9 steps for prenatal health care according to the law in Vietnam

9 steps for prenatal health care according to the law in Vietnam - image from internet

The 9 steps for prenatal health care are promulgated in the National Guidelines for Reproductive Health Services issued by the Minister of Health in Decision 4128/QD-BYT in 2016 as follows:

Every pregnant woman should receive antenatal care and prenatal check-ups at least 4 times during the pregnancy (once in the first 3 months, once in the middle 3 months, and twice in the final 3 months).

Prenatal care should be conducted according to the following 9 steps:

1. Interview

1.1. Personal information.

- Full name.

- Age.

- Occupation, working conditions: sitting or standing position, rest periods, exposure to hazards.

- Address (notably remote or rural areas).

- Ethnicity (notably ethnic minorities).

- Educational level.

- Living conditions, economic situation (notably poverty, deprivation).

1.2. Health.

1.2.1. Current health status.

Are there any abnormal symptoms or conditions? If so, when did they occur, how did they progress, have they been treated, treatment outcomes, any impact on health, current medication use? Pay attention to circulating infectious diseases in the local area and chronic diseases.

1.2.2. Medical history.

What diseases have been diagnosed? Note any hospitalizations, surgeries, blood transfusions, accidents, allergies, addiction to alcohol, tobacco, drugs, diabetes, cardiovascular diseases, mental health issues, endocrine disorders, blood, liver, kidney diseases.

1.2.3. Obstetric history (PARA).

- Number of pregnancies: use a 4-digit format (excluding the current pregnancy):

+ The first number represents the number of full-term pregnancies.

+ The second number represents the number of preterm pregnancies.

+ The third number represents the number of miscarriages or abortions.

+ The fourth number represents the number of living children.

For example: 2012: 2 full-term pregnancies, no preterm pregnancies, 1 miscarriage or abortion, currently 2 living children.

- For each pregnancy:

+ Gestational age at delivery (to determine if it was preterm or full-term).

+ Place of delivery: hospital, health station, home, unattended birth.

+ Duration of labor.

+ Method of delivery: normal, difficult (forceps, vacuum extraction, cesarean section).

+ Any abnormalities during pregnancy (bleeding, preeclampsia), during delivery (abnormal presentation, difficult labor, fetal malformation), after delivery (bleeding, infection).

+ Birth weight of the baby.

+ Gender of the baby.

+ Condition of the baby at birth: immediate crying, asphyxia, stillborn...

1.2.4. Gynecological history.

Any infertility treatment, endocrine treatment, reproductive tract infections, sexually transmitted diseases, cervical procedures (thermal ablation, electrocautery, laser, cryotherapy), gynecological tumors, history of sexual abuse, gynecological surgeries...

1.2.5. Inquire about contraceptive methods used.

- Type of contraceptive method.

- Duration of use for each method.

- Reasons for discontinuing use.

- Contraceptive method used just before this pregnancy (if used, reasons for getting pregnant).

1.2.6. Inquire about this pregnancy.

- Menstrual cycle regularity and the start date of the last menstrual period.

- Any cravings or food aversions.

- Estimated date of conception.

- Lower abdominal pain (appearing 1 month before delivery, due to the descent of the fetus).

- Any abnormal signs such as abdominal pain, bleeding, increased vaginal discharge.

- Fatigue, weakness, headaches, poor appetite (signs of anemia).

- Headaches, blurred vision, upper abdominal pain, nausea, vomiting (signs of preeclampsia).

1.3. Family.

- Health and age of parents, siblings (whether deceased or alive). If deceased, provide the reason.

- Any family members with internal diseases: hypertension, diabetes, cardiovascular diseases, liver, kidney, etc.

- Any family members with infectious diseases: tuberculosis, sexually transmitted diseases (STDs), HIV/AIDS, malaria.

- Other medical conditions: twins, birth defects, allergies...

- Inquire for screening of domestic violence against women. If detected, follow the steps outlined in the article "Screening and Response of Healthcare Workers to Domestic Violence against Women."

1.4. Marital history.

- Age at marriage.

- Full name, age, occupation, health, and illnesses of the spouse.

1.5. Estimating the due date based on the start date of the last menstrual period.

- Calculate precisely 40 weeks from the start date of the last menstrual period.

- According to the Gregorian calendar, add 7 to the start date of the last menstrual period, add 9 to the last month (or subtract 3 if the total is greater than 12).

For example: Start date of the last menstrual period is 15/9/2007.

Estimated due date is 22/6/2008.

A pregnancy due date calculator can be used.

- If the start date of the last menstrual period is not remembered, ultrasound results can be used to determine the gestational age (most accurate in the first 3 months of pregnancy).

- If the pregnant woman does not remember the Gregorian date but only remembers the lunar date, healthcare workers can convert the lunar date to the Gregorian date using a calendar.

- In the case of sperm insemination into the uterus, embryo transfer in assisted reproductive technology, the start date of the last menstrual period is calculated as 14 days before the insemination date. The estimated due date is calculated as described above.

2. Full body examination

- Measure body height (at the first prenatal visit).

- Weighing (at each prenatal visit).

- Skin examination, mucous membranes, assess for edema or anemia (at each prenatal visit).

- Measure blood pressure (at each prenatal visit).

- Cardiopulmonary examination (at each prenatal visit).

- Breast examination.

- Examine other body parts if there are any abnormal signs.

3. Obstetric examination

3.1. First trimester.

- Assess the position of the cervix by pressing on the pubic bone to check if the uterus has risen.

- Check for any scars from previous abdominal surgeries.

- Use a speculum to examine the cervix for signs of inflammation if there is suspicion of genital tract infection.

- Only perform a vaginal examination if the signs of pregnancy are not clear and further confirmation is needed.

3.2. Second trimester.

- Measure the height of the uterus.

- Listen to the fetal heartbeat when the uterus is at the level of the navel (preferably using a fetal doppler if available).

- Assess fetal movements, number of fetuses, and presentation.

- If there is suspicion of genital tract infection, observe the vagina and cervix using a speculum.

3.3. Third trimester.

- It is best to have a prenatal visit once a month.

- Measure the height of the uterus/belly circumference.

- Assess fetal position and presentation (from 36 weeks gestation).

- Listen to the fetal heartbeat.

- Evaluate the descent of the fetal head (within one month before the expected due date).

- Assess fetal movements, number of fetuses, and presentation.

- When resting or sleeping, it is recommended to lie on the side, preferably the left side, with both knees slightly elevated if there is swelling in the legs due to fluid retention.

- If there is suspicion of genital tract infection, observe the vagina and cervix using a speculum.

4. Conduct other laboratory tests and diagnostics

4.1. Urine protein test.

- Collect urine in the morning, midstream.

- In rural areas, a protein test strip (compared to color scale) or a burning method can be used.

- Urine testing should be done at each prenatal visit.

- If test strips are available, pregnant women should be instructed to do the test themselves.

4.2. Hemoglobin test.

4.3. Other laboratory tests.

- Test for HIV, syphilis, hepatitis B, C, and other sexually transmitted diseases if necessary, as early as possible.

- If there is anemia, test the stool for parasites.

- At district and commune health centers, additional tests should include blood type, hematocrit, red blood cell count, blood film, liver function, and kidney function.

- Gas test (if there is suspicion of genital tract infection).

- For low-risk individuals: At 24 weeks of pregnancy, perform a glucose challenge test (GCT). If the GCT is positive, refer for further evaluation by an internal medicine specialist combined with regular prenatal visits.

- For high-risk individuals (parents with diabetes, obese pregnant women, etc.): In the first trimester, test blood sugar, HbA1C, and perform a glucose tolerance test. Repeat the test at 24 weeks of pregnancy (or in the second trimester) and again in the last 3 months of pregnancy. If the GCT is positive, refer for further evaluation by an internal medicine specialist combined with regular prenatal visits.

- Early diagnosis of preeclampsia using the Elecsys sFlt-1/PlGF diagnostic test at 25-28 weeks of pregnancy.

- Ultrasound and prenatal screening tests:

+ First ultrasound: Ideally performed around 11-13 weeks of pregnancy to accurately determine gestational age and screen for abnormalities.

If possible: Perform prenatal screening and diagnosis for abnormal chromosomal numbers 21, 18, 13 of the fetus based on nuchal translucency thickness on ultrasound and double test (concentration of PAPP-A and free β-hCG in maternal serum) to detect fetuses at risk for chromosomal abnormalities.

+ Second ultrasound: Ideally performed around 20-24 weeks of pregnancy to detect fetal abnormalities.

If possible: Perform triple test at 16-18 weeks of pregnancy (AFP, β-hCG, and serum estradiol).

If triple test is positive: Offer amniocentesis for definitive diagnosis of fetal chromosomal abnormalities.

+ Third ultrasound: Ideally performed at 30-32 weeks of pregnancy to assess amniotic fluid, fetal heart, gastrointestinal tract, and brain.

Note: It is strictly prohibited to disclose information about the gender of the fetus to the pregnant woman.

5. Tetanus vaccination

- For women who have not received or have an unclear history of receiving tetanus-containing vaccines, the tetanus vaccination schedule consists of 5 doses as follows:

+ Dose 1: Given early in the first pregnancy or at the time of delivery.

+ Dose 2: At least 1 month after Dose 1.

+ Dose 3: At least 6 months after Dose 2 or during the subsequent pregnancy.

+ Dose 4: At least 1 year after Dose 3 or during the subsequent pregnancy.

+ Dose 5: At least 1 year after Dose 4 or during the subsequent pregnancy.

- If the interval between doses exceeds the recommended schedule, the next dose should be given without starting the series over.

6. Provision of essential medications

- Malaria medication (in areas with malaria transmission) according to the prescribed regimen for malaria control.

- Iron/folic acid tablets:

+ Take 1 tablet daily throughout the duration of pregnancy until 6 weeks postpartum. Start taking the tablets at least 90 days before delivery.

+ If the pregnant woman shows signs of severe anemia, the dose can be increased from the preventive dose to a treatment dose of 2-3 tablets per day.

+ Provision of iron/folic acid tablets should be initiated during the first prenatal visit. Monitor the usage and provide additional tablets during subsequent prenatal visits.

7. Health education

7.1. Nutrition.

Pregnancy diet.

- Increase food intake by at least 1/4 (increase the number of meals and the amount of food in each meal).

- Increase nutrient intake: ensure the development of both the mother and the baby (meat, fish, shrimp, milk, eggs, peanuts, sesame seeds, cooking oil, fresh fruits and vegetables).

- Drink at least 2 liters of water per day (milk + fruit juice + filtered water) until the end of the breastfeeding period.

- Avoid excessive salt intake, vary the dishes to enhance taste.

- Avoid smoking and alcohol consumption.

- Do not take medication without a doctor's prescription.

- Prevent constipation through a balanced diet, avoid using laxatives.

7.2. Work routine during pregnancy.

- Work according to one's ability, take regular breaks but avoid heavy physical exertion, especially during the seventh month onwards.

- Do not work in the final month to ensure the mother's health and promote baby weight gain.

- Avoid carrying heavy loads on the head or shoulders.

- Avoid exhaustion.

- Avoid working underwater or at heights.

- Avoid exposure to harmful substances.

- Avoid long-distance travel and minimize the risk of strong impacts or collisions.

- Exercise caution during sexual intercourse.

- Maintain a comfortable lifestyle and avoid stress.

- Get at least 8 hours of sleep per day. Allow time for napping.

7.3. Hygiene during pregnancy.

- Ensure the living environment is well-ventilated, clean, and free from dampness, heat, and smoke.

- Wear loose and breathable clothing.

- Practice regular bathing and daily hygiene of the breasts and genital area.

- Avoid douching the vagina.

8. Record in the prenatal care book and appointment forms

- Record in the prenatal care book.

- Record in the health monitoring book for the mother and child (if applicable) or in the prenatal care form used at healthcare facilities.

Note: When recording, in addition to the pregnant woman's condition and examination results, it is essential to include an evaluation of the current prenatal visit, important signs for the pregnant woman to self-monitor, medication names and dosages, instructions for use, and the next scheduled appointment.

- At the commune health station, record the "con tom" form (childbirth plan) from the first prenatal visit and display it on the "Pregnancy Management" board.

In subsequent visits, if any high-risk conditions are detected, mark them on the form. Write the next appointment form for the pregnant woman and place it in the appointment box.

9. Conclusion - Advice

Inform the pregnant woman about the results of the prenatal visit, whether it was normal or abnormal, the mother's health status, and the baby's development. Highlight any important points to be noted until the next visit.

If any abnormal signs are detected, proper management should be provided if the facility has the necessary conditions. At the commune health station or facilities without adequate conditions, provide counseling and refer the pregnant woman to a higher-level healthcare facility.

Provide essential medications and instructions on how to use them (if necessary). Give advice on the following:

9.1. For the first trimester.

- Schedule for tetanus vaccination.

- Schedule the next prenatal visit.

- Inform the nearest healthcare facility for any necessary visits.

9.2. For the second trimester.

- Schedule the next prenatal visit.

- Schedule for tetanus vaccination (if not yet completed).

9.3. For the third trimester.

- Schedule the next prenatal visit (if requested).

- Estimated due date and place of delivery.

- Provide instructions on preparing necessary items for the mother and baby during childbirth (including support person and blood donation if necessary).

- Explain warning signs that require immediate reevaluation, such as abdominal pain, bleeding, and swelling.

- Provide guidance on positioning and breathing techniques during labor and pushing.

- Instruct on breastfeeding immediately after delivery and care for the newborn.

Note:

- Before concluding the prenatal visit, ask important questions and provide essential advice to ensure that the pregnant woman understands and remembers correctly.

- Treat STDs and provide preventive treatment for diseases transmitted from mother to child if necessary.

The above information outlines the 9 steps of prenatal healthcare. For a better understanding of this issue, please refer to Decision 4128/QD-BYT in 2016.

Best regards!