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  2. 2. EVOLUTION OF MCH SERVICES IN INDIA. 1885-Association for medical aid by the women to the women of India. Established by countess of Dufferin. 1918-Lady Reading Health School. Delhi. (HV). 1992-Lady Chelmsford League was formed to develop MCH services. 1931-Indian Red Cross Society established. Victoria Memorial Scholarship fund established.
  3. 3. 1938-Indian Research Fund Association for assessing causes of IMR,MMR. 1946-Bhore Committee report. 1931-Madras State – MCH Welfare. 1951-BCG vaccination prog. 1952.PHC established 1953-NFPP started.
  4. 4. 1962-Mudhaliar Committee report. 1970-AIHPPP started. 1971-MTP Act passed. 1974-75-ICDS prod enunciated. 1976-National Prog for Prevention of Blindness formulated. 1977-MPHW scheme launched.
  5. 5. 1978-EPI launched. 1983-NHP launched. 1985-UIP launched.Separate dept of women & child development launched under Min of HRD. 1987-Safe Motherhood Campaign launched by the World Bank. 1990-ARI Cont Prog –pilot project.
  6. 6. 1992-Infant Milk Substitute,Feeding bottles & Infant Food (Regulation of Production,Supply & Distribution Act). 1994-Prenatal Diagnostic Technique & Prevention 0f Misuse Act.In force from 1996. 1995-ICDS,PPP launched. (Dec-20 Jan 1996). 1996-PPP, Family Welfare Prog made target free approach.
  8. 8. To give expert advice to the the couples to plan their families. Provide health supervision for AN mothers. To detect “High Risk” cases & provide special attention. To fore see complication & prevent them. To give skilled assistance at the time of child birth & during Puerperium.
  9. 9. To supervise trained Dias. To give newborn & child health supervision. To impart useful knowledge on desirable health practices to be adopted during provision of MCH care.
  10. 10. ANTE NATAL CARE.
  11. 11. AIMS OF ANTE NATAL CARE To promote & maintain good mental & physical health during pregnancy. To monitor the progress of pregnancy. To detect & treat medical & obstetrical conditions. To ensure safe delivery of mature & healthy infant. To prepare the women for delivery,breast feeding & subsequent care of the child. To encourage concept of having regular AN
  12. 12. IMPORTANCE OF ANTENATAL CARE. To confirm pregnancy & assess the period of gestation. To prevent maternal & neo natal tetanus. To facilitate health education regd diet,rest,avoidance of un necessary travel & preparation for delivery.
  13. 13. COMPONENTS OF AN CARE. Identification of pregnant women’s & importance of early registration. Diagnosis of pregnancy. Clinical assessment. Advice during AN visit. Nutrition. Management of minor ailments. Risk assessment & appropriate management.
  14. 14. Complications & management. Complications of late pregnancy. Management of medical disorders during pregnancy. Screening for congenital malformations during pregnancy. Management of Anaemia during pregnancy.
  15. 15. IDENTIFICATION / REGISTRATION. Early identification helps, 12 wks.. Assessing the health status of the mother. Obtain baseline information of the mother. Screen for factors, referral to FRU. Recall LMP easily. Do MTP if required.(< 10 wks.) Counsel on hygiene diet , rest. Build up rapport with pregnant women.
  16. 16. WITH IN 20 Wks. Screen & treat anemia. Initiate prophylaxis against anemia. Screen risk factors & medical conditions. Develop individualized birth plan. Immunize with tetanus toxoid. Investigate – Hb,bld grp, typing,urine examination, VDRL, Bld grouping.
  17. 17. 28-32 Wks Aimed at the following.Detect, PIH. Multiple gestation. Anemia. Develop individualized birth plan. Give TT. Assess IUGR. Repeat HB estimation.
  18. 18. 36 Wks. PIH. Detect the following. Identify foetal & presentation. Rule out CPD in primi gravida.
  19. 19. DIAGNOSIS OF PREGNANCY. Women may report with symptoms of, Cessation of menstruation. Nausea with or without vomiting. Disturbance in micturation. Fatigue. Perception of fetal movements.
  20. 20. O/E………………….FIN D, Breast enlargement. Changes in skin colour of areola. Discoloration of vaginal mucosa. Enlargement of abdomen. Softening of cervix & uterus. Uterine enlargement. Internal & external ballotment. Ability to discern fetal parts.
  21. 21. CLINICALLY, Perception of fetal movements by the examiner. Detection of fetal heart sounds at 20 wks. Detection of HCG in urine. Detection of fetus & placenta on USG.
  22. 22. CLINICAL ASSESMENT . Age. Duration of marriage. The order of pregnancy. Number of living children. A.General history.-Date,LMP. Last child birth. Last abortion. Problems during previous pregnancy.
  23. 23. PROBLEMS DURING PREVIOUS PREGNANCY Abortion or premature birth. Eclampsia/Pre-Eclampsia. APH. Malaria ,anemia,UTI. Complicated delivery,PROM. Sepsis.
  24. 24. CONT…. Sepsis. Operations. Still birth,Neonatal death. Induced labour. Baby weigh at birth, Sex,alive,well.
  25. 25. HISTORY OF SYSTEMIC ILLNESS. Heart diseases. DM TB. HT UTI. Malaria. Thyroid diseases.
  26. 26. FAMILY HISTORY. Twins. Congenitally mal formed baby.
  27. 27. COMPLAINTS DURING PRESENT PREGNANCY. Breathlessness. Excessive tiredness. Palpitation. Puffiness of face. Tightening of bangles. Headache,blurring of vision. Bleeding,leaking PV. Pain Abdomen,fever,presence of fetal movements.
  28. 28. PHYSICAL EXAMINATIOIN Ht. Wt. Bp,Hb,grouping,typing,U/S, U/A. Pallor. Odema. Breast examination. Respiratory rate. CVS-prominent neck vein.
  29. 29. ABDOMINAL EXAMINATION. 16 wks-Just above symphysis pubis. 20 wks-Midway between symphysis pubis & umbilicus. 24 wks-At the level of umbilicus. 28 wks-At the junction of the lower third,& upper two third of distance between umbilicus & xiphisternum. 32 wks-Junction of upper & middle third between umbilicus & xiphisternum.
  30. 30. 40 wks- Fundal height comes down but flanks are full. If the fundal ht does not co-rrelate with period of amenorrhea, it could be due to, Wrong dates. Full bladder. Multiple pregnancy. Hydramnios. Molar pregnancy. Pregnancy with pelvic tumor.
  31. 31. IF less, Wrong dates. IUGR. Missed abortion. IUD. Molar pregnancy. Trasverse lie.
  32. 32. ADVICE DURING AN VISIT. Iron & folic acid supplementation. TT injections.(2), 4-6 wks apart . If the previous child birth was within 3 years-1TT. To bring AN card during every visit. Pregnant women may continue her usual activities,throughout her pregnancy.if not tired. Hard & strenuous work should be avoided. Should take bath daily.
  33. 33. Cont………… Should sleep for 8-10 hrs at night & 2 hrs during day. Clean loose cotton cloth should be worn. Retracted nipples should be corrected during the last 6 wks. Coitus should be avoided during 1’st & last trimester. Travel by vehicles having jerks is to be avoided. AN mothers & the at tender to be told regarding
  34. 34. NUTRITION DIETARY ADVICE DURING PREGNANCY. Advice a diet that is nutritious,easily digest able, rich in protein,minerals & vitamins consisting of normal food plus………… least….. Half lit milk./ day. One egg. Plenty of green leafy veg. Fruits. Fiber rich diet.
  35. 35. Advice extra calories for maternal health & to meet the needs of the growing foetus. Advice diet keeping in mind the socio economic condition.
  36. 36. MANAGEMENT OF MINOR AILMENTS. VOMITING IN PREGNANCY. Wanes off at 12-14 wks. Advice small frequent feeds. Avoid greasy foods. Include plenty of green leafy vegetables. Advice plenty of fluids. Encourage dry foods in the morning.
  37. 37. HEART BURN & NAUSEA. Avoid spicy , rich foods. Take cold milk & bland diet. If severe administer antacids.
  38. 38. FREQUENCY OF MICTURATION. Experienced more frequently up to 10-12 wks is mostly self limiting.
  39. 39. CONSTIPATION. Encourage increased fiber intake.
  40. 40. RISK ASSESSMENT & MANAGEMENT. OBSTETRIC FACTORS. Gravidity- Primigravida./ Grand multipara. Age- >35 yrs, below 19 yrs. Height-<145 cm (pre pregnancy wt less or overweight 20% as per height weight standard. Multipara with BOH – loss of previous baby, caesarian section,HY, recurrent premature labour,abortion,IU fetal death,III stage abnormalities, congenitral malformations,neo natal deaths.
  41. 41. Cases of disproportion.- Pelvic contraction, pelvic tumor primi gravid a with non engaged head at / near term. Mal presentations / multiple pregnancy. Obstetric complications---- hemorrhage , threatened abortion,APH,PIH. High risk fetus– premature lab our, IUGR, Rh incompatibility, post maturity. Infertility– conceived after treatment for infertility.
  42. 42. MEDICAL FACTORS. Refer to FRU in following situation. BOH,repeated abortion. Bleeding during pregnancy.(< 12 WKS.) PIH/ Eclampsia. Abnormal presentations. Multiple pregnancy/ Over distended uterus. Grand multipara. Previous history of operative surgery.
  43. 43. Floating head in primi gravid a at 38 wks, & later. Pre term labour. Premature rapture of membrane (labour pain does not start with in 6 hrs.) Very big or very mall baby. Hyper emesis gravidarum not responding to treatment. Heart diseases in pregnancy. Jaundice in pregnancy.
  44. 44. COMPLICATIONS OF EARLY PREGNANCY. Hyper emesis gravid arum. Retroverted gravid uterus with retention of urine. Vaginal bleeding during pregnancy.
  45. 45. PREVENTION OF ANEMIA. CAUSES. Nutritional. Iron deficiency. Folic Acid deficiency. Iron & Folic acid deficiency.
  46. 46. TYPES OF ANEMIA. Hypo chromic microcytic anemia. Macrocytic anemia. Dimorphic anemia. Normocytic normochromic anemia.
  47. 47. INVESTIGATIONS. Hb investigations. Stool for ova cyst. Urine analysis, UTI. Hb electrophorosis.
  48. 48. TREATMENT. Mild-moderate– Oral Fe+ & FA. Diet rich in protein & Iron. Vit C supplementation. Treatment of UTI. Oral iron. Supplementation of vitamins. Referral to FRU.
  49. 49. CALCULATION OF IRON REQUIREMENT. FOR PARENTERAL IRON. SUPPLEMENTATION. Wt in pounds * deficit of Hb * .3 +300 mg. Prophylactic-IFA Large- 1 / day. Therapeutic-IFA large- 2 / day.
  50. 50. COMPLICATIONS OF ANENEMIA DURING PREGNANCY. PRE TERM LABOUR. Prone to infections. CCF,APH,PPH, Maternal mortality. IUGR,Pre maturity,IUD.
  51. 51. COMPLICATIONS OF LATE PREGNANCY. IUD. Pre Eclampsia. Eclampsia. PROM. IUGR.
  52. 52. PRE ECLAMPSIA. Is development of hypertension with or without proteinuria with edema, induced by pregnancy after 20 wks of pregnancy. -----diagnosis. Bp- 140/ Hg. Or Sudden /excessive wt gain. > 1 Kg /wk or, 3 Kgs / month.
  53. 53. MANAGEMENT. Bed rest- Lt latereal position. Exmination twice a week. Control of Bp– Nifidipine 10 mg (o), or sublingually. ------------------Sedation- Inj Largectil (50) mg.IM. ------------------Inj Diazepam 100 mg IM. Refer tp FRU.
  54. 54. ECLAMPSIA. HYPERTENSION,PROTEINURIA,EDEMA,CON VULSIONS charecterize eclampsia. management Refer to FRU. Brefore referal--- Diazepam 10 mg IM. Nifidipine 10 mg sublingual.
  55. 55. DURING TRANSPORTATION. Women must lie on sides & head turned. Put soft gag between teeth. Monitor Bp every 20 min. Establish IV line with splint. Give Oxygen. Start antibiotics. Do continuous catheterizations.
  56. 56. PROM SPONTANEOUS RAPTURE OF MEMBRANES any time during pregnancy beyond 28 wks, before the onset of labour. CONFIRMATION OF DIAGNOSIS. Speculum examination. pH detection 7 – 7.5 – Liquour amni. Fern test.
  57. 57. TREATMENT. Minimal vaginal examination. Start antibiotics ( A Bed rest. Use vulval pad. Ref to FRU. Conduct delivery. moxy 500 mg 6 hrly).
  58. 58. IUGR When the birth weight is below 10 % of the average for gestational age.
  59. 59. MANAGEMENT. Take adequate bed rest. Avoid smoking & alcohol. Correct malnutrition. Refer to FRU.
  60. 60. MEDICAL DISORDERS DURING PREGNANCY. Pregnancy with heart disease. Pregnancy with diabetes. Pregnancy with UTI. Pregnancy with jaundice. Pregnancy with malaria. Pregnancy with TB.
  61. 61. SCREENING FOR CONGENITAL MALFORMATIONS. HIGH RISK FACTORS. Hydramnios. Severe IUGR. Abnormal presentation. Elderly mother. History of drug intake. Uncontrolled DM.
  62. 62. Hypothyroidism-mother. H/O mentally retarded offsprings in the family.
  63. 63. PREVENTION. Administration of folic acid 5 mg daily – 3 months before conception. Controlling DM. Prevention of all kinds of infection. Early diagnosis of malformation & termination. Avoidance of medication ( without physician’s Prescription.).