The highlight is that most of the states recording unfavorable maternal mortality rates are the ones with the highest number of birth rates and huge population bases with poor health infrastructure. There are a number of reasons India has such a high maternal mortality ratio. Marriage and childbirth at an early age, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel, all contribute to pregnancies proving fatal. The common causes of maternal mortality in India are anaemia, haemorrhage, sepsis, obstructed labour, abortion, and toxaemia. Maternal morbidities are the anaemias, chronic malnutrition, pelvic inflammations, liver and kidney diseases. In addition, the pathological processes of some preexisting diseases, such as chronic heart diseases, hypertension, kidney diseases and pulmonary tuberculosis are aggravated by pregnancy and childbirth.
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ANTENATAL CARE Lt Col A S Kushwaha
INDIA Health of Women• Falling low sex ratio of 933 female per thousand male.• Early marriage in women and universality of marriage are important social issues.• The median age at first marriage among women is 17.2 years.• Among young women age 15-19, 16 percent have already begun childbearing.• Less than half of women received antenatal care during the first trimester of pregnancy, as is recommended..• Three out of every five births in India take place at home;. Postnatal care is most common following births in a medical facility.• Every seven minutes an Indian woman dies from complications related to pregnancy and childbirth.09/05/2012 Lt Col A S Kushwaha
Problems in MCH• Varies from developing to developed countries• Triad of malnutrition, infection & Unregulated fertility• Lack of health infrastructure• Gender based discrimination• Poor socio-economic conditions09/05/2012 Lt Col A S Kushwaha
ANTENATAL CAREWhy ?Three types of health problems exist in pregnancy.1. The complications of pregnancy itself,2. Second, diseases that happen to affect a pregnant woman and which may or may not be aggravated by pregnancy, and3. Third, the negative effects of unhealthy lifestyles
Definitions• Antenatal care• Preconception care• Prenatal care
Antenatal care ANC includes• visit to antenatal clinic,• examination,• investigations,• immunization,• supplements (Iron, Folic acid, Calcium, Nutritional)• and interventions as required.
Preconception care• Refers to physical and mental preparation of both parents for pregnancy and childbearing in order to improve the pregnancy outcome.
Objectives of ANCGoal - Healthy mother and a healthy babyObjectives-???
Objectives of Antenatal Care1. To promote , protect and maintain health of the mother2. To detect ‘ at risk’ cases and provide necessary care3. To provide advise on self care during pregnancy4. To educate women on warning signals, child care, family planning5. To prepare the woman for labour and lactation6. To allay anxiety associated with pregnancy and childbirth7. To provide early diagnosis and treatment of any medical8. condition/ complication of pregnancy9. To plan for “ Birth” and emergencies / complications ( where, how, by whom, transport, blood )10. To provide care to any child accompanying the mother
Visits• Regular• Ideally - once a month during first seven months, - twice a month for 8th month - and every week thereafter till delivery• Minimum -4• Besides 1st visit, visits at 20, 32 and 36 weeks are recommended.• Essential Antenatal Care
Preconception Care Indications for Preconception Care• Advanced maternal (>35 years) or paternal (>55 years) age• history of neural tube defects in family or previous pregnancy• Congenital heart disease, hemophilia, thalassemia, sickle cell disease, Tay-sach’s disease, cystic fibrosis, Huntington chorea, muscular dystrophy, Down’s syndrome.• maternal metabolic disorders• recurrent pregnancy loss (>3)• Use of alcohol, recreational drugs or medications• Environmental or occupational exposures
ANC – First Visit The functions of this visit are-1. Confirmation of pregnancy2. Screening for high risk pregnancy3. Baseline investigations4. Initiation of Iron and Folic Acid supplementation5. Immunization with Tetanus toxoid6. Education of the mother on pregnancy and childbirth
Identify “High Risk” pregnancies• Maternal factors --???• BOH ??• Medical conditions ??
Maternal factors -• Age- <18 years or > 35 years (especially in primigravida)• Multiparity (>4)• Short stature ( < 140 cms )• Weight < 40 Kg / weight gain < 5 Kg• Rh negativeBOH- Recurrent abortions ( 2 x1st trimester or 1 mid-trimester)• Intrauterine death or intrapartum death/ stillbirth • Prolonged Labour, birth asphyxia , early neonatal death • Previous caesarean section / scar dehiscence • Postpartum hemorrhage , manual removal of placenta • Baby which is LBW, SFD or large for date, congenitally malformed • Malpresentation, instrumental delivery, ectopic pregnancy • Twins, hydramnios, pre-eclampsia Medical Disorders- • Cardiac ( RHD, CHD, Valve defects), renal or endocrine (Thyroid) • Infections- TB, Leprosy, etc • Hypertension, diabetes, IHD, seizures • Malaria, acute febrile, gastrointestinal disease • Anemia
pregnancy at any stage can be classified as high risk if -• Bleeding PV at any point ( Antepartum hemorrhage)• Excessive vomiting ( Hyperemesis gravidarum)• Hypertension, proteinuria• Severe anemia• Abnormal weight gain• Multiple pregnancy, hydramnios, oligohydramnios• Abnormal presentation in 9th month• Preterm Labour, PROM• Pre-eclampsia, eclampsia
Supplements• Iron & Folic Acid• Tetanus Toxoid Immunization
Rh Iso-immunisation• Abortion• LSCS• Labour• Monitor antibody titer at 28 and 36 wks• Anti-D Ig- given at 28 wks/ within 72 hrs
Health Education• Diet & Rest• Personal Hygiene and Habits-.• Sexual intercourse-• Drugs• Exercise• Travel-• Care of Breasts• Warning signs
Warning Signs• Swelling of feet• Convulsions/ unconsciousness• Severe headache• Blurring of vision• Bleeding or discharge per vaginum• Severe abdominal pain• any other unusual symptom
Subsequent Visits• Monitor – Progress of pregnancy Foetal wellbeing• Identify and manage any condition
1st Trimester• Confirmation of pregnancy• define maternal risk status,• counsel on early pregnancy discomforts• Offer early prenatal screening tests ( chorionic villous sampling, amniocentesis, USG) to those with genetic risk factors.
2nd Trimester• confirmation of EDD,• certain screening tests like maternal serum alpha fetoprotein ( 16-18 weeks) for Neural tube defects ( 4 per 10,000 live births).• Rule out gestational diabetes.• Rh negative women are given anti-D immunoglobulin at 28 weeks
3rd Trimester• watch for complications.• Counsel the lady on warning signs, labour and delivery• Work out birth plan.• Assess adequacy of pelvis
Symptoms & their Mgt• Nausea & Vomiting• Headache• GI symptoms• Urinary symptoms• Vaginal discharge• Vaginal bleeding• Backache• Swelling of feet & ankles• Varicose veins
Pre-eclampsia• Hypertensive disorders of pregnancy are the cause of 12% of maternal deaths.• If the diastolic BP is >or =90 mm Hg , ask for symptoms like severe headache, blurred vision, epigastric pain and check for proteins in urine.• Pre-eclampsia is diagnosed if diastolic BP is 90-110 mm Hg and proteinuria (++) is detected.
Pregnancy & HIV• Provide key information on HIV• HIV testing and Counselling• Care & Counselling• Provide support• Give ART• Counsel on infant feeding
Pregnancy & HIV `where HIV prevalence amongst antenatal cases is high.• special handling.• PMTCT• Mothers2Mothers (m2m)• ART- -AZT 300 mg every 12 hours is given from 36 weeks of pregnancy till onset of labour and thereafter 300mg every 3 hours. - Alternatively, Nevirapine 200 mg single dose as early as possible in labour and 50 mg in oral solution form to the newborn within 72 hours• Replacement feeding using principles of AFASS (acceptable, feasible, affordable, safe and sustainable)
Child birth – a miracle of life should notbecome a nightmare of death
Some facts• 85 % women will deliver normally• 10-15 % women will develop complications• 3-5 % women will need surgical interventions (blood/Cesarean etc.) More chances of women having a normal deliveryHowever delivery complications can occur suddenly, without any warning signals 30
Some facts• 20-25% deaths occur during pregnancy.• 40-50% deaths occur during labour and delivery• 25-40% deaths occur after childbirth (More during the first seven days) It is important to focus attention during pregnancy and also after childbirth 31
Scenario in India Every seven minutes an Indian woman dies from complications related to pregnancy and childbirth. The maternal mortality ratio in India stands at 300 per 100,000 live births. It has some high performing states like Kerala with MMR of 110 and poorly doing states like Uttar Pradesh with MMR of 517.
Birth Plan• Where is the birth going to take place?• Who will conduct the delivery?• Are adequate arrangements available in case of an emergency?• What is the arrangement for transportation?• If required, what is the arrangement for blood?• What is the arrangement for any neonatal resuscitation?• Who is going to be the attendant with the mother and child?• Is financial support available?
Objectives of Intra-natal Care• Intranatal care (AMC-N)• Thorough Asepsis (“The Five Cleans” - clean hands, surface, blade, cord, tie)• Minimum injury to mother and child• To deal with any Complications• Care of the Newborn
Institutional deliveryInstitutional delivery is a must if there is-1. Mild pre-eclampsia2. PPH in the previous pregnancy3. More than 5 previous births or a primi4. Previous assisted delivery5. Maternal age less than 16 years6. H/o third-degree tear in the previous pregnancy7. Severe anaemia8. Severe pre-eclampsia/eclampsia9. APH10.Transverse fetal lie or any other Malpresentation11.Caesarean section in the previous pregnancy12.Multiple pregnancies13.Premature or pre-labour rupture of membranes (PROM)14.Medical illnesses such as diabetes mellitus, heart disease, asthma, etc.15.Pregnancy in women who are HIV positive
• DELIVERY AT REFERRAL CENTRE1. Prior delivery by caesarean.2. Age less than 14 years.3. Transverse lie or other obvious malpresentation within one month of expected delivery.4. Obvious multiple pregnancy.5. Tubal ligation or IUD desired immediately after delivery.6. Documented third degree tear.7. History of or current vaginal bleeding or other complication during this pregnancy.DELIVERY AT PHC IF------■ First birth.■ Last baby born dead or died in first day.■ Age less than 16 years.■ More than six previous births.■ Prior delivery with heavy bleeding.■ Prior delivery with convulsions.■ Prior delivery by forceps or vacuum.■ HIV-positive woman.AS PREFERRED BY WOMAN if ---■ None of the above.
Role of Birth Attendant/ Midwife• Explain all the procedures• Praise the woman, encourage her and reassure her that things are going well.• Encourage the woman to bathe or wash herself and her genitals at the onset of labour.• Always wash your hands with soap and water before examining the woman• Ensure cleanliness of the birthing area.• Enema should be given only when needed.• Encourage the woman to empty her bladder frequently.• Non-pharmacological methods of relieving pain during labour
PARTOGRAPHvisual graphic account of the salient features of labour.RECORD OF-Contractions, their intensity, frequency and duration are recorded.Cervical dilatation and effacement are recorded.FHS, amniotic fluid, vitals of the mother, fluid balance, drugs administered etc.Readily available tool for decision making.Advantages: 1. reduced prolonged labours and instrumental deliveries; 2. higher APGAR scores and 3. lower perinatal mortality. WHO modified Partograph- No latent phase
Domiciliary Care• Pre-requisites for a safe home delivery-• If the woman has chosen to deliver at home, all family members must be explained that safe and clean delivery with the skilled birth attendant is ensured.• A disposable delivery kit must be provided and instructions on its usage are given
Home delivery with a skilled attendantAdvise how to prepareReview the following with her:■ Who will be the companion during labour and delivery?■ Who will be close by for at least 24 hours after delivery?■ Who will help to care for her home and other children?■ Advise to call the skilled attendant at the first signs of labour.■ Advise to have her home-based maternal record ready.■ Advise to ask for help from the community, if needed I2 .Explain supplies needed for home delivery■ Warm spot for the birth with a clean surface or a clean cloth.■ Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for cleaning the baby’s eyes, for the birth attendant to wash and dry her hands, for use as sanitary pads.■ Blankets.■ Buckets of clean water and some way to heat this water.■ Soap.■ Bowls: 2 for washing and 1 for the placenta.■ Plastic for wrapping the placenta.
Home Delivery without Skilled Birth Attendant1. To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. She should also keep her nails clean.2. To, after delivery, place the baby on the mother’s chest with skin-to-skin contact and wipe the baby’s eyes using a clean cloth for each eye.3. To cover the mother and the baby.4. To use the ties and razor blade from the disposable delivery kit to tie and cut the cord. The cord is cut when it stops pulsating.5. To dry the baby after cutting the cord. To wipe clean but not bathe the baby until after 6 hours.6. To ensure a clean delivery surface for the birth
7. To wait for the placenta to deliver on its own.8. To start breastfeeding when the baby shows signs of readiness, within the first hour after birth.9. To NOT leave the mother alone for the first 24 hours.10. To keep the mother and baby warm. To dress or wrap the baby, including the baby’s head.11. To dispose of the placenta in a correct, safe and culturally appropriate manner (burn or burry).
Advise to avoid harmful practicesFor example:1. Not to use local medications to hasten labour.2. Not to wait for waters to stop before going to health facility.3. NOT to insert any substances into the vagina during labour or after delivery.4. NOT to push on the abdomen during labour or delivery.5. NOT to pull on the cord to deliver the placenta.6. NOT to put ashes, cow dung or other substance on umbilical cord/stump.7. Encourage helpful traditional practices: