2023-04-21 12:40:47
So far, the maternity guideline has set the tone in the care of pregnant women. Now the guideline recommends innovations. You can find out what you should know about it here.
The Maternity Guidelines of the Federal Joint Committee were last amended in 2021. They form a guideline for medical prenatal care and childcare. In the S3 guideline “Fetal Surveillance in Pregnancy” of February 1, 2023, new recommendations were added that you should be aware of. And in addition to all the physiological changes, the expectant mother will also experience a completely new attitude towards life, which is usually not addressed much in preventive care.
Care according to maternity guidelines
The primary goal is the early detection of high-risk pregnancies and births. In the gynecological practice, a precautionary concept for pregnancy can be drawn up based on the maternity guidelines, from which individual risk constellations must be deviated from.
Initial consultation: Here, personal and family anamnesis are recorded, possible risk factors are identified early on and detailed advice on behavioral measures regarding nutrition, medication and avoidance of infection is discussed. Particularities of the individual lifestyle such as job, sport and family situation are taken into account. Adequate substitution of, among other things, Iodide and folic acid notified and the vaccination card viewed. There is a recommendation for pregnant women Pertussis- and possibly also Influenza– and Corona vaccination. Questions about prenatal diagnostics are discussed and adapted to personal security needs. The maternity record is created and explained.
Laboratory diagnosis: It done Blood groups-, rhesus factor– and antibody determination. Further collection of hemoglobin value, Tuberculosis (possibly documented double vaccination), Slow down– and HIV-Serology (with consent) and a Chlamydienscreening. In the course of this, hemoglobin and antibody determinations are repeated, a screening on Gestationsdiabetes and a Hepatitis-B-Serologie carried out. In RhD-negative pregnant women, the fetal Rhesus factor can be determined according to the Genetic Diagnostics Act. If the child is positive, the pregnant woman receives anti-D prophylaxis. If the course is unremarkable, the urine tests are limited to the parameters protein and glucose. As IGeL are among other things investigations on toxoplasmosis, Zytomegaly and ß-hemolytic streptococci of group B possible.
investigations: Optional vaginal examinations to rule out infections, leakage of amniotic fluid and determination of the cervical length. With every check-up, determination of the fundus position, fetal position and fetal heartbeat as well as maternal blood pressure and body weight. If the course of the pregnancy is normal, the examination intervals are every 4 weeks up to 32+0 weeks of gestation, then every 2 weeks. They can also be done in a midwife consultation.
Ultrasonic: In the case of an unremarkable course, only three ultrasound examinations are planned in the entire pregnancy.
1. Screening: 8 + 0 bis 11 + 6 SSW
2. Screening: 18 + 0 bis 21 + 6 SSW
3. Screening: 28 + 0 bis 31 + 6 SSW
childbed: Check-ups should take place within the first postpartum week and 6–8 weeks after birth. In addition to a gynecological examination, determination of the maternal hemoglobin level, blood pressure and urine test, a consultation is the priority. It explains questions about childbed, breastfeeding and birth control.
Comparison of maternity guidelines and guideline
With regard to the indications for CTG and Doppler examinations, there are significant additions to the guideline.
Cardiotogography (CTG)
Neither the maternity guidelines nor the guideline see any evidence-based indication for a routine CTG in prenatal care in the low-risk group.
Indications according to maternity guidelines:
Indications for the first CTG
- threatened premature birth (in the 26th and 27th week of pregnancy)
- Auscultatory heart sound alterations (from the 28th week of pregnancy)
- V. a. Labor (from the 28th week of pregnancy)
Indications for CTG repeat
- Status after intrauterine fetal death
- suspected CTG
- Placental insufficiency (retardation)
- uterine bleeding
- inhibition of labor
- Mehrlingen
- appointment transfer
Additional indications according to guidelines:
- obesity
- Diabetes mellitus
- Gestationsdiabetes
- labor induction
- Hypertensive disease of pregnancy
Fetomaternaler-Doppler
Indications according to maternity guidelines:
- Status post fetal growth restriction
- Status after intrauterine fetal death
- Z. n. Preeclampsia/Eclampsia
- current fetal growth restriction
- current gestational hypertension/pre-eclampsia
- Multiples with discordant growth
- conspicuous CTG
- V. a. Malformations/fetal diseases
- V. a. Heart defects/fetal arrhythmia
Additional indications according to guidelines:
- pre-existing maternal vascular diseases (hypertension, Nephropathydiabetes, autoimmune diseases)
- V. a. fetal anemia and V. a. fetal infection
- Hydrops fetalis
- Monitoring in multiple pregnancies
- Diagnosis of pathological umbilical cord insertions and vasa previa
- Diagnosis of placental disorders
A completely new phase of life
The term motherhood derives from the English term matrescence, which first appeared in the 1970s. He describes the transition phase that a woman goes through on the way to motherhood. This phase can be as violent as puberty and affects not only the somatic, but also the psychological, social and spiritual level. It sometimes takes women several years to adjust to their new role.
Scientific aspects are also interesting: A research team from Holland has identified differences in cranial MRI scans of mothers and non-mothers, which particularly affect the emotional areas of care and empathy and are at the expense of short-term memory. Some of these restructurings will be scaled back after a few years, others will remain in place.
My conclusion as a gynaecologist
The additional indications for feto-maternal Doppler examinations and CTG controls have already arrived in gynecological practice. It has long been questionable why, for example, there was no CTG indication in the case of gestational diabetes or hypertensive pregnancy diseases, or why multiple births should not generally be monitored more intensively using Doppler and CTG. The guideline is up-to-date here and the maternity guidelines would have to be supplemented as a result.
The maternity guidelines as well as the guideline advocate completely dispensing with antepartum CTG diagnostics in the low-risk collective. At first glance it seems plausible, but difficult to implement. The classification into low and high risk is sometimes fluent and who does not know the interaction of all parameters, which, coupled with intuition that has been tried and tested over many years, point to the right track? A CTG expert, Prof. Frank Reister from the University Hospital Ulm, when asked whether one should follow this recommendation, replied: “There is nothing wrong with doing CTGs. You just have to be able to interpret them correctly.”
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It is questionable whether the third ultrasound screening will detect late retardation. Another examination between 34+0 and 36+0 weeks’ gestation would be useful and is usually carried out.
The care of pregnant women is extremely demanding, but there is concern for the well-being of several lives: nothing can and should be overlooked. All of these tasks leave little room to help the pregnant woman into her new role as a mother. It is possible that healthcare workers are completely overwhelmed here and need the support of society as a whole.
Image source: Nathan Dumlao, unsplash
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