SOSCG_6Jul2013_v5

7/27/2019 SOSCG_6Jul2013_v5

1/32

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...

7/27/2019 SOSCG_6Jul2013_v5

2/32

Introduction to SOSCG

What

Why

(by) Who

(for) Whom

Where (setting)

When (started) How

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

3/32

What

SOSCG S Sabah

O Obstetric

S Shared

C Care

G Guidelines

Yum!

SOSCG !

7/27/2019 SOSCG_6Jul2013_v5

4/32

Why

Objectives

To streamline the management of

obstetric patients between O&G

department and health clinics, in aneffort to provide efficient and cost-

effective obstetric health service.

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

5/32

Objectives (cont)

To complement existing relevantdepartmental, regional or national

protocol / Clinical Practice Guidelines

/Standard Operating Procedures, and

to supplement*/prepare where it

was inadequately covered /notavailable.

6 July 2013

*Viral Hepatitis B in Pregnancy

*Single Mother

*Morbidly Adherent Placenta

*HIV viral level

7/27/2019 SOSCG_6Jul2013_v5

6/32

In short

To better manage obstetric patient

in shared care manner

Towards MDG5

an after thought!

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

7/32

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)6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

8/32

The SOSCG-ians Dr Carol Lim Dr Lee Wai KhewDr 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)

7/27/2019 SOSCG_6Jul2013_v5

9/32

SOSCG-ians ?!!

7/27/2019 SOSCG_6Jul2013_v5

10/32

Whom

Users

The nurses in Klinik Kesihatan

Medical & Health Officers (M&HO)

O&G Medical Officers (MO)

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

11/32

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)

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

12/32

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.

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

13/32

Focus on:

Antenatal (+ Prenatal) issues

(intrapartum LR protocol)

Clinical & operational

Adapted to local settings

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

14/32

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

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

15/32

Format

Two main components:

Guidelines

Appendices

Emphasis on:

Common antenatal problems

Medical Eligibility Criteria (MEC)Flowcharts, algorithm

Other relevant documents

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

16/32

Format of Contents:

Phases

- Seven phases

Plan of action

- Special clinics, investigations, etc

Remark

- Reminder on values, definition, etc

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

17/32

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

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

18/32

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

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

19/32

Topics (cont)

Medical Conditions (cont):7. Heart disease

8. Hyperthyroidism complicating

pregnancy

9. Hypothyroidiam complicating pregnancy

10.Epilepsy11.Bronchial asthma

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

20/32

Topics (cont)

Infectious diseases:

12.Retroviral Disease

13.Viral Hepatitis B14.Urinary Tract Infection in Pregnancy

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

21/32

Topics (cont)

Pregnancy / patient factor:15.Breech / Malpresentation

16.Multiple pregnancy

17.Placenta Previa

18.Previous Scars

19.Risk for macrosomia / shoulder dystocia20.Single mother, teenage pregnancy

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

22/32

Example: (1) Anemia

Phase Plan of Action Remark

1. At

diagnosis

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

If confirmed

thalassaemia carrier,

screen husband as

well

If husbandconfirmed

thalassaemia carrier,

see SOSCG guideline

Known Case of

Thalassaemia Carrier

6 July 2013

and more

7/27/2019 SOSCG_6Jul2013_v5

23/32

Example: (1) AnemiaPhase Plan of Action Remark

2. Subsequentantenatal follow-

up

Monitor Hb level at health clinicMonthly fetal growth monitoring by health

clinic

3.Delivery plan Keep Hb > 8 g/dL

Generally may allow postdates, unless specified

otherwise

4. Delivery Hospital delivery

PPH prophylaxis

5. Postpartum Discuss options of contraception with patient /

couple

Refer Appendix

Medical EligibilityCriteria for

Contraceptive Use

6. Upon discharge

from hospitalRoutine discharge procedure

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

24/32

(2) Known Case of Thalaassemia Carrier


1. Pre-pregnancy

If both couple are thalassaemiacarriers, refer to FMS / O&G (Pre-

pregnancy Clinic) for counselling,

including information regarding

prenatal diagnosis

DNA molecular analysisof the couple is a pre-

requisite 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 (Pre-

pregnancy 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

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

25/32



3. Subsequentantenatal

follow up

Refer to MFM Clinic for detailedscan appointment at 18-22 weeks

if both couple are -thalassaemia

carriers

Monitor Hb level

Check serum ferritin & TIBC

before giving iron supplement

Tab. Folate should be given

throughout pregnancy

Iron supplement forthalassaemia minor

without coexisting iron

deficiency anaemia

(IDA) can cause iron

overload & has adverse

systemic effect

Low ferritin & high

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

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

26/32



6.Postpartum Babies (at risk of beingthalassaemia 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

Refer AppendixMedical Eligibility

Criteria for

Contraceptive Use

7. Upon

discharge

from hospital

Routine discharge procedure

Pre-pregnancy Clinic appointment

at 3/12 postnatal (if futurepregnancy possible) if both couple

are thalassaemia carriers

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

27/32

Appendices examples:

High risk discharge notification

CS Summary

MEC for respective conditions

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

28/32

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 damagecontrol

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

29/32

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

7/27/2019 SOSCG_6Jul2013_v5

30/32

Impact of SOSCG

Nurse empowerment

Maternal deaths in Sabah - lesser number of

clinic / booked patients:

2008: 48% of maternal deaths were clinic cases2012: 38.2% of maternal deaths were clinic cases

Opportunity to bring up issues Platform for clinical risk management

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

31/32

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?

6 July 2013

7/27/2019 SOSCG_6Jul2013_v5

32/32

Thank youcarolkklim@yahoo com

The best preparation for good work tomorrow is to do good

work today.

-Elbert Hubbard

Documents

SOSCG_6Jul2013_v5