Introduction to maternal


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Introduction to maternal

  1. 1. Introduction to Maternaland Child health<br />
  2. 2.  70% of the population of developing<br />countries<br /> In India women of child bearing age (15-<br />44 Yrs) are 19%<br /> Children under 15 years 40%<br /> Together 59%<br /> They are vulnerable or special –risk group<br /> Risk –connected with childbearing for<br />women<br /> Growth development and survival<br />-children<br />
  3. 3.  50% of deaths are above 70 yrs of age<br /> Same among under-five children<br /> Maternal mortality rates vary from 13- 440 per<br />100000 live births<br /> Sickness and deaths among mothers and children<br />are largely preventable<br /> This have led to the formation of special health<br />services for mother and children all over the<br />world<br /> The present strategy is to provide maternal and<br />child as an integrated package of “Essential<br />health care” also known as “Primary health care”<br />
  4. 4. Mother and child as one unit- because<br />1. During the antenatal period , the fetus is part<br />of the mother – development – 280 days,<br />during this period fetus receives nutrition and<br />oxygen from the mother<br />2. Child health is closely related to maternal<br />health; a healthy mother brings forth a<br />healthy baby; there is less chances of<br />premature, still birth or abortion<br />
  5. 5. 1. Certain diseases and conditions of the<br />mother during pregnancy ( eg. Syphilis,<br />German measles, drug intake) are likely to<br />have their effects on the fetus<br />2. After birth, the child is dependant on the<br />mother. Up to 6 - 9 months completely for<br />feeding. The mental and social<br />development is also dependant on the<br />mother, if the mother dies the child's<br />growth and development are affected<br />(maternal deprivation syndrome)<br />
  6. 6. 1. In the care cycle of women, there are few<br />occasions when the service of the child is<br />simultaneously called for . For instance<br />post partum care is inseparable from<br />neonatal care and family planning advice<br />2. The mother is also the first teacher of the<br />child<br />
  7. 7. Obstetrics, Pediatrics and PSM<br /> In the past , maternal and child health services were rather fragmented and provided<br />piecemeal “ personal health services” by<br />different agencies, in different ways and<br />separate clinics the current trend in many<br />countries is to provide integrated MCH and<br />family planning services as compact family<br />welfare service<br />
  8. 8.  This implies a close relationship of<br />maternity health to child health, of<br />maternal and child health to the health of<br />the family; and of family to the general<br />health of the community<br /> In providing these services , specialists in<br />obstetrics and child health have joined<br />hands , and are now looking beyond the<br />four walls of hospitals into community to<br />meet health needs of mothers and children<br />aimed at positive health<br />
  9. 9.  In the process they have linked to<br />community medicine( preventive and<br />social medicine ) and as a result , terms<br />such as “social obstetrics” , “preventive<br />pediatrics” and “social pediatrics” have<br />come into vogue<br />
  10. 10. Obstetrics<br /> Obstetrics is largely preventive medicine<br /> The aims are same, to ensure that throughout<br />pregnancy and puerperium, the mother will have<br />good health and that every pregnancy may culminate<br />in a healthy mother and healthy baby<br /> The age old concept that obstetrics is now<br />considered as a very narrow concept, and is being<br />replaced by the concept of community obstetrics<br />which combines obstetrical concerns with the<br />concepts of primary health care<br />
  11. 11. Social obstetrics<br /> Gained usage in recent years<br /> Defined as the study of the interplay of social<br />and environmental factors and human<br />reproduction going back to the<br />preconceptional or even premarital period<br />
  12. 12.  The social and environmental factors<br />which influence human reproduction are a<br />legion viz. age at marriage , childbearing,<br />child spacing , family size , fertility<br />patterns, level of education, economic<br />status , level of education, economic<br />status , customs and beliefs, role of women<br />in society , etc.<br /> The social and obstetric problem in India<br />differs from other developed countries<br />
  13. 13.  While accepting the influence of<br />environmental and social factors on human<br />reproduction, social obstetrics has yet<br />another dimension, that is influence of<br />these factors on the organization, delivery<br />of comprehensive MCH services including<br />family planning so that they could be<br />brought within the reach of the total<br />community<br />
  14. 14. Preventive pediatrics<br /> Like obstetrics pediatrics has a large component of<br />Preventive and Social Medicine<br /> There is no other discipline that teaches the value of<br />preventive medicine<br /> Recent years have witnessed further specialization<br />within the broad field of pediatricsviz preventive<br />pediatrics, social pediatrics, neonatology,<br />perinatology, developmental pediatricspediatric<br />surgery, pediatric neurology<br />
  15. 15.  Preventive pediatrics comprises efforts to<br />avert rather than cure disease and<br />disabilities<br /> It has been broadly divided into antenatal<br />pediatrics and postnatal pediatrics<br /> The aims of preventive pediatrics and<br />preventive medicine are the same –<br />prevention of disease and promotion<br />physical , mental and social well being of<br />children so that each child may achieve<br />genetic potential with which he is born<br />
  16. 16.  To achieve these aims , hospitals for<br />children have adopted the strategy of<br />“primary health care “ to improve child<br />health care through such activities as<br />growth monitoring, oral rehydration,<br />nutritional surveillance, promotion of<br />breast feeding, immunization, community<br />feeding, regular health check ups etc.<br /> Primary health care with its potential for<br />vastly increased coverage through an<br />integrated system of service delivery is<br />increasedly looked upon as the best<br />solution to reach millions of children<br />
  17. 17. Social pediatrics<br /> Defined as the application of the<br />principles of social medicine to pediatrics<br />to obtain a more complete understanding of<br />the problems of children in order to<br />prevent and treat disease and promote their<br />adequate growth and development, through<br />an organized health structure<br />
  18. 18.  To study child health in relation to<br />community, to social values and to social<br />policy<br /> This has given rise to concept of social<br />pediatrics it is concerned not only with the<br />social factors which influence child health<br />but also with the influence of these factors<br />on the organization, delivery and<br />utilization of child health care services<br />
  19. 19.  In other words , social pediatrics is<br />concerned with the delivery of<br />comprehensive and continuous child health<br />care services and to bring these services<br />within the reach of the local community.<br /> Social pediatrics also covers various social<br />welfare measures – local , national,<br />international – aimed to meet the total<br />health needs of the child<br />
  20. 20. Contribution of Preventive and Social Medicineto Social Obstetrics and Pediatrics<br />1. Collection and interpretation of community<br />statistics, delineating groups “at risk” for special<br />care<br />2. Correlation of vital statistics ( eg., maternal and<br />infant morbidity and mortality rates, perinatal and<br />child mortality rates )with social and biological<br />characteristics such as birth weight , parity, age,<br />stature, employment etc., in the elucidation of<br />etiological relationships<br />
  21. 21. 1. Study of cultural patterns, beliefs and<br />practices relating to childbearing and<br />childrearing, knowledge of which might<br />be useful in promoting acceptance and<br />utilization of obstetric and pediatric<br />services by the community<br />2. To determine priorities and contribute to<br />the planning of MCH services and<br />programmes<br />3. For evaluating whether MCH services and<br />programmes are accomplishing their<br />objectives<br />
  22. 22. Maternity cycle - stages<br />1. Fertilization<br />2. Antenatal or prenatal period<br />3. Intranatal period<br />4. Postnatal period<br />5. Inter - conceptional period<br />
  23. 23.  Fertilization takes place in the outer part of<br />the fallopian tube.<br /> Segmentation of the fertilized ovum begins<br />at once and proceeds at a rapid rate<br /> The fertilized ovum reaches the uterus in<br />8- 10 days.<br /> Cell division proceeds at a rapid rate<br /> By a process of cell division and<br />differentiation, all the organs and tissues of<br />the body are formed<br />
  24. 24. Period of growth<br />1. Prenatal period<br />1. Ovum – 0-14 days<br />2. Embryo - 14 days to 9 weeks<br />3. Fetus – 9th week to birth<br />2. Premature – 28 to 37 weeks<br />3. Birth, full term – average 280 days<br />
  25. 25. Antenatal care<br />
  26. 26. Objectives<br /> To promote, protect and maintain the health<br />of the mother during pregnancy<br /> To detect “high risk” cases and give them<br />special attention<br /> To foresee complications and prevent them<br /> To remove anxiety and dread associated with<br />delivery<br />
  27. 27.  To reduce maternal and infant mortality<br />and morbidity<br /> To teach the mother elements of child care,<br />nutrition, personal hygiene and<br />environmental sanitation<br /> To sensitize the mother to the need for<br />family planning, including advice to cases<br />seeking medical termination of pregnancy<br /> To attend to the under fives accompanying<br />the mother<br />
  28. 28. Antenatal visits<br /> Mother should attend AN clinics<br /> Once a month during first 7 months<br /> Twice a month during the next month<br /> Thereafter once a week in the ninth month<br />If everything is normal<br />
  29. 29. Minimum 3 antenatal visits<br />1. At 20 weeks or as soon as pregnancy is<br />known<br />2. At 32 weeks<br />3. At 36 weeks<br />4. At least 1 home visit by health worker<br />
  30. 30. Preventive services for the mothers<br /> Prenatal services ( before delivery)<br /> First visit should include following<br /> Health history<br /> Physical examination<br /> Laboratory examination<br />
  31. 31. Lab tests<br />1. Complete urine analysis<br />2. Stool examination<br />3. Complete blood count, including Hb<br />estimation<br />4. Serological examination<br />5. Blood grouping and Rh determination<br />6. Chest x- ray if needed, pap tests, Gonorrhea<br />culture (Optional)<br />
  32. 32. On subsequent visits<br /> Physical examination( weight gain, Blood<br />pressure)<br /> Laboratory tests should include<br />1. Urine examination<br />2. Hemoglobin estimate<br />
  33. 33.  Iron and folic acid supplementation<br /> Tetanus Immunization<br /> Group or individual instruction on<br />nutrition, family planning, self care,<br />delivery and parenthood<br /> Home visiting by female health worker /<br />trained dai<br /> Referral services , where necessary<br />
  34. 34. Risk approach<br /> Identify high risk cases from a large group of<br />antenatal mothers and arrange them for<br />skilled care, while continuing to provide<br />appropriate care for all mothers<br />
  35. 35. At risk mothers<br />1. Elderly primi (30 years and over)<br />2. Short statured primi ( 140 cms and over)<br />3. Mal-presentations( breech, transverse lie)<br />4. Ante-partum hemorrhage, threatened<br />abortion<br />5. Pre – eclampsia and eclampsia<br />6. Anemia<br />
  36. 36. 1. Twins, hydramnios<br />2. Previous still birth, intrauterine death,<br />manual removal of placenta<br />3. Elderly grand multiparas<br />4. Prolonged pregnancy( 14 days after<br />expected date of delivery)<br />5. History of previous cesarean or<br />instrumental delivery<br />6. Pregnancy associated with general<br />diseases – cardiovascular disease, kidney<br />disease, diabetes, tuberculosis, liver<br />disease<br />
  37. 37. Risk approach is a managerial tool<br /> Services for all but with special attention to<br />those who need them the most<br /> Maximum utilization of all resources<br />including some which are not involved in<br />in such care – traditional birth attendants,<br />community health workers, women groups<br /> Improvements in coverage & quality of<br />health care<br />
  38. 38. Maintenance of records<br /> Antenatal card- in first examination, thick paper to<br />facilitate filing<br /> Registration number. Identifying data, previous<br />health history, main health events<br /> Record is kept at MCH/FP center<br /> A link is maintained between the antenatal card,<br />postnatal card and under-fives card<br /> Essential for evaluation and further improvement<br />
  39. 39. Home visits<br /> Home visiting is the backbone of all MCH<br />services<br /> Even if the expectant mother is attending the<br />ante natal clinic regularly, she must be paid<br />one home visit by the health worker female or<br />public health nurse<br /> More visits are required if the delivery is<br />planned at home<br />
  40. 40. Prenatal advice<br /> Mother s more receptive to the advice<br />concerning herself and her baby at this time<br />than at other times<br /> The talking points should cover not only the<br />specific problems of pregnancy and childbirth<br />but also about family and child health care<br />
  41. 41. Prenatal advice - diet<br /> Reproduction costs energy<br /> Pregnancy in total duration consumes<br />about 60000 k cal over and above normal<br />metabolic requirements<br /> Lactation demands about 550 kcal / day<br /> Child survival is correlated with birth<br />weight<br /> Birth weight is correlated to the weight<br />gain of the mothewrww .dsimuilimar.ciomng pregnancy<br />
  42. 42.  On an average . A normal healthy women<br />gains about 12 kg of weight during<br />pregnancy<br /> Average poor Indian women gains 6.5 Kgs<br /> Thus pregnancy imposes extra calorie and<br />nutritional requirements<br /> If maternal stores of iron are poor (as may<br />happen after repeated pregnancies) and if<br />enough iron is not available to the mother<br />during pregnancy, it is possible that fetus<br />may lay down insufficient iron stores<br />
  43. 43.  Such a baby may show a normal Hb. at<br />birth but will lack the stores of iron<br />necessary for rapid growth and increase in<br />blood volume and muscle mass in the first<br />year of life<br /> Stresses in the form of malaria and other<br />childhood infections will make the<br />deficiency more acute, and many infants<br />become severely anemic during the early<br />months of life<br /> Therefore a balanced diet is necessary<br />
  44. 44. Personal hygiene<br /> Personal cleanliness – bathe, clean clothes,<br />hair<br /> Rest and sleep – 8 hrs sleep, 2 hrs rest after<br />midday meals<br /> Bowels – constipation should be avoided by<br />taking green leafy vegetables, fruits and extra<br />fluids purgatives like castor oils should be<br />avoided<br />
  45. 45.  Exercise – light household work is advised<br />but manual physical labour during late<br />pregnancy may adversely affect the foetus<br />Smoking – should be cut down, causes<br />Intrauterine growth retardation, low birth<br />weight babies.<br /> Vasoconstrictor action produces placental<br />insufficiency.<br /> Mothers who smoke heavily produces on an<br />average 170 g less weight babies at term.<br /> The perinatal mortality amongst babies<br />whose mother smoked during pregnancy is<br />10-40% higher<br />
  46. 46.  Alcohol :alcohol causes fertility problems<br />in mothers, pregnancy loss, various<br />physical and mental problems in the child,<br />causes fetal alcohol syndrome in the child<br />– includes IUGR, developmental delay<br /> Dental care – oral hygiene<br /> Sexual intercourse – should be restricted<br />especially in the last trimester<br />
  47. 47. Drugs<br /> Drugs which are not absolutely essential<br />should be discouraged<br /> Can cause fetal malformations – like<br />thalidomide – more serious when taken 4-8<br />weeks of pregnancy<br /> LSD produces chromosomal damage,<br />streptomycin causing deafness, iodide causing<br />congenital goitre<br />
  48. 48.  Corticosteroids may impair growth<br /> Sex hormones – virilism<br /> Tetracyclines- growth of bones and enamel<br />formation<br /> Anesthetics – pethidine administered<br />during labour- can have depressant effect<br />and delay the onset of respiration<br /> Certain drugs are excreted in breast milk<br />
  49. 49. Radiation<br /> Exposure to radiation, X ray during<br />pregnancy - mortality from leukemia and<br />other neoplasms are significantly higher<br /> Congenital malformations such as<br />microcephaly<br /> X rays should be avoided in the last 2 weeks<br />preceding menstrual cycle<br />
  50. 50. Warning signs<br /> Report immediately<br />1. Swelling of the feet<br />2. Fits<br />3. Headache<br />4. Blurring of vision<br />5. Bleeding or discharge per vagina<br />6. Any other unusual symptoms<br />
  51. 51. Child care<br /> The art of child care should be learnt<br /> Special classes to be conducted<br /> Mother craft includes – nutrition education,<br />advice on hygiene and childrearing, cooking<br />demonstrations, family planning education,<br />family budgeting etc.<br />
  52. 52. Specific health protection – 1.anemia<br /> About 50% to 60% of mothers in India of<br />low socio economic groups are anemic in<br />the last trimester of pregnancy<br /> Etiology is iron and folic acid deficiency<br /> Associated with high incidence of<br />premature births, postpartum hemorrhage,<br />peuerperal sepsis and thromboembolic<br />phenomena in the mother<br /> IFA supplementation is done by Govt. of<br />India<br />
  53. 53. Other nutritional deficiencies<br /> Protein, vitamin and minerals<br /> Especially vit A and iodine<br /> Milk should be supplemented, or skimmed<br />milk should be given<br /> Capsules of vitamin A and D also supplied<br />free of cost<br />
  54. 54. Toxemias of pregnancy<br /> Presence of albumin in urine and increase in<br />blood pressure<br /> Their early detection and management<br />
  55. 55. Tetanus<br /> 2 doses of adsorbed tetanus toxoid should be<br />given<br /> First dose 16 – 20 weeks and second 20-24<br />weeks of pregnancy<br /> Minimum interval between 2 doses should be<br />1 month<br /> Second dose should be given at least 1 month<br />before the EDD<br />
  56. 56.  However , no dose of TT should be denied<br />to the mother even in late pregnancy<br /> For a mother who have been immunized<br />earlier, 1 booster dose will be sufficient<br /> When such booster doses are given it will<br />cover subsequent pregnancies in the next 5<br />years<br /> It is advised not to immunize the mother in<br />every pregnancy in order to prevent hyperimmunization<br />
  57. 57. Syphilis<br /> Important cause of pregnancy wastage in<br />some countries<br /> Pregnancies in primary and secondary<br />syphilis end in spontaneous abortion, still<br />birth, perinatal death or birth of a child with<br />congenital syphilis<br /> Syphilitic infection in pregnant women is<br />transmissible to the foetus<br />
  58. 58.  Neurological damage with mental<br />retardation is one of the most serious<br />consequences of congenital syphilis<br /> Infection of the foetus does not occur in 4th<br />month of pregnancy<br /> it is most likely to occur after the 6th<br />month of pregnancy by which time the<br />Langhans cell layer has completely<br />atrophied<br /> Infection of the foetus most likely in<br />primary and secondary stage of syphilis but<br />rare in late syphilis<br />
  59. 59. German measles<br /> In a long-term prospective study done in<br />Great Britain, when rubella is contracted to<br />the mother in the first 16 weeks of<br />pregnancy, foetal death or death during the<br />first year of life occurred in 17% of<br />offspring's<br /> Among survivors who were followed up<br />the age of 8 years, 15 % had major defects<br />like cataract, deafness and congenital heart<br />diseases<br />
  60. 60.  Risk of malformations is about 20% up to<br />20 weeks of gestation<br /> In some countries all school aged children<br />are vaccinated<br /> Before vaccinating the women of child<br />bearing age should be made sure that they<br />are not pregnant and they follow<br />contraception for 8 weeks later to prevent<br />risk of rubella to the fetus<br />
  61. 61. Rh status<br /> The fetal red cells may enter the maternal<br />circulation in a number of difficult<br />circumstances, during labor, caesarean<br />section, therapeutic abortion, external<br />cephalic version and apparently<br />spontaneously in the late pregnancy<br />
  62. 62.  The intrusion of these cells, if the mother is<br />Rh –ve and the child is Rh +ve, provokes<br />an immune response in her so that she<br />forms antibodies to Rh which can cross<br />placenta and produces fetal RBC<br />hemolysis<br /> The same response may be seen by the<br />transfusion of Rh+ve blood<br /> In a pregnant woman, iso-immunisation<br />mainly occurs in labour, so that the first<br />child although Rh+ve, is unaffected except<br />where the mother is already sensitized.<br />
  63. 63.  In the second or subsequent pregnancies, if<br />the child is Rh +ve, the mother will react to<br />the smallest intrusion of fetal cells, by<br />producing antibodies to destroy fetal blood<br />cells causing hemolytic disease in the fetus<br /> Clinically hemolytic disease takes the form<br />of Hydropsfetalis, icterus gravis<br />neonatorum( of which Kernicterus is a<br />common sequel) and congenital hemolytic<br />anemia<br />
  64. 64.  Routinely test the blood for rhesus type<br />early in pregnancy<br /> If the women is Rh-ve and the husband is<br />+ve , she is kept under surveillance for Rh<br />antibody levels during antenatal care<br /> The blood should be further examined at<br />28 weeks and 34-36 weeks of gestation for<br />antibodies<br /> Rh anti D immunoglobulin should be given<br />at 28 weeks of gestation so that<br />sensitization during the first pregnancy can<br />be prevented<br />
  65. 65.  If the baby is Rh +ve, the Rh anti D<br />immunoglobulin is given again within 72<br />hrs of delivery<br /> It should also be given after abortion<br /> Post maturity should be avoided<br /> Whenever evidence of hemolysis in-utero<br />is suspected mother should be shifted to<br />special centers equipped to deal with such<br />problems<br /> Incidence of hemolysis due to Rh factor in<br />India is 1 for every 400- 500 live births<br />
  66. 66. HIV infection<br /> HIV in child may occur through placenta,<br />delivery, breast feeding<br /> 1/3 of the children get infected through<br />above routes<br /> Risk is higher if the mother is newly<br />infected or she had already developed<br />AIDS<br /> Voluntary prenatal testing for HIV<br />infection should be done as early in<br />pregnancy for all wmww.simoilimtah.coemrs<br />
  67. 67. Prenatal genetic screening<br /> Prenatal genetic screening includes<br />screening for chromosomal abnormalities<br />associated with serious birth defects,<br />screening for direct evidence of congenital<br />structural anomalies, screening for<br />hemoglobinopathies and other inherited<br />conditions detectable by biochemical<br />assays<br /> Universal genetic screening is generally<br />not recommended<br /> 67<br />
  68. 68.  Screening for chromosomal abnormalities<br />and for direct evidence for structural<br />anomalies is performed in pregnancy in<br />order to take decisions regarding<br />therapeutic abortions<br /> Typical examples are Down’s syndrome<br />and severe neural tube defects<br /> Women aged above 35 years and those<br />who are having afflicted child are at higher<br />risk<br />
  69. 69. Mental preparation<br /> It is also important<br /> A free and frank talks on all aspects of<br />pregnancy and delivery<br /> Removing the fears about confinement<br /> The mother craft classes at the MCH centers<br />
  70. 70. Family planning<br /> Related to every phase of maternity cycle<br /> Mothers are psychologically more<br />receptive to the advice on family planning<br />than at other times<br /> Motivation and education should be done<br />during the antenatal period<br /> If the mother has had 2 or more children<br />she should be motivated for puerperal<br />sterilization<br /> All India post partum programme services<br />are available<br />
  71. 71. Pediatric component<br /> Pediatrician should be in attendance at all<br />antenatal clinics to pay attention to the under<br />fives accompanying the mother<br />
  72. 72. Intranatal care<br />
  73. 73.  Childbirth is a normal physiological process, but<br />complications may arise<br /> Septicemia may result from unskilled and septic<br />manipulationsand tetanus neonatorum from the<br />use of unsterile instruments<br /> The need for effective in tranatal care is<br />indispensable<br /> The emphasis is on cleanliness<br /> 5 cleans - clean hands and fingernails,a clean<br />surface for delivery, clean blade for cutting the<br />cord, clean cord tie, clean cord stump and care of<br />the cord<br />
  74. 74.  Keep the birth canal clean by avoiding<br />harmful practices<br /> Hospital and health centers should be<br />equipped for delivery with midwifery kits, a<br />regular supply of sterile gloves and drapes,<br />towels, cleaning materials, soap and antiseptic<br />solution, as well as equipment for sterilizing<br />instruments and supplies<br />
  75. 75.  There are delivery kits available with the<br />items needed for basic hygiene for delivery<br />at home, where a midwife with a<br />midwifery kit is not likely to be present<br />
  76. 76. AIMS<br />1. Thorough asepsis<br />2. Delivery with minimum injury to the<br />infant and mother<br />3. Readiness to deal with complications such<br />as prolonged labour, antepartum<br />haemorrhage, convulsions,<br />malpresentations, prolapse of the cord<br />4. Care of the baby at delivery- resusitation,<br />care of the cord, eyes etc.<br />
  77. 77. Domiciliary care<br /> Confinement can be in home if the conditions<br />are satisfactory<br /> In such cases delivery may be conducted by<br />the health worker female or trained dai<br /> This is called as domiciliary midwifery<br />service<br />
  78. 78. Advantages of domiciliary care<br />1. The mother delivers in the familiar<br />surroundings of her home and this may<br />tend to remove the fear associated with<br />delivery in a hospital<br />2. The chances for cross infection are<br />generally fewer at home than in<br />nursery/hospital<br />3. The mother is able to keep an eye upon<br />other children and domestic affairs; this<br />may tend to ease her mental tension<br />
  79. 79. Disadvantages of domiciliary care<br />1. The mother may have less medical and<br />nursing supervision than in the hospital<br />2. The mother may have less rest<br />3. May resume her duties too soon<br />4. Her diet may be neglected<br />5. Many homes in India may be unsuitable for<br />even a normal delivery<br />
  80. 80.  Since 74% of India’s population live in<br />rural areas, most deliveries will have to<br />take place at home with the aid of female<br />health workers and trained dai’s<br /> Female health worker who is a pivot of<br />domiciliary care should be adequately<br />trained to recognize the ‘danger signals’<br />during labour and seek immidiate help in<br />transferring the motherto the nearest<br />Primary health center or hospital<br />
  81. 81. Danger signals<br />1. Sluggish pains or no pains after rupture of<br />membranes<br />2. Good pains for an hour after rupture off<br />membranes but no progress<br />3. Prolapse of cord or hand<br />4. Meconium stained liquor or a slow irregular<br />or excessively fast fetal heart rate<br />
  82. 82. 1. Excessive ‘show’ or bleding during labour<br />2. Collapse during labour<br />3. A placenta not separated within half an<br />hour after delivery<br />4. Post partum hemorrhage or collapse<br />5. A temperature of 38 deg C or over during<br />labour<br />There should be a close liaison between<br />domiciliary and institutional delivery<br />services<br />
  83. 83. Institutional care<br /> About 1% of deliveries tend to be<br />abnormal and 4% difficult requiring the<br />services of a doctor<br /> Recommended for all high risk cases and<br />where home conditions are unsuitable<br /> The mother is allowed to rest in bed on the<br />first day after delivery, next day to be up<br />and about, discharge after 5 days of lying<br />period<br />
  84. 84. Rooming in<br /> Keeping the baby’s crib by the side of the<br />mother’s bed is called “rooming in”<br /> This arrangement gives an opportunity for the<br />mother to know her baby<br /> Mothers interested in breast feeding usually find<br />there is a better chance for success<br /> It also allays the fear in the mother’s mind that<br />the baby is not misplaced in the central nursery<br /> It also builds up her self confidence<br />www.<br />
  85. 85. Post natal care<br />
  86. 86.  Care of the mother and the newborn after<br />delivery is known as postnatal care or post<br />partal care<br /> Broadly this care falls into 2 areas - care of<br />the mother ( primarily the responsibility of<br />the obstetrician), care of the<br />newborn( combined responsibility of the<br />pediatrician and the obstetrician)<br /> The combined area of responsibility is also<br />called perinatology<br />
  87. 87. Care of the mother<br />The objectives of postpartal care are<br />1. To prevent the complications of postpartal<br />period<br />2. To provide care for the rapid restoration of the<br />mother to the optimum health<br />3. To check the adequacy of breast feeding<br />4. To provide family planning services<br />5. To provide basic health education to mother/<br />family<br />
  88. 88. Complications of the post partumperiod<br />Should be recognized early and dealt with promptly<br />1. Puerperal sepsis ; this is infection of the genital<br />tract within 3 weeks after delivery<br />2. This is accompanied by rise in temperature and<br />pulse rate, foul smelling lochia, pain and<br />tenderness in lower abdomen<br />Prevented by asepsis before, during and after<br />delivery<br />
  89. 89. 2. Thrombophlebitis: infection of the veins of<br />the legs, frequently associated with<br />varicose veins<br />The leg may become tender, pale and<br />swollen<br />3. Secondary hemorrhage : Bleeding from<br />vagina anytime from 6hrs after delivery to<br />the end of peurperium(6weeks ) is called<br />secondary hemorrhage, and may be due to<br />retained placenta or membranes<br />4. Others UTI, mastitis<br />
  90. 90. Restoration of the mother to optimumhealth<br /> Physical<br /> Psychological<br /> Social<br />
  91. 91. Physical<br />Postnatal examinations- health check ups must be<br />frequent- twice a day during first 3 days and<br />subsequently once a day till the umbilical cord<br />drops off. At each of these examinations, the FHW<br />checks temperature, pulse and respiration,<br />examines the breasts, checks progress of normal<br />involution of uterus, examines lochia for any<br />abnormality, checks urine and bowels and adviseson perinatal toilet including care of the stitches, if<br />any<br />
  92. 92.  The immidiate postnatal complications, viz<br />peurperal sepsis, thrombophlebitis<br />secondary haemorrhage should be kept in<br />mind<br /> At the end of 6 weeks , an examination is<br />necessary to check up involution of uterus<br />which should be complete by then<br /> Further visits should be done once a month<br />during the first 6 months, and thereafter<br />once in 2-3 months till the end of 1 year<br />
  93. 93.  In rural areas only limited postnatal care is<br />possible<br /> Efforts should be made by the FHWs to<br />give at least3-6 postnatal visits<br /> The common conditions seen during the<br />postnatal period are subinvolution of<br />uterus, retroverted uterus, prolapse of<br />uterus and cervicitis.<br />
  94. 94. 1. Anemia – to be detected and treated<br />2. Nutrition – breast feeding mothers should<br />be given nutritious diet<br />3. Postnatal exercises –are necessary to bring<br />the stretched abdominal and pelvic<br />muscles back to normal as quickly as<br />possible<br />
  95. 95. Psychological<br /> Fear and insecurity which is generally born of<br />ignorance – to be eliminated by prenatal instruction<br /> Timidity and insecurity regarding the baby<br /> To endure cheerfully the emotional stresses of<br />childbirth, she requires the support and<br />companionship of her husband<br /> Postpartum psychosis - rare<br />
  96. 96. Social<br /> Women to have a baby – part of the truth<br /> To nurture and raise the child in a<br />wholesome family atmosphere<br /> She with her husband should develop her own<br />methods<br />
  97. 97. Breastfeeding<br /> Breast milk provides the main source of nourishment<br />– first year of life and in India up to 18 months of<br />life<br /> Feeding bottle is nutritionally poor and<br />bacteriologically dangerous<br /> Indian mothers feed up to 2 years<br /> They secrete 400- 600ml of milk /day during first<br />year<br />
  98. 98.  Exclusive breast feeding up to 6 months<br /> Complementary or supplementary foods<br />thereafter<br /> weaning<br />
  99. 99. Family planning<br /> Related to every phase of maternity cycle<br /> Motivate mothers when they attend maternity clinics<br /> Spacing or terminal<br /> Post partum sterilization generally recommended on<br />the second day<br /> Lactational amenorrhea cannot be relied on for<br />contraception<br />
  100. 100.  To ask the mother to come at first<br />menstrual cycle may be too late<br /> Contraceptive should not affect lactation<br /> IUD and non hormonal are choice in first<br />6months<br /> Oral pills to be avoided<br /> DMPA- successful without suppressing<br />lactation, but causes irregular bleeding and<br />prolonged infertility- so not recommended<br />for general use<br />
  101. 101. Basic health education<br /> Hygiene – personal and environmental<br /> Feeding – mother and infant<br /> pregnancy spacing<br /> Importance of check –up<br /> Birth registration<br />