24 mgg à Skrining kelainan bawaan

Structural Anomalies
Type of anomaly frequency (per 1000)
Cardiovascular 8
Craniospinal 2-4
Renal tract 1
Gastrointestinal 1

* Defek “ neural tube ” peningkatan kadar

α-fetoprotein di cairan amnion dan darah.
* Down’s Syndrome :
Þ Test biokimia meliputi α-fetoprotein (reduced), β-HCG
(raised), dan unconjugated estriol (reduced) →
test dikerjakan pada minggu ke 15 – 20 (gestational
age dependent).
Þ USG nuchal translucevcy.
Þ Amniosentesis karyotyping.
Þ Chorion villus sampling.
Type of Recommendation Type of Eight scheduled ANC contacts
intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Ultrasound scan B.2.4: One ultrasound scan before 24 weeks of gestation (early Recommended X X
ultrasound) is recommended for pregnant women to estimate
gestational age, improve detection of fetal anomalies and multiple
pregnancies, reduce induction of labour for post-term pregnancy, and
improve a woman’s pregnancy experience.

Doppler B.2.5: Routine Doppler ultrasound examination is not recommended Not recommended
ultrasound of fetal for pregnant women to improve maternal and perinatal outcomes.v
blood vessels

C. Preventive measures
Antibiotics for C.1: A seven-day antibiotic regimen is recommended for all pregnant Recommended X X X
asymptomatic women with asymptomatic bacteriuria (ASB) to prevent persistent
bacteriuria (ASB) bacteriuria, preterm birth and low birth weight.

Antibiotic C.2: Antibiotic prophylaxis is only recommended to prevent recurrent Context-specific

prophylaxis to urinary tract infections in pregnant women in the context of rigorous recommendation
prevent recurrent research. (research)
urinary tract
infections

Antenatal anti-D C.3: Antenatal prophylaxis with anti-D immunoglobulin in non- Context-specific
immunoglobulin sensitized Rh-negative pregnant women at 28 and 34 weeks of recommendation
administration gestation to prevent RhD alloimmunization is only recommended in (research)
the context of rigorous research.
Edukasi Antenatal

Diet :
Þ Kalori 2000 – 2500 Kcal / hari.
Þ Protein : 60 – 80 gr / hari.
Þ Lemak.
Þ Karbohidrat.
Þ Mineral & Vitamin
WHO recommendations on antenatal care for a positive pregnancy experience

Table 2: The 2016 WHO ANC model for a positive pregnancy experience: recommendations mapped to eight scheduled ANC contacts
Overarching aim: To provide pregnant women with respectful, individualized, person-centred care at every contact, with implementation of effective clinical practices (interventions and tests), and provision of relevant
and timely information, and psychosocial and emotional support, by practitioners with good clinical and interpersonal skills within a well functioning health system.
Notes:
• These recommendations apply to pregnant women and adolescent girls within the context of routine ANC.
• This table does not include good clinical practices, such as measuring blood pressure, proteinuria and weight, and checking for fetal heart sounds, which would be included as part of an implementation manual aimed
at practitioners.
• Remarks detailed in the shaded box with each recommendation should be taken into account when planning the implementation of these recommendations.

Type of Recommendation Type of Eight scheduled ANC contacts

intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)

A. Nutritional interventions

Dietary A.1.1: Counselling about healthy eating and keeping physically active Recommended X X X X X X X X
interventions during pregnancy is recommended for pregnant women to stay
healthy and to prevent excessive weight gain during pregnancy.a
A.1.2: In undernourished populations, nutrition education on Context-specific X X X X X X X X
increasing daily energy and protein intake is recommended for recommendation
pregnant women to reduce the risk of low-birth-weight neonates.
A.1.3: In undernourished populations, balanced energy and protein Context-specific X X X X X X X X
dietary supplementation is recommended for pregnant women to recommendation
reduce the risk of stillbirths and small-for-gestational-age neonates.
A.1.4: In undernourished populations, high-protein supplementation Not recommended
is not recommended for pregnant women to improve maternal and
perinatal outcomes.
Iron and folic acid A.2.1: Daily oral iron and folic acid Recommended X X X X X X X X
supplements supplementation with 30 mg to 60 mg of elemental ironb and 400 µg
(0.4 mg) of folic acidc is recommended for pregnant women to
prevent maternal anaemia, puerperal sepsis, low birth weight, and
preterm birth.d

a. A healthy diet contains adequate energy, protein, vitamins and minerals, obtained through the consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts, whole grains and fruit.
b. The equivalent of 60 mg of elemental iron is 300 mg of ferrous sulfate hepahydrate, 180 mg of ferrous fumarate or 500 mg of ferrous gluconate.
c. Folic acid should be commenced as early as possible (ideally before conception) to prevent neural tube defects.
d. This recommendation supersedes the previous recommendation found in the 2012 WHO publication Guideline: daily iron and folic acid supplementation in pregnant women (36).
Type of Recommendation Type of Eight scheduled ANC contacts
intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Iron and folic acid A.2.2: Intermittent oral iron and folic acid supplementation with 120 Context-specific X X X X X X X X
supplements mg of elemental irone and 2800 µg (2.8 mg) of folic acid once weekly recommendation
is recommended for pregnant women to improve maternal and
neonatal outcomes if daily iron is not acceptable due to side-effects,
and in populations with an anaemia prevalence among pregnant
women of less than 20%.f
Calcium A.3: In populations with low dietary calcium intake, daily calcium Context-specific X X X X X X X X
supplements supplementation (1.5–2.0 g oral elemental calcium) recommendation
is recommended for pregnant women to reduce the risk of
pre-eclampsia.g

Vitamin A A.4: Vitamin A supplementation is only recommended for pregnant Context-specific X X X X X X X X

supplements women in areas where vitamin A deficiency is a severe public health recommendation
problem,h to prevent night blindness.i

Zinc supplements A.5: Zinc supplementation for pregnant women is only recommended Context-specific
in the context of rigorous research. recommendation
(research)

Multiple A.6: Multiple micronutrient supplementation is not recommended for Not recommended
micronutrient pregnant women to improve maternal and perinatal outcomes.
supplements

Vitamin B6 A.7: Vitamin B6 (pyridoxine) supplementation is not recommended Not recommended

(pyridoxine) for pregnant women to improve maternal and perinatal outcomes.
supplements

e. The equivalent of 120 mg of elemental iron equals 600 mg of ferrous sulfate heptahydrate, 360 mg of ferrous fumarate or 1000 mg of ferrous gluconate.
f. This recommendation supersedes the previous recommendation in the 2012 WHO publication Guideline: intermittent iron and folic acid supplementation in non-anaemic pregnant women (55).
g. This recommendation is consistent with the 2011 WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia (57) and supersedes the previous recommendation found in the 2013 WHO
publication Guideline: calcium supplementation in pregnant women (38).
h. Vitamin A deficiency is a severe public health problem if 5% of women in a population have a history of night blindness in their most recent pregnancy in the previous 3–5 years that ended in a live birth, or if
20% of pregnant women have a serum retinol level < 0.70 µmol/L. Determination of vitamin A deficiency as a public health problem involves estimating the prevalence of deficiency in a population by using
specific biochemical and clinical indicators of vitamin A status.
WHO recommendations on antenatal care for a positive pregnancy experience

Type of Recommendation Type of Eight scheduled ANC contacts

intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Vitamin E and C A.8: Vitamin E and C supplementation is not recommended for Not recommended
supplements pregnant women to improve maternal and perinatal outcomes.

Vitamin D A.9: Vitamin D supplementation is not recommended for pregnant Not recommended
supplements women to improve maternal and perinatal outcomes.j

Restricting A.10.1: For pregnant women with high daily caffeine intake (more than Context-specific X X X X X X X X
caffeine intake 300 mg per day),k lowering daily caffeine intake during pregnancy recommendation
is recommended to reduce the risk of pregnancy loss and low-birth-
weight neonates.

B. Maternal and fetal assessment"l

Anaemia B.1.1: Full blood count testing is the recommended method for Context-specific X X X
diagnosing anaemia in pregnancy. In settings where full blood recommendation
count testing is not available, on-site haemoglobin testing with a
haemoglobinometer is recommended over the use of the haemoglobin
colour scale as the method for diagnosing anaemia in pregnancy.

Asymptomatic B.1.2: Midstream urine culture is the recommended method for Context-specific X X X
bacteriuria (ASB) diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings recommendation
where urine culture is not available, on-site midstream urine Gram-
staining is recommended over the use of dipstick tests as the method
for diagnosing ASB in pregnancy.
Exercise
Choose activities with minimal risk of loss of balance and fetal
trauma
Coitus

Perawatan Payudara
Keluhan umum sering pada kehamilan :
Þ Tumpah.
Þ Nyeri perut.
Þ Nyeri epigastrium (heartburn)
Þ Konstipasi.
Þ Nyeri punggung.
Þ Syncope
Þ Varices haemorrhoid.
Þ Carpal tunnel syndrome.
D. Interventions for common physiological symptoms
Recommendation Type of
recommendation
Nausea and D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are Recommended
vomiting recommended for the relief of nausea in early pregnancy, based on a
woman’s preferences and available options.

Heartburn D.2: Advice on diet and lifestyle is recommended to prevent and Recommended
relieve heartburn in pregnancy. Antacid preparations can be offered to
women with troublesome symptoms that are not relieved by lifestyle
modification.

Leg cramps D.3: Magnesium, calcium or non-pharmacological treatment options can Recommended
be used for the relief of leg cramps in pregnancy, based on a woman’s
preferences and available options.

Low back and D.4: Regular exercise throughout pregnancy is recommended to prevent Recommended
pelvic pain low back and pelvic pain. There are a number of different treatment
options that can be used, such as physiotherapy, support belts and
acupuncture, based on a woman’s preferences and available options.

Constipation D.5: Wheat bran or other fibre supplements can be used to relieve Recommended
constipation in pregnancy if the condition fails to respond to dietary
modification, based on a woman’s preferences and available options.

Varicose veins and D.6: Non-pharmacological options, such as compression stockings, Recommended
oedema leg elevation and water immersion, can be used for the management
of varicose veins and oedema in pregnancy, based on a woman’s
preferences and available options.
WHO recommendations on antenatal care for a positive pregnancy experience

Type of Recommendation Type of Eight scheduled ANC contacts

intervention recommendation (weeks of gestation)
1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Tetanus toxoid C.5: Tetanus toxoid vaccination is recommended for all pregnant Recommended X
vaccination women, depending on previous tetanus vaccination exposure, to
prevent neonatal mortality from tetanus.y

Malaria C.6: In malaria-endemic areas in Africa, intermittent preventive Context-specific X X X X X X

prevention: treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommendation (13
Intermittent recommended for all pregnant women. Dosing should start in the weeks)
preventive second trimester, and doses should be given at least one month apart,
treatment in with the objective of ensuring that at least three doses are received.z
pregnancy (IPTp)

Pre-exposure C.7: Oral pre-exposure prophylaxis (PrEP) containing tenofovir Context-specific X

prophylaxis for disoproxil fumarate (TDF) should be offered as an additional recommendation
HIV prevention prevention choice for pregnant women at substantial risk of HIV
infection as part of combination prevention approaches.aa

D. Interventions for common physiological symptoms

Nausea and D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are Recommended X X X
vomiting recommended for the relief of nausea in early pregnancy, based on a
woman’s preferences and available options.

Heartburn D.2: Advice on diet and lifestyle is recommended to prevent and Recommended X X X X X X X X
relieve heartburn in pregnancy. Antacid preparations can be used to
women with troublesome symptoms that are not relieved by lifestyle
modification.

y. This recommendation is consistent with the 2006 WHO guideline on Maternal immunization against tetanus (134). The dosing schedule depends on the previous tetanus vaccination exposure; please refer to
Recommendation C.5 for details.
z. Integrated from the 2015 WHO publication Guidelines for the treatment of malaria, which also states: “WHO recommends that, in areas of moderate-to-high malaria transmission of Africa, IPTp-SP be given to
all pregnant women at each scheduled antenatal care visit, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. WHO recommends a package of
 1 2 3 4 5 6 7 8
(12 (20 (26 (30 (34 (36 (38 (40
weeks) weeks) weeks) weeks) weeks) weeks) weeks) weeks)
Ultrasound scan B.2.4: One ultrasound scan before 24 weeks of gestation (early Recommended X X
ultrasound) is recommended for pregnant women to estimate
gestational age, improve detection of fetal anomalies and multiple
pregnancies, reduce induction of labour for post-term pregnancy, and
improve a woman’s pregnancy experience.

Doppler B.2.5: Routine Doppler ultrasound examination is not recommended Not recommended
ultrasound of fetal for pregnant women to improve maternal and perinatal outcomes.v
blood vessels

C. Preventive measures
Antibiotics for C.1: A seven-day antibiotic regimen is recommended for all pregnant Recommended X X X
asymptomatic women with asymptomatic bacteriuria (ASB) to prevent persistent
bacteriuria (ASB) bacteriuria, preterm birth and low birth weight.

Antibiotic C.2: Antibiotic prophylaxis is only recommended to prevent recurrent Context-specific

prophylaxis to urinary tract infections in pregnant women in the context of rigorous recommendation
prevent recurrent research. (research)
urinary tract
infections

Antenatal anti-D C.3: Antenatal prophylaxis with anti-D immunoglobulin in non- Context-specific
immunoglobulin sensitized Rh-negative pregnant women at 28 and 34 weeks of recommendation
administration gestation to prevent RhD alloimmunization is only recommended in (research)
the context of rigorous research.

Preventive C.4: In endemic areasw, preventive anthelminthic treatment is Context-specific X

anthelminthic recommended for pregnant women after the first trimester as part of recommendation
treatment worm infection reduction programmes.x

v. Doppler ultrasound technology evaluates umbilical artery (and other fetal arteries) waveforms to assess fetal well-being in the third trimester of pregnancy.
w. Areas with greater than 20% prevalence of infection with any soil-transmitted helminths.
x. Consistent with the 2016 WHO publication Guideline: preventive chemotherapy to control soil-transmitted helminth infections in high-risk groups (140).
KIA 2020

• Buku KIA dimulai 1994 oleh JICA, berawal penggabungan catatan terpisah
• Tujuannya KIA:
Tingkatkan Kemandirian Keluarga Dgn Tingkatkan Ilmu & Keterampilan
• Standar pelayanan, penyuluhan dan konseling kesehatan
• Membantu skrining dini keluarga guna menekan AKI-balita
• Buku di bagian depan memuat tentang ibu hamil –nifas (bolak-balik
• Buku di bagian belakang ttg neonates – balita (bolak-balik)
• Buku KIA wajib dimiliki ibu hamil s/d balita
• Samapai bulan November 2020 (belum tersebar/sedang di cetak)
Manfaat Buku KIA
secara umum adalah ibu dan anak mempunyai catatan kesehatan yang
lengkap, sejak ibu hamil sampai anaknya berumur lima tahun

(1) Untuk mencatat dan memantau kesehatan ibu dan anak.

(2) Alat komunikasi dan penyuluhan yang dilengkapi dengan informasi

penting bagi ibu, keluarga dan masyarakat tentang kesehatan, gizi dan
(standar) KIA.
(3) Alat untuk mendeteksi secara dini adanya gangguan atau masalah
kesehatan ibu dan anak.

(4) Catatan pelayanan gizi dan kesehatan ibu dan anak termasuk
rujukannya

(Depkes RI dan JCA, 2003)

 APA SAJA I S I KIA 2020
?
o Identitas Pasien
o Riwayat Persalinan
/ Kehamilan
sebelumnya
o Riwayat Kehamilan
saat ini
o Riwayat Penyakit
o Skrining
Preeklamsia
<20mg
Tenaga kesehatan : lakukan KIE ibu/keluarga o Pemeriksaan FISIK
Jelaskan isi buku KIA Informasikan ke Pasien
– Penunjang
KIA merupakan MR
Dampingi cara isi (kader) (di –Px)
o Lab USG
Isi lembar catatan resume & Tx o Ringkasan
Pemeriksaan
Dokter
( Keluhan Pemeriksaan
Tindakan)
o Ringkasan persalinan
o Ringkasan pelayanan Nifas
Informasi Tambahan di Buku KIA 2020

• Pelayanan : beberapa tambahan

- USG dasar terbatas utk trimester 1 dan 3
- Grafik bumil
• Nutrisi & asupan gizi bumil
• Olahraga / aktifitas fisik
• Info tanda bahaya bumil
• Tentang persalinan
• Nifas (mis: baby blues) & dan laktasi (menyusui menyimpan asi, dst)
• Kontrasepsi (KB) macam dan memilih KB
KESIMPULAN
1. Hamil / tidak
2. Nulli / multi gravida
3. Umur kehamilan ?
4. Janin hidup / mati
5. Janin tunggal / kembar
6. Letak janin
7. Intra / ekstra uteri
8. Panggul ?
9. Penyulit Obstetri
10. Penyulit non-obstetrik

PROGNOSA
1. Dubious Ad Bonam / Ad Malam
2. Low Risk / High Risk