PREGNANCY CARE, OBSTETRICS, ANTENATAL CARE, DELIVERY, FETUS, CHILD, FERTILITY, MOTHER, GIRL

1. BASIC OBSTETRIC CARE
DR. RABI NARAYAN SATAPATHY
ASST.PROFESSOR
DEPT. OF OBST.& GYNAECOLOGY
SCB MEDICAL COLLEGE, CUTTACK
MOB-09861281510
EMAIL-drrabisatpathy@gmail.com

2. WHY BASIC OBSTETRIC CARE FOR
HOMOEOPATHY AND AYURVEDIC PHYSICIANS?
AREN’T THE
OBSTETRICIANS OF
MODERN MEDICINE
THERE?

3. THEY ARE NOT THERE WHERE THE
WORST OCCURS!

4. Deaths Worldwide from Complications of Pregnancy
and Childbirth( Maternal & Child Health-JHPIEGO)

5. 529,000 women die per year world wide from
maternal causes, 99% occur in developing
countries …India leads with 136,000 deaths
Life-time risk of dying from pregnancy-
related complications is 45 times higher in
developing nations compared to the
developed
MMR reaches 1000/100,000 live births in
some countries
India’s MMR 400 to 500/100,000
(Ref: RHO ARCHIVES)

6. For every maternal death 100 women
who survive have disability; long term
consequences ( prolapse, p.i.d, fistula,
incontinence, infertility, dyspareunia)
>28 million disability-adjusted life
years (DALY)
18% of the burden of diseases in
women
(Ref: RHO ARCHIVES)

7. > one million children are left
motherless every year
> ½ (3.4 out of 8 million) of infant
deaths per year result from poor
maternal health & inadequate delivery
care
(Ref: RHO ARCHIVES)

8. KEY REASONS OF THESE ALARMING
FIGURES…..
LACK of SKILLS of the Provider at the
VITAL POINT in the community  at
the Primary Health Care site
LACK of Drugs, Supplies & Equipment
LACK of ‘Functioning Referral System’
No provider available!

9. EVOLUTION OF MATERNAL HEALTH
IN THE WEST
 IN THE 19TH
CENTURY - WORSE THAN WHAT WE ARE NOW
↓
 IN EARLY 20TH
CENTURY- INSPITE OF THE RISE IN ECONOMY
AS BAD AS WE ARE NOW
↓
 AFTER CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS
↓
 UPGRADATION OF SKILLS AT THE SENSITIVE LINK & ATTENTION TO
BROADER ISSUES
↓
 DRASTIC IMPROVEMENT OCCURRED THAT CAME TO STAY

10. ATTENTION TO THE THIRD WORLD WITH
GRADUAL GLOBALISATION IN HUMAN
CONSCIOUSNESS
SAFE MOTHERHOOD INITIATIVE IN
1987- Nairobi, Kenya by World Bank
WHO & UNFPA - did improve matters
but IMR & MMR are still very high-
Reasons vary from country to country

11. SAFE MOTHERHOOD INTER-AGENCY GROUP
WHO
WORLD BANK
UNICEF
UNPF
International Confederation of Midwives
FIGO
IPPF
IPC
Family Care International
Safe Motherhood Network of Nepal
Regional Prevention of Maternal Mortality
Programme(Africa)

12. ‘SAFE MOTHERHOOD INTER AGENCY
GROUP’ currently focuses on……….
Skilled attendance at childbirth by the
provider
Attention to broader issues like ‘policy
& regulatory mechanisms’ on
availability of
drugs,supplies,equipments.
Presence of functioning referral
system

13. SKILLED PROVIDER AT THE VITAL
STATION…..
MIDWIFE
GRADUATE DOCTOR
NURSE (with midwifery & lifesaving
skills)
WHY NOT THE GRADUATES OF
HOMOEOPATHY & AYURVEDA???

14. current REQUIREMENT
Addressing…….
A VERY CRITICAL GAP IN MATERNAL
CARE

15. GOAL for India…..
Bring down MMR to
109/ 100,000 live births
by 2015

16. OBSTETRIC CARE REDEFINED
EOC/CEOC= Essential Obstetric
Care/Comprehensive Essential Obstetric
Care:
provides not only the means to manage
emergency complications when they happen
but also the procedures for early detection
and treatment to prevent the progression of
problem pregnancies to the level of an
emergency
(Ref:Global Health Council)

17. EmOC = a subset of EOC
Responds to unexpected complications
such as hemorrhage, and obstructed labor. It
does not include management of problem
pregnancies, monitoring labor, or neonatal
special care
(Ref:Global Health Council)

18. BEOC = Basic Essential Obstetric Care -
it is another subset of EOC
- includes all EOC elements with the
exception of surgery, anesthesia, and blood
replacement
-enhances front-line care and should be able
to prevent majority of complications
progressing to emergent situation
- appropriate for rural settings
(Ref:Global Health Council)

19. URGENT NEED
Build capacity of providers in ‘Basic’ &
‘Comprehensive’ Emergency Obstetric &
Neonatal Care
Strengthening infrastructure, manpower etc
at health care set ups
Advocate for policy guidelines & minimum
set of standards of care at health care
settings

20. Over all objective for EmOC in India
Develop capacity of General
Practitioners & Non specialist Medical
Officers in India to provide high quality
Emergency Obstetric Care (EmOC)
services in rural areas where skilled
obstetricians are not available to
prevent maternal mortality & morbidity

21. Strategy for Basic Essential Obstetric
Care in India?
Develop capacity of Homoeopathy &
Ayurvedic Medical Officers also in India
to provide high quality Basic Essential
Obstetric Care (BEOC) services in rural
areas where neither skilled
obstetricians nor graduate medical
officers are available - to prevent
maternal mortality & morbidity

22. WHY BEOC?
IT FORESTALLS the need for EmOC
Majority of emergent life threatening
complications are prevented by BEOC
CERTAINLY PREVENTION IS BETTER
THAN CURE!

23. ESSENTIAL SKILLS OF BASIC OBSTETRIC
CARE COMPONENTS
Manage normal labour & childbirth
Recognize the onset of complications
Perform essential ‘BASIC’ emergency
interventions
Safely refer the mother &/or newborn
when necessary

24. OTHER RELATED COMPONENTS OF THE
ESSENTIAL BASIC SKILLS
Antenatal & postpartum care
Management of abortion complications
Family planning counseling & services
New born care

25. MANAGEMENT OF LABOR
Diagnose stages & phases of labor
Care in latent labor
Use of WHO partograph as management
& referral tool in active labor after 4 cm
dilatation of cx
Use of specific drugs & fluids in labor
IP practices

26. Stages of labour
1st
stage – from beginning of labor until
complete (10 centimeters) dilation
2nd
stage – from complete dilation to
complete birth of baby
3rd
stage – from complete birth of baby to
complete birth of placenta
4th
stage – from complete birth of placenta
to 2 hours after birth

27. Phases of 1st stage
Latent phase
Cervix: 1-3 centimeters dilated
Contractions: Irregular, variable frequency,
duration < 20 seconds
Active phase
Cervix: 4-10 centimeters
Contractions: Regular, increase to 3-5/10
min; duration may become > 40 seconds

28. Care in 1st stage of labor
Ongoing assessment
Ongoing supportive care
Key action: once active phase begins,
start a partograph

29. Care in latent phase of labor
Provide plenty of nutritious drinks
Encourage small meals as tolerated
Encourage woman to empty bladder at
least every 2 hours
Do NOT give an enema

30. Latent phase care cont…
Encourage bath before active phase
begins
Replace soiled blankets, sheets
Use proper infection prevention
procedures:
hand washing
antisepsis before exams
Do not shave vulva

31. Supportive Care during Active Phase:
Activity and Comfort Measures
Allow freedom to choose position
Assist her in relaxing between contractions
Encourage position changes throughout
labor
Massage or apply pressure to back as
woman desires
Coach in effective breathing
Provide comfort measures such as cool
cloth to face

32. Supportive Care during Active Phase:
Hygiene
Maintain clean environment
Clean genital area if needed prior to exam
Wash hands before and after each exam
Wear gloves for all vaginal exams
Clean up spills immediately
Replace soiled or wet blankets, sheets, or
clothes

33. Key Action: Start Partograph
A decision-making tool rather than only a
record
Start when dilation reaches 4 centimeters
Use throughout labor to help:
Evaluate fetal and maternal well-being
Assess progress of labor
Identify problems
Guide decision making for care
Provide a record of findings

35. CHILD BIRTH
Conduct as per clinically standardized
best practices
Restricted use of episiotomy and repair
Basic new born resuscitation & care
AMTSL
Repair of Perineal injuries, cervical tears
Recognize onset of complications

36. Recognition of complications & Rapid
Initial Assessment
Every woman presenting with a danger is
assessed for:
Breathing difficulty (respiratory distress)
Convulsion/loss of consciousness
Shock
Hypertension with proteinuria
Fever

37. BASIC EMERGENCY PROCEDURES
Antibiotics (injectables) use
Oxytocics (injectables) use
Anti-convulsants (injectables) use
Manual removal of placenta
Removal of retained products
Assisted vaginal deliveries ( vacuum
extraction & forceps)

38. Early Referral
Unsatisfactory progress of labor-
Ante-partum hemorrhage
Eclampsia –after instituting magsulf
Morbid adherence of placenta
Inversion of uterus
Post partum hemorrhage uncontrolled by
oxytocics & massage

39. Components of proper referral
safe, rapid transportation
care during transport
communication with referral facility
follow-up with client

40. Antenatal (assessment & care)
ASSESSMENT (oriented to excluding risk)
-History (Personal info, MH, OH, Lifestyle,
Medical, Interim)
-Physical examination( General,
Abdominal, Pelvic)
-Testing (Hb%, VDRL, HIV, Grouping &
Rh typing, others as per prevalence)

41. CARE PROVISION:-
- Diet & Nutrition – including daily iron/folate tabs
- Develop Birth plan, educate on danger signs etc
- Advice on common discomforts
- Counseling on hygiene; Rest & activity; Early
exclusive breast feeding; FP;
-Encourage questions
-Ask questions to ensure she understands

42. IMMUNISATION & OTHER PROPHYLAXIS (as
per region specific need)
Tetanus Toxoid
Iron folate & diet rich in vit. C
Anti-malarial
Mebendazole
Vitamin A
Iodine

43. Postpartum care
Ongoing assessment for first 6 hours
Basic assessment
History
Physical Examination
Testing
Note: Before performing assessment:
welcome woman
offer her (and companion, if she desires) a seat
ensure that she has undergone quick check

44. Focus physical examination on following:
General well-being (every visit)
Vital signs (every visit)
Breasts (every visit)
Abdomen (every visit)
Legs (every visit)
Genitals (every visit)

45. Postpartum fundal height

46. Post partum examination
Gait and movement – no limp,
steady/moderately paced gait and
movements
Facial expression – alert, responsive, calm
Behavior – normal for culture
General cleanliness – no visible dirt, odor
Condition of skin – no lesions, bruises
Color of conjunctiva – pink

47. Postpartum examination…
Lochia (color and character):
Day 1: bright red blood, like heavy
menses
Days 2-4: red lochia, fleshy odor, new pad
every 2-4 hours
Days 5-14: pink lochia, musty odor,
decrease in amount
Day 11 thru week 3 or 4: white lochia,
decrease in amount

48. Lochia (cont.):
Foul-smelling lochia requires urgent
further evaluation/ additional care (life-
threatening complication)
Red lochia (lochia rubra) for more than 2
weeks requires further
evaluation/additional care (special need)

49. Vaginal bleeding:
The following s/s require urgent further
evaluation/ additional care (life-
threatening complication):
Frank heavy bleeding
Steady slow trickle
Intermittent gushes
Clots larger than lemons

50. Postpartum care
Focus history taking on following areas:
Personal history (1st
visit)
Daily habits and lifestyle (1st
visit)
Present pregnancy and labor/birth (1st
visit)
Present postpartum period (every visit)
Obstetric history (1st
visit)
Contraceptive history/plans (1st
visit)
Medical history (1st
visit)
Interim history (on return visits)

51. During every visit:
Provide all elements of basic care
package
If abnormal s/s (based on assessment),
provide additional care
Note: Information gathered through assessment
should be
taken into consideration during care provision.

52. Postpartum care provision
Ongoing supportive care up to discharge
Basic care package:
Breastfeeding and breast care
Complication readiness plan
Support for mother-baby-family relationships
Family planning
Nutritional support
Self-care and other healthy practices
HIV counseling and testing
Immunizations and other preventive measures
source: Maternal & Neonatal Health

53. Management of abortion complications
MVA in incomplete & missed abortions,
molar pregnancy
Parenteral Antibiotics
Management of shock
Post abortion counseling

54. FAMILY PLANNING COUNSELING
Skills required in communication & inter-
personal relationship
Benefits of optimum birth spacing-at least
3 yrs
Method choice
Starting before fertility returns

55. Basic New born physical examination
Overall appearance/
general well-being:
Weight
Respiration
Temperature
Color
Movements and
posture
Level of alertness and
muscle tone
Skin
Head, face and
mouth, eyes
Chest, abdomen and
cord, external
genitalia
Back and limbs
Breastfeeding
Mother-baby bonding

56. New Born Care
Basic care:
Early and exclusive breastfeeding
Complication readiness plan
Newborn-care and other healthy practices
Immunizations and other preventive
measures

57. Breastfeeding guidelines:
Give baby colostrum
Breastfeed immediately
Breastfeed exclusively and on demand
Information on benefits/general
principles of breastfeeding; additional
advice for mother, including breast
care; and breastfeeding support –
provide as needed

58. Maintaining warmth
Skin-to-skin contact for first 6 hours
Do not bathe in first 6 hours; and
preferably not in the first 24 hours
Avoid tight clothing
Cover head
Keep room warm (25°C), free of drafts
Check feet every 4 hours for first day

59. Prevention of Infection/Hygiene
Baby’s immune system still developing
Wash hands before touching baby; after
changing diaper
Take care of own baby as much as possible
Avoid sharing equipment/supplies
Keep baby away from sick family members
Be alert for s/s of infection

60. Cord Care
Wash hands before and after cord care
Avoid getting cord wet – if wet, dry immediately
Apply no lotions, powders, etc.
Keep cord outside of diaper
If bleeding, retie immediately
Cord should separate from umbilicus 2-7 days
after birth
Enact complication readiness plan for s/s of
infection or delayed separation

61. Sleep and Other Behaviors/Needs
Sleeping:
Should sleep on side or back
Will sleep about 20 hours/day at first; will
gradually stay awake longer
Protection:
Falls or harm by animals/other children
Suffocation (e.g., from pillows)
Crying – Address cause of discomfort
(e.g., hunger, dirty diaper)
Mother-baby-family relationships –
provide support

62. Immunizations and Other Preventive
Measures
Before discharge, give BCG, OPV-0, HB-1
Advise mother to return for additional
newborn vaccines at 6, 10, and 14 weeks
Within 6 hours after birth, give vitamin K1
1
mg IM
For newborns in malaria-endemic areas,
counsel on sleeping beneath insecticide-
treated bed net

63. IMPLEMENTATION…
EDUCATION PROCESS & ITS
SUPPORTS
EDUCATION SYSTEM
LEARNING RESOURCE PACKAGE

64. EDUCATION PROCESS
(MASTERY/ADULT LEARNING)
Problem solving, critical thinking &
clinical decision making skills
Appropriate interpersonal
communication skills
Competency in a range of essential
clinical skills for maternal and new
born health care

65. EDUCATION PROCESS SUPPORTED
BY…
1.Appropriate training programme
2.Skilled classroom & clinical teachers
3.Teaching methods that are current &
comprehensive

66. policy environment of the ‘Educational
System’:-
Acknowledges fundamental importance of
educational continuum (Pre-service, In-service,
Continuing education)
Provides enough financing to sustain the
educational programme
Authorizes the skilled provider to practice the
skills for which she has been trained
Incorporates comprehensive programme of
supportive supervision, evaluation,
feedback & monitoring in which the
community serves as a vital partner

67. LEARNING RESOURCE PACKAGE
for
BEOC
Does not replace existing curriculum
Includes teaching/learning methods, materials &
other resources to support implementation of
educational programme for-
‘skilled providers’
homoeopathy and Ayurvedic doctors
just as midwives, doctors & nurses
of modern medical science

68. Partners involved in EmOC
FOGSI
CMC VELLORE WITH JHPIEGO
TRAINED TRAINERS
AVNI Health Foundation
GOVT. OF INDIA
STATE GOVT.

69. Who then are the partners for BEOC for
Homoeopathy & Ayurvedic doctors?
AYUSH?
NRHM?
WHO?
STATE GOVT?
MEDICAL COLLEGES WITH EmOC TRAINING
CENTRES?
HOMOEOPATHY& AYURVEDIC
ASSOCIATIONS?
OBSTETRICIANS & PEDIATRICIANS
sensitive to the issue?

70. The Orissa initiative in view of shortage
of graduate doctors in the periphery
Mainstreaming of 1132 AYUSH doctors into
the health care delivery system has been
initiated by NRHM
Some of these will be identified and given the
competency based Skilled Attendance at
Birth (SAB) training at district head quarters
by O&G specialists that are already being
given to graduate doctors, nurses and female
health workers

71. DESIGN for EmOC…
Master Training centres are set up in
medical colleges with suitable
infrastructures
Each training centre offers two
courses- 1) short course of 3 weeks
2) long course of 16 wks
Competency based course adapted
from JHPIEGO modules

72. What would be the design for
Homoeopathy & Ayurvedic graduates?
Where should it be imparted?
Would the duration be equal,
or longer ? Certainly not shorter!
What would be the issues involved?
Especially ‘legal’?

73. CRITERIA OF TRAINEE??
Homoeopathy/Ayurvedic Medical
Officers posted in a PHC/ Dispensary/
FRU whether or not actively involved
with labour cases ?
Providing/oriented to provide minimum
level services as per GOI guidelines?

74. By capacity building of Homoeopathy &
Ayurvedic graduates in BEOC…..
CAN WE FURTHER
PREVENT THE MOTHER &
NEWBORN
FROM
DYING ?!

75. What’s your answer?