Maternal health handout iii copy

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Maternal health handout iii copy

  1. 1. Maternal Health Handout III.2.1The “Six Pillars” of Safe MotherhoodThe basic principles of safe motherhood are neither new nor controversial. They areconsidered the “six pillars” of safe motherhood:1. Family Planning-to ensure that individuals and couples have theinformation and services to plan the timing, number, and spacing ofpregnancies.2. Antenatal Care-to provide vitamin supplements, vaccinations, and screenfor risk factors in order to prevent complications where possible, and toensure that complications of pregnancy are detected early and treatedappropriately.3. Obstetric Care-to ensure that all birth attendants have the knowledge,skills, and equipment to perform a clean and safe delivery, and to ensurethat emergency care for high-risk pregnancies and complications is madeavailable to all women who need it.4. Postnatal Care-to ensure that postpartum care is provided to motherand baby, including lactation assistance, provision of family planningservices, and managing danger signs.5. Postabortion Care-to prevent complications where possible and ensurethat complications of abortion are detected early and treatedappropriately; to refer other reproductive health problems; and to providefamily planning methods as needed.6. STD/HIV/AIDS Control-to screen, prevent, and manage transmission tobaby; to assess risk for future infection; to provide voluntary counselingand testing; to encourage prevention; and where appropriate to expandservices to address mother to child transmission.THE POLICY PROJECT MATERNAL HEALTH SUPPLEMENT III-5III. THE ADVOCACY STRATEGY 2. ISSUES, GOALS, AND OBJECTIVES SECTION IIIUNIT 2Safe MotherhoodFamily PlanningAntenatal CareObstetric CarePostnatal CarePostabortion CareSTD/HIV/AIDS ControlPrimary Health CareEquity and Education for WomenCommunication for Behavior ChangeThePrinciplesof AntenatalCare
  2. 2. Dr Sue Page Quic kFind The Principles of Antenatal Care Table of Contents Risk factors Detailed history Self-medication Diet Exercise Ante-natal visits Pathology tests Common discomforts of pregnancy<> Antenatal care ideally consists of: Pre-conception counselling Assessment of risk factors (including maternal health) Aboriginal Ongoing assessment of fetal well-beingHealth Ongoing assessment of complications Education about normal discomforts of pregnancy, Adolescent emotional aspects (including post-natal depression), localMedicine antenatal classes, reducing risk of SIDS, parenting issues (including child-proofing the house and coping with Anaesthetics crying infants) Discussion of birthing care options Complementary Medicine Risk factors Dermatology Assessment of risk factors largely occurs at the first visit. If it is not possible to prolong the appointment confirming the Drugs and pregnancy, it is as well to re-book the woman for a doubleAlcohol appointment. The date of onset of LMP should be noted, but also the pattern of menses preceding this, as irregular cycles or OCP Emergency withdrawal bleeds will make dating the pregnancy unreliable. (If doubt exists then an ultrasound can be performed - the earlier the ENT scan the more accurate it is for dating the conceptus but the less accurate for fetal morphology.) Also a full history and Geriatrics examination, including breast&thyroid, and a Pap smear if not done recently. ICU Internal Detailed historyMedicine As GPs we are ideally suited to obtain details of the womans
  3. 3. Musculoskelet medical history and examination, but also any financial and socialal aspects that may have a bearing on the pregnancy. For example, previous history, or her personality and lack of family supports, Paediatrics may put her at increased risk of post-natal depression; in which case early involvement of social workers and mothercraft services Palliative Care may avert a crisis. Psychiatry Self-medication Sexual Health A history of smoking, alcohol, and drug intake should be taken and women advised not to self-medicate without checking first Surgery for safety. It is worth specifically mentioning vitamin and herbal therapies as some of these are to be limited in pregnancy, eg. Womens Vitamin A>2500 I.U. daily (>2 capsules) may cause birth defects;Health or avoided, eg. Golden Seal which increases miscarriage rates. I would also recommend advising minimising chemical and Amniotic FluidEmbolism infection exposure in general - which includes occupational exposure. Antenatal Diagnosis ofCongenital Abnormality Diet Emotional aspects ofmenopause Dietary advice should focus on a well-balanced and varied diet with an emphasis on complex carbohydrates and protein, and with Endoscopic Surgery in adequate daily folate (0.5mg, or 5mg if high NTD risk), ironGynaecology (15mg), calcium (1200mg) and fluids (2-3L). Foods likely to be contaminated with listeria should be avoided eg. raw meat, raw IMB - Guidelines For seafood, soft cheeses. Many first trimester women can minimiseReferral nausea by frequent small meals rich in B group vitamins and low LBH Antenatal Shared in spice and fat. Severe caloric restriction can result in reducedCare fetal growth, so as a general policy weight reduction is best deferred to post-natally. Obstetric Emergencies -Antepartum Exercise Obstetric Emergencies -Intrapartum Exercise is commonly restricted to non-contact sports after 16 weeks, and exercise intensity should be reduced by 25%, always Obstetric Emergenies - followed by a cool-down period. Core temperature should notPostpartum exceed 38*C and HR 140/min, so ideally, strenuous exercise should be limited to 15-20 minutes. Further, walking more than Osteoporosis five hours a day increases preterm labour risk by 1.4 compared to Preventable Causes of les than two hours a day. (References available)Congenital Abnormalities Shared Antenatal Ante-natal visitsProtocol
  4. 4. The Principles of Visits are usually monthly to 28 weeks, fortnightly to 36 weeks,Antenatal Care then weekly to delivery. Each visit should involved checks on maternal and fetal well-being. As these are usually in a share-care capacity, a joint record card should be carried by the woman to each visit. Cards can be obtained through any public hospital stationery department and will record: Weight gain (12-15 kg in total, with 3kg in first 20 weeks) BP (a diastolic pressure>90, or increase of >20 from first Submit Options visit is significant) Urinalysis (watch for protein, glucose, and UTIs) Fetal movements Uterine size in accordance with dates and ultrasound Fetal lie, presentation, and engagement, especially after 36 weeks Pathology tests Certain pathology tests are routinely performed at intervals and the current recommendations are: First visit: FBC, Blood group and antibody screen (BG), TPHA/RPR, Rubella, MSU, Hep B and C, Pap smear if nil recent, and offer HIV screening after counselling (NSW Health circular 95/44-A13866). Reinforce BSE. 10-12 weeks: Chorionic villous sampling if needed 15-18 weeks: Ultrasound, with serum AFP (or "triple test" if considered appropriate). Amniocentesis if needed. 28 weeks: Hb and differential, BG, ferritin, modified GTT, and low vaginal swab to exclude Group B strep. (Requiring intrapartum antibiotic treatment to reduce neonatal morbidity) 36 weeks: Hb and differential, BG (Other tests may also be indicated eg. TSH if goitre or Hb EPG if thalassaemia suspected by low MCV.) It is common to refer the woman for obstetric care after the 15-18 week ultrasound has confirmed dates and fetal morphology, and thereafter care is shared as dictated by the conditions of the pregnancy and the experience of the GP concerned. Common discomforts of pregnancy These are worth mentioning and include:
  5. 5. Pelvic pains, especially if lateral and referring to the upperthighs, are usually due to ligamentous stretch. Theyrequire reassurance only. Pain is reproduced by gentlesideways traction on an otherwise non-tender and softwomb. Maximal 13 & 16 weeks.Urinary frequency is common but should be investigatedas 8% of pregnant women will have otherwiseasymptomatic UTIs.Ankle oedema may relate to compression of inferior venacava and to vasodilatation due to increased hormones. Ifno associated proteinuria or hypertension, it is best treatedby rest with leg elevation, or natural diuretics such ascelery or Vitamin B6.Varicosities occur for the same reasons, and relief afterconfinement can be dramatic. Once recognised, the earlyuse of support stockings is wise; while the short term useof pelvic elevation and ice packs can ease the symptomsof vulval varicosities.Heartburn is due to gastro-oesophogeal reflux combinedwith increased abdominal pressure. Postural and dietaryadvice with the use of antacids settles most, butoccasionally H2 antagonists (category B in pregnancy) arerequired.Constipation can occur early so at least in part is due tohormones, but is aggravated by enlarging pelvic contents.With the vasodilatation and compression of pelvic veinsthis may result in haemorrhoids. Women should beadvised to increase their fluid and fibre intake, and iflaxatives are needed they should be of the fibre basedtype, eg. Metamucil or Fybogel.Low back pain is common due to altered posture; but alsoto the affects of the hormone relaxin on ligaments,allowing excessive movement of sacro-iliac andapophyseal joints. A regular exercise program, preferablyswimming, with physiotherapy as required, complementspostural back care. Some women develop symphysis-pubis pain, especially. If coexistent scoliosis, and mayrequire a s-p. Corset, obtainable through physiotherapydepartments.Dental decay and periodontal disease accelerates inpregnancy and should be reviewed by a dentist as early aspossible.Skin changes include chloasma and spider naevi, whichcommonly disappear after the pregnancy. The increasedproduction of melanin in pregnancy may lead to the
  6. 6. diagnosis of pre-existent melanomas. Itch occurs in 17% gravid women. Interestingly, 50% women with atopic dermatitis improve during pregnancy. If no rash, consider iron deficiency, or the potentially more serious cholestasis of pregnancy. Antihistamines may be helpful. Stretch marks may occur when growth has been rapid. The dryness and irritation may be eased by vegetable oil or Vitamin E cream and soap avoidance. Dr Sue Page General Practioner Lennox Head NSW Australia 2477 cmitchell@om.com.auReturn to top of pageThis page was lastbuilt on 18/5/99; Shared Antenatal Amniotic Fluid Index7:42:04 AM. Protocol EmbolismIt was originallyposted on 12/4/98;8:40:22 AM.Webmaster: MedicineAulemlink@medicineau.net.au

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