GOOD MORNING: Batch 2012-13
Maternal and Child Health
(MCH)
DR RUPALI ROY
INTRODUCTION

Mothers

and children are both vulnerable
groups of the community.

Women

in the child-bearing period (15...
The term "MATERNAL AND CHILD HEALTH"
refers to the promotive, preventive, curative and
rehabilitative health care for moth...
The specific objectives of MCH are
(a) Reduction of maternal, perinatal, infant and
childhood mortality and morbidity;
(b)...
Mother and Child - One Unit
(1) During the antenatal period, the fetus is
part of the mother. The period of
development of...
4) After birth, the child is dependent upon
the mother
(5) In the care cycle of women, there are few
occasions when servic...
Obstetrics and preventive medicine
It is that throughout pregnancy and
puerperium, the mother will have good
health and th...
Maternity cycle –
The stages in maternity cycle are:
1. Fertilization;
2. Antenatal or prenatal period
3. Intra-natal peri...
Maternal Health Care
MHC
MHC

Preconceptional
Care

Including
Premarital
Care

Antenatal
Care

Intra-natal
Care

Postnatal...
Pre-Conceptional Care
Preconceptional Care
It
It

is a care of female before conception.

is continued care from birth, through
stages of grow...
Components of Preconceptional Care
Health

promotion and prevention of health
hazards specially those of particular risk ...
Antenatal Care
(ANC )
Antenatal

care is the care of the woman during
pregnancy.

The

primary aim of antenatal care is to achieve
at the end ...
The objectives of antenatal care
(1) To promote, protect and maintain the
health of the mother during pregnancy.
(2) To de...
(6) To teach the mother elements of
child care, nutrition, personal hygiene,
and environmental sanitation.
(7) To sensitiz...
ANTENATAL CARE COMPRISES?
1. Registration of pregnancy
2. History taking
3. Antenatal examinations [general and
obstetrica...
Registration of pregnancy:
The

registration of pregnancy must be
done in an antenatal clinic within 12
weeks.
History Taking
General

information
Name, age, gravidity, parity, education qualification,
occupation, income, religion, ...
Menstrual History Age at menarche, Cycle duration
Amount of Flow, Dysmenorrhea
Intermenstrual bleeding
LMP and EDD(Expecte...
Past Obstetrics History
Pregnancy
Gestational

age at time of delivery
Outcome of pregnancy

Labour/delivery
Normal

va...
Past Obstetric History
Puerperium

Any complications
Baby

Gender of baby
Age of baby
Breast fed, length of breast feedi...
Present obstetric history
 Date

of Registration
 No of antenatal visits

1st Trimester
 Ask

about nausea, vomiting
 ...
Present obstetric history
2nd Trimester
Ask

about regular use of folic acid, iron and calcium
supplements
Ultrasound at...
Obstetric history
General - Any history of disease –
Hyperemesis
Bleeding

,dizziness, urinary complications
Headache, ...
Past History
Past

medical: HTN, Diabetes, TB, Seizures, Asthma , heart
disease, malaria, kidney disease, syphilis
Past ...
Personal History
 Appetite
 Sleep
 Bowel
 Micturition
 Recent

weight gain/weight loss

 History

of any addictions ...
Social History
Family members
Earning members
Approximate income
Living condition
Aspects of Antenatal Assessment
Head

to toe examination
Breast examination
Abdominal palpation
Physical Examination
General Examination
◦ Height: Patients measuring 5 feet or less is
more likely to have a small pelvis...
Physical Examination
General Appearance
 Build
 Pallor
 Jaundice
Gait
Physical Examination
Head and Scalp
◦ Scalp, infection, infestation
◦ Tongue
◦ Teeth
◦ Gums
◦ Tonsils
◦ Thyroid
Physical Examination
Breasts
◦ Pregnancy changes
◦ Size
◦ Nipples
 Inverted
 Flat
 Retracted
 Cracked
Physical Examination
Skin
◦
◦
◦
◦

Colour changes
Texture
Striae Gravida
Linea Nigra
Abdominal Examination
Aim
 Observe signs of pregnancy
 Assess foetal size and growth
 Assess foetal health
 Diagnose t...
Physical Examination
Abdomen
◦ Size: Liver, Spleen
◦ Shape: Scaphoid, Pendulous
◦ Umbilicus: Protuberant, Dimpled

Extremi...
Physical Examination
Perineum
◦
◦
◦
◦
◦

Oedema of vulva
Discharge
Vaginal bleeding
Bartholin’s cyst
Perineal hygiene
Preliminaries for Examination
Before

performing Obstetric Examination
the bladder should be empty.

Make

her lie down ...
Inspection
Size

and shape of the uterus is assessed
Observe the fetal movements.
Ovoid in primigravid woman
Multiparo...
Palpation
Warm

hands before palpation

Centralize

uterus, place ulnar border of left
hand on upper most level of fundu...
Pelvic Grip or Leopold
maneuver
Leopold's

Maneuvers are a common and
systematic way to determine the position of
a fetus...
First Leopold maneuver.
FUNDAL
PALPATION
:
The uterine
fundus is
palpated to
determine
which fetal part
occupies the
fund...
Second Leopold maneuver.
LATERAL PALPATION:
Each side of the maternal
abdomen is palpated to
determine which side is
the ...
Third Leopold/Pawlik’s maneuver
One

hand applies
pressure on the
fundus while the
index finger and
thumb of the other
ha...
Fourth Leopold maneuver.
The

area above the
symphysis pubis is palpated
to
locate
the
fetal
presenting part and thus
det...
Calculations:
Calculation of gestation using fundal

height

◦ McDonald’s method: Measure from
symphasis pubis to top of ...
12 weeks :the uterus
fills the pelvis so that the
fundus of the uterus is
palpable at the symphysis
pubis .

16 weeks, the...
Laboratory investigations
1)
2)
3)
4)
5)
6)
7)
8)
9)

Complete urine analysis
Stool examination
Complete blood count, incl...
Laboratory data
Test

Purpose

Blood group

To determine blood type.

Hgb & Hct

To detect anemia.

(RPR) rapid plasma rea...
Test

Purpose

Stool analysis

for ova and parasites

Venereal disease research To screen for syphilis
laboratory tests (V...
Biophysical Test
Basic Ultrasonogrphic Evaluation
2. Targeted Ultrasonographic Evaluation
3. Cardiotocography
1.
Health education
1.

Diet: The diet during pregnancy
should be adequate to provide
for(Around 300 Kcal extra)

a. the main...
The

pregnancy diet should be light,
nutritious and easily digestible.
It should be rich in protein, minerals
vitamins a...
2. Personal hygiene:
Daily all over wash is necessary because it is
stimulating, refreshing, and relaxing.
Warm

bath.

...
3. Rest and sleep: The woman may
continue her usual activities throughout
pregnancy. Hard and strenuous work
should be avo...
4. Clothing: The patient should wear loose
but comfortable dresses. High heel shoes
are better avoided.
5. Dental hygiene:...
7. Coitus: Contact with the husband to be
avoided during the first trimester and last 6
weeks.
8. Travel: Long distance tr...
10. The pregnant women should avoid
over-the counter drugs (drugs without
medical prescription). The drugs may
have terato...
Antenatal visits
The

antenatal clinic should attend
--once a month during the first 7 months;
--twice a month, during th...
On subsequent visits:
Physical examination (e.g., weight gain, blood
pressure)
Laboratory tests should include: 1. Urine...
Danger signs of pregnancy
Vaginal bleeding including spotting.
Persistent abdominal pain.
Sever & persistent vomiting.
...
RISK APPROACH
1. Elderly primi (30 years and over)
2. Short statured primi (140 cm and below)
3. Malpresentations, viz bre...
8. Previous still-birth, intrauterine death,
manual removal of placenta
9. Elderly grandmultiparas
10. Prolonged pregnancy...
Specific Health Protection
ANAEMIA
(ii) OTHER NUTRITIONAL
DEFICIENCIES
(iii) TOXEMIAS OF PREGNANCY
(iv) TETANUS
(v) SYPHIL...
INTRANATAL CARE
The

emphasis is on the cleanliness.
It entails - clean hands and fingernails, a
clean surface for delivery, clean cutti...
Aims of good intra-natal care
(i) Thorough asepsis
(ii) Delivery with minimum injury to the infant
and mother
(iii) Readin...
Partograph
A

partograph is a
graphical record of the
observations made of a
women in labour
For progress of labour
and ...
Objectives
Early detection of abnormal progress of a labour
 Prevention of prolonged labour
 Recognize cephalopelvic dis...
Components of the Partograph
Part

1 : Fetal condition
( at top )

Pqrt

11 : Progress of
labour ( at middle )

Part

1...
Part 1 : Fetal condition
This part of the graph is used to monitor and assess fetal
condition
1 - Fetal heart rate
2 - Mem...
Fetal heart rate
Basal fetal heart rate: 120-160/min
 < 160 beats/mi =tachycardia
 > 120 beats/min = bradycardia
 >100 ...
Membranes and Liquor
Intact

membranes………………………….I
Ruptured membranes + Clear liquor …………C
Ruptured membranes + Meconiu...
Moulding the Fetal Skull Bones
Molding

is an important indication of how
adequately the pelvis can accommodate the fetal...
Part11 – Progress of labour
 Cervical

diltation
 Descent of the fetal head
 Fetal position
 Uterine contractions
 Th...
Active phase :
Contractions

at least 3 /

10 min
Each lasting < 40
sceonds
The cervix should dilate
at a rate of 1 cm ...
Alert line ( health facility line )
The

alert line drawn from 3 cm diltation
Represents the rate of dilation of 1 cm /
h...
Action line ( hospital line )
The

action line is drawn 4 hour to the
right of the alert line and parallel to it
This is...
Partogram - Maternal
Name / DOB /Gestation
Medical / Obstetrical issues
HR / BP/ Temp
Urinalysis
Partogram - Fetal
Gestational age
Fetal heart rate
Liquor
Partogram - Progress
Uterine contractions
Cervical dilatation
Descent of presenting part
Caput / Moulding
Fetal position
Partogram - delivery
Time of birth
Gender of infant
Birthweight
Apgar scores at 1/5 mins
Cord gas
Resuscitation
Complicati...
MCH 3 ON 5TH Oct,2013
Institutional Care –
About

1% of deliveries tend to be abnormal,
and 4% "difficult", requiring the services of a
doctor....
Essential obstetric care package
Early

registration of pregnancy (within 12-16
weeks).

Provision

of a minimum of 3 an...
Emergency Obstetric Care
Enhance availability of facilities for
institutional deliveries.



Operationalize

all CHCs an...
JANANI SURAKSHA YOJANA
ELIGIBILITY:LPS StatesAll pregnant women delivering in
Government health centres like Sub-centre,
...
Scale of Cash Assistance :
Category Rural Area

LPS

Total Urban Area

Mother ASHA Rs.

Total

Mother ASHA Rs.

1400

HPS
...
Balika Samriddhi Yojana
The girl children eligible under BSY will be
entitled to the following benefits:
◦ A post-birth gr...
CLASS

AMOUNT OF ANNUAL
SCHOLARSHIP

I-III

Rs.300/- per annum for
each class

IV

Rs.500/- per annum

V

Rs.600/- per ann...
POSTNATAL CARE
POSTNATAL CARE
Care

of the mother (and the newborn) after
delivery is known as postnatal or post-partal
care(Up to 6 Wee...
Objectives of post-partal care
(1) To prevent complications of the
postpartal period.
(2) To provide care for the rapid
re...
Patho-physiology of Postpartum
 Involution

- rapid reduction in size of uterus and return to
pre-pregnant state
 Subinv...
Patho-physiology of Postpartum
Uterus

rids itself of debris remaining after birth
through discharge called lochia
Lochi...
Postpartum Assessment
Vital

signs: Temperature elevations should last
for only 24 hours – should not be greater than
100...
(2) Anaemia (3) Nutrition (4) Postnatal
exercises
PSYCHOLOGICAL: Postpartum psychosis
is perhaps precipitated by birth, ti...
Breasts Assessment
Breasts

should be soft, warm, non-tender
upon palpation.

Secrete

colostrum for 1st 2-3 days –
yell...
Uterus Assessment
Monitor

uterus and vaginal bleeding, every
30 minutes x 2 for first PP hour, then
hourly for 2 more ho...
Abnormalities in Postpartum Period
Elevated BP
Pallor
Vaginal Bleeding
Foul smelling lochia
Dribbling Urine

REFER

Pus or...
Complications of postpartal period
Puerperal

sepsis:
Infection of the genital tract within 3 weeks
after delivery, Puerp...
Secondary

haemorrhage:
Bleeding from vagina anytime from 6 hours
after delivery to the end of the puerperium (6
weeks) i...
Breast Feeding
No

other food is required to be given until 6
months after birth.

An

average Indian mother, although p...
Family Planning
Motivate

mothers in postnatal clinics or
during postnatal contacts to adopt a
suitable method for spacin...
Because Giving birth should
be about giving life not giving
up a life.
The periods of growth have been
divided as follows:
1. Prenatal-period:

◦ (a) Ovum – 0 to 14 days
◦ (b) Embryo – 14 days ...
Maternal Health
According to 2000 WHO estimations it was
concluded that:
◦ From every 210 pregnant women who annually get
...
Other components of ANC service
MAINTENANCE
HOME

OF RECORDS

VISITS
Prenatal advice :
(i) DIET
(ii) PERSONAL HYGIENE(a)...
Streptomycin cause 8th nerve damage and
deafness in the foetus,
Iodide-containing preparations cause
congenital goitre in ...
High Risk Deliveries
Mother

Delivery

Fetus

Toxemia of
pregnancy

Prolonged labor

Prematurity

Diabetes
mellitus

Breec...
Maternal Mortality


Nearly 2/3rds of
maternal deaths
worldwide results from
five causes:
 Hemorrhage (24%)
 Obstructed...
Some Factors that Contribute to
Maternal Mortality and Morbidity
The

◦
◦
◦
◦

4 “too”s of pregnancy:

Too young
Too old
...
Ante Natal, Intra Natal AND Post Natal Care of Asian Women
Ante Natal, Intra Natal AND Post Natal Care of Asian Women
Ante Natal, Intra Natal AND Post Natal Care of Asian Women
Ante Natal, Intra Natal AND Post Natal Care of Asian Women
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CURATIVE AND PREVENTIVE CARE DURING PREGNANCY, DURING DELIVERY AND AFTER DELIVERY

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Ante Natal, Intra Natal AND Post Natal Care of Asian Women

  1. 1. GOOD MORNING: Batch 2012-13
  2. 2. Maternal and Child Health (MCH) DR RUPALI ROY
  3. 3. INTRODUCTION Mothers and children are both vulnerable groups of the community. Women in the child-bearing period (15-49 years) constitute about 19% of the population in India. Children on the other hand constitute about 40% to 45% of the population in developing countries. This group is characterized by relative high mortality and morbidity rates.
  4. 4. The term "MATERNAL AND CHILD HEALTH" refers to the promotive, preventive, curative and rehabilitative health care for mothers and children. It includes the sub-areas of Maternal health, Child health, Family planning,  School health,  Handicapped children, Adolescence and  Health aspects of care of children in special settings such as day care . 
  5. 5. The specific objectives of MCH are (a) Reduction of maternal, perinatal, infant and childhood mortality and morbidity; (b) Promotion of reproductive health; and (c) Promotion of the physical and psychological development of the child and adolescent within the family.
  6. 6. Mother and Child - One Unit (1) During the antenatal period, the fetus is part of the mother. The period of development of fetus in mother is about 280 days. (2) Child health is closely related to maternal health. (3) Certain diseases and conditions of the mother during pregnancy (e.g., syphilis, german measles, drug intake, diet intake) are likely to have their effects upon the fetus;
  7. 7. 4) After birth, the child is dependent upon the mother (5) In the care cycle of women, there are few occasions when service to the child is not simultaneously called for. For instance, postpartum care is inseparable from neonatal care and family planning advice; (6) The mother is also the first teacher of the child. It is for these reasons, the mother and child are treated as one unit.
  8. 8. Obstetrics and preventive medicine It is that throughout pregnancy and puerperium, the mother will have good health and that every pregnancy may culminate in a healthy mother and a healthy baby. SOCIAL OBSTETRICS – It is defined as the study of the interplay of social and environmental factors and human reproduction going back to the pre-
  9. 9. Maternity cycle – The stages in maternity cycle are: 1. Fertilization; 2. Antenatal or prenatal period 3. Intra-natal period; 4. Postnatal period; 5. Inter-conceptional period Fertilization takes place in the outer part of the fallopian tube. The fertilized ovum reaches the uterus in 8 to 10 days.
  10. 10. Maternal Health Care MHC MHC Preconceptional Care Including Premarital Care Antenatal Care Intra-natal Care Postnatal Care
  11. 11. Pre-Conceptional Care
  12. 12. Preconceptional Care It It is a care of female before conception. is continued care from birth, through stages of growth and development, and until the time of conception and pregnancy, so as to prepare the female for normal child bearing and delivery in the future.
  13. 13. Components of Preconceptional Care Health promotion and prevention of health hazards specially those of particular risk to pregnancy. Regular health appraisal for early case detection and management, and prevention of sequelae or complications. Health education of young girls e.g. determinants and requirement of health, family health, family planning….. Premarital care (for both partners).
  14. 14. Antenatal Care (ANC )
  15. 15. Antenatal care is the care of the woman during pregnancy. The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby. Ideally this care should begin soon after conception and continue throughout pregnancy. In some countries, notification of pregnancy is required to bring the mother in the prevention care cycle as early as possible.
  16. 16. The objectives of antenatal care (1) To promote, protect and maintain the health of the mother during pregnancy. (2) To detect "high risk" cases and give them special attention (3) To foresee complications and prevent them (4) To remove anxiety and dread associated with delivery (5) To reduce maternal and infant mortality and morbidity
  17. 17. (6) To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation. (7) To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy; and (8) To attend to the under-fives accompanying the mother.
  18. 18. ANTENATAL CARE COMPRISES? 1. Registration of pregnancy 2. History taking 3. Antenatal examinations [general and obstetrical] 4. Laboratory investigations 5. Health education
  19. 19. Registration of pregnancy: The registration of pregnancy must be done in an antenatal clinic within 12 weeks.
  20. 20. History Taking General information Name, age, gravidity, parity, education qualification, occupation, income, religion, marital status Husband - age, education, occupation, income, religion Current History problem/ complaint of current complaint
  21. 21. Menstrual History Age at menarche, Cycle duration Amount of Flow, Dysmenorrhea Intermenstrual bleeding LMP and EDD(Expected date of delivery (EDD) is calculated as followed: 1st day of LMP −3 months +7 days, and change the year. Example: calculate EDD if LMP was august 30, 2007. = June 6, 2008.)  -  Marital History - years of marriage, consanguineous marriage, late marriage  Contraceptive History - use and type of devices
  22. 22. Past Obstetrics History Pregnancy Gestational age at time of delivery Outcome of pregnancy Labour/delivery Normal vaginal delivery, C-section Labor- Normal, prolonged D & C Place of delivery (at home or at the hospital) Any other complications
  23. 23. Past Obstetric History Puerperium Any complications Baby Gender of baby Age of baby Breast fed, length of breast feeding Birth weight
  24. 24. Present obstetric history  Date of Registration  No of antenatal visits 1st Trimester  Ask about nausea, vomiting  Other associated symptoms such as fever  Abdominal/pelvic/back pain, burning micturition  Vaginal discharge  Bleeding per vagina  Use of folic acid tablets (small yellow colored pills)  Was an ultrasound done at 6 or 7wks (Dating scan)  Tetanus Vaccination
  25. 25. Present obstetric history 2nd Trimester Ask about regular use of folic acid, iron and calcium supplements Ultrasound at 18-22wks (Anomaly scan) Quickening: fetal movements (normally felt around 20 weeks gestation) Fever, rash, abdominal pain 3rd Trimester Tetanus toxoid vaccine Regular doctor checkups Ultrasound
  26. 26. Obstetric history General - Any history of disease – Hyperemesis Bleeding ,dizziness, urinary complications Headache, visual disturbances, constipation, edema, abdominal pain, indigestion History of drugs ,radiation Total weight gain
  27. 27. Past History Past medical: HTN, Diabetes, TB, Seizures, Asthma , heart disease, malaria, kidney disease, syphilis Past Surgical - pelvic surgeries, abdominal surgeries, caesarian, lower genital tract infections Blood Transfusions Family History :Heart disease, Hypertension, DM, TB History of Breast Cancer, Ovarian Cancer, Uterine Cancer History of Obstetrical Disorders, Twin Pregnancy, Abortion
  28. 28. Personal History  Appetite  Sleep  Bowel  Micturition  Recent weight gain/weight loss  History of any addictions (such as smoking, alcoholism, tobacco chewing etc..)  History of any allergies to foods or medicines Dietetic History
  29. 29. Social History Family members Earning members Approximate income Living condition
  30. 30. Aspects of Antenatal Assessment Head to toe examination Breast examination Abdominal palpation
  31. 31. Physical Examination General Examination ◦ Height: Patients measuring 5 feet or less is more likely to have a small pelvis ◦ Weight: Weight gain 12-15kg in total ◦ Temperature, Pulse, Respiration ◦ Blood Pressure: DBP>90 or increase > 20 from first visit is significant
  32. 32. Physical Examination General Appearance  Build  Pallor  Jaundice Gait
  33. 33. Physical Examination Head and Scalp ◦ Scalp, infection, infestation ◦ Tongue ◦ Teeth ◦ Gums ◦ Tonsils ◦ Thyroid
  34. 34. Physical Examination Breasts ◦ Pregnancy changes ◦ Size ◦ Nipples  Inverted  Flat  Retracted  Cracked
  35. 35. Physical Examination Skin ◦ ◦ ◦ ◦ Colour changes Texture Striae Gravida Linea Nigra
  36. 36. Abdominal Examination Aim  Observe signs of pregnancy  Assess foetal size and growth  Assess foetal health  Diagnose the location of foetal parts  Detect any deviation from normal
  37. 37. Physical Examination Abdomen ◦ Size: Liver, Spleen ◦ Shape: Scaphoid, Pendulous ◦ Umbilicus: Protuberant, Dimpled Extremities ◦ Oedema ◦ Varicosities ◦ Deformities
  38. 38. Physical Examination Perineum ◦ ◦ ◦ ◦ ◦ Oedema of vulva Discharge Vaginal bleeding Bartholin’s cyst Perineal hygiene
  39. 39. Preliminaries for Examination Before performing Obstetric Examination the bladder should be empty. Make her lie down in dorsal position. Knees should be flex position while doing pelvic palpation. Abdomen should be fully exposed. Examiner stands on right side of mother.
  40. 40. Inspection Size and shape of the uterus is assessed Observe the fetal movements. Ovoid in primigravid woman Multiparous woman – pendulous abdomen in which uterus sags forward. Skin condition and presence of any scar is noted. Linea nigra may be seen.
  41. 41. Palpation Warm hands before palpation Centralize uterus, place ulnar border of left hand on upper most level of fundus and measure till symphysis pubis with help of an inch tape. Abdominal girth: measure around abdomen at the level of umbilicus
  42. 42. Pelvic Grip or Leopold maneuver Leopold's Maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold.
  43. 43. First Leopold maneuver. FUNDAL PALPATION : The uterine fundus is palpated to determine which fetal part occupies the fundus.
  44. 44. Second Leopold maneuver. LATERAL PALPATION: Each side of the maternal abdomen is palpated to determine which side is the fetal spine and which is the extremities. Spine : smooth curved and resistant feel Limbs : small knob like irregular parts
  45. 45. Third Leopold/Pawlik’s maneuver One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement.
  46. 46. Fourth Leopold maneuver. The area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. If hands are converging indicates un engagement ; diverging indicates engagement of head.
  47. 47. Calculations: Calculation of gestation using fundal height ◦ McDonald’s method: Measure from symphasis pubis to top of fundus in cm. ◦ Gestation is measurement + or – 2 weeks
  48. 48. 12 weeks :the uterus fills the pelvis so that the fundus of the uterus is palpable at the symphysis pubis . 16 weeks, the uterus is midway between the symphysis pubis and the umbilicus. 20 weeks, it reaches the umbilicus
  49. 49. Laboratory investigations 1) 2) 3) 4) 5) 6) 7) 8) 9) Complete urine analysis Stool examination Complete blood count, including Hb estimation, Blood grouping and Rh typing Blood for VDRL Serological examination Chest X-ray, if needed Hepatitis B HIV G.C. culture (Gonorrhoea test, if needed)
  50. 50. Laboratory data Test Purpose Blood group To determine blood type. Hgb & Hct To detect anemia. (RPR) rapid plasma reagin To screen for syphilis Rubella To determine immunity Urine analysis To detect infection or renal disease. protein, glucose, and ketones Papanicolaou (pap) test To screen for cervical cancer Chlamydia To detect sexual transmitted disease. Glucose To screen for gestational diabetes.
  51. 51. Test Purpose Stool analysis for ova and parasites Venereal disease research To screen for syphilis laboratory tests (VDRL) Hepatitis B surface antigen To detect carrier status or active disease
  52. 52. Biophysical Test Basic Ultrasonogrphic Evaluation 2. Targeted Ultrasonographic Evaluation 3. Cardiotocography 1.
  53. 53. Health education 1. Diet: The diet during pregnancy should be adequate to provide for(Around 300 Kcal extra) a. the maintenance of maternal health. b. the needs of the growing fetus. c. the strength and vitality required during labour and d. the successful lactation.  
  54. 54. The pregnancy diet should be light, nutritious and easily digestible. It should be rich in protein, minerals vitamins and fibres and of the required calories. Dietary advice should be given with due consideration to the socio-economic condition, food habits and taste of the individual. Supplementary iron therapy is needed for all pregnant mothers from 12 weeks onwards.
  55. 55. 2. Personal hygiene: Daily all over wash is necessary because it is stimulating, refreshing, and relaxing. Warm bath. shower or sponge baths is better than tub Hot bath should be avoided because they may cause fatigue & fainting Regular washing for genital area, axilla, and breast due to increased discharge and sweating. Vaginal douches should avoided except in case of excessive secretion or infection.
  56. 56. 3. Rest and sleep: The woman may continue her usual activities throughout pregnancy. Hard and strenuous work should be avoided. On an average, a patient should have 10 hours of sleep (8 hours at night and 2 hours at noon) 4.Bowel: As there is a tendency of constipation during pregnancy, regular bowel movement may be facilitated by regulation of diet taking plenty of fluids, vegetables and milk.
  57. 57. 4. Clothing: The patient should wear loose but comfortable dresses. High heel shoes are better avoided. 5. Dental hygiene: The dentist should be consulted at the earliest, if necessary. 6. Care of the breasts: Cleanliness of the breasts is maintained. If anatomical defects are present advise to seek medical help.
  58. 58. 7. Coitus: Contact with the husband to be avoided during the first trimester and last 6 weeks. 8. Travel: Long distance travel better to be avoided. Rail route is preferable. 9.Smoking and alcohol: Smoking and alcohol are to be avoided totally during pregnancy as both cause variable injuries to the fetus.
  59. 59. 10. The pregnant women should avoid over-the counter drugs (drugs without medical prescription). The drugs may have teratogenic effects on the growing fetus especially during the first trimester.
  60. 60. Antenatal visits The antenatal clinic should attend --once a month during the first 7 months; --twice a month, during the next month; and once a week, if everything is normal. A minimum of 3 visits covering the entire period of pregnancy should be the target: 1. 1st visit at 20 weeks or as soon as the pregnancy is known 2. 2nd visit at 32 weeks 3. 3rd visit at 36 weeks
  61. 61. On subsequent visits: Physical examination (e.g., weight gain, blood pressure) Laboratory tests should include: 1. Urine examination 2. Hemoglobin estimation  Iron and folic acid supplementation(Tab IFA100mg Fe & 0.5mg Folic Acid)  Immunization against tetanus two doses  Group or individual instruction on nutrition, family planning, self care, delivery and parenthood  Home visiting by a female health worker  Referral services, where necessary
  62. 62. Danger signs of pregnancy Vaginal bleeding including spotting. Persistent abdominal pain. Sever & persistent vomiting. Sudden gush of fluid from vagina. Absence or decrease fetal movement. Sever headache. Edema of hands, face, legs & feet. Fever above 100 F( greater than 37.7°C). Dizziness, blurred vision, double vision & spots before eyes. Painful urination.
  63. 63. RISK APPROACH 1. Elderly primi (30 years and over) 2. Short statured primi (140 cm and below) 3. Malpresentations, viz breech transverse lie, etc. 4. Antepartum haemorrhage, threatened abortion 5. Preeclampsia and eclampsia 6. Anaemia 7. Twins, hydramnios
  64. 64. 8. Previous still-birth, intrauterine death, manual removal of placenta 9. Elderly grandmultiparas 10. Prolonged pregnancy (14 days-after expected date of delivery) 11. History of previous caesarean or instrumental delivery 12. Pregnancy associated with general diseases, cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease, etc.
  65. 65. Specific Health Protection ANAEMIA (ii) OTHER NUTRITIONAL DEFICIENCIES (iii) TOXEMIAS OF PREGNANCY (iv) TETANUS (v) SYPHILIS (vi) GERMAN MEASLES (vii)RH STATUS (viii)HIV INFECTION and (ix) PRENATAL GENETIC SCREENING (i)
  66. 66. INTRANATAL CARE
  67. 67. The emphasis is on the cleanliness. It entails - clean hands and fingernails, a clean surface for delivery, clean cutting and care of the cord, and keeping birth canal clean by avoiding harmful practices. Hospitals and health centres should be equipped for delivery with midwifery kits, a regular supply of sterile gloves and drapes, towels, cleaning materials, soap and antiseptic solution, as well as equipment for sterilizing instruments and supplies.
  68. 68. Aims of good intra-natal care (i) Thorough asepsis (ii) Delivery with minimum injury to the infant and mother (iii) Readiness to deal with complications such as prolonged labour, antepartum haemorrhage, convulsions, malpresentations, prolapse of the cord, etc. (iv) Care of the baby at delivery resuscitation, care of the cord, care of the eyes, etc.
  69. 69. Partograph A partograph is a graphical record of the observations made of a women in labour For progress of labour and salient conditions of the mother and fetus It was developed and extensively tested by the world health organization WHO
  70. 70. Objectives Early detection of abnormal progress of a labour  Prevention of prolonged labour  Recognize cephalopelvic disproportion long before obstructed labour Assist in early decision on transfer , augmentation , or terminnation of labour  Increase the quality and regularity of all observations of mother and fetus  Early recognition of maternal or fetal problems 
  71. 71. Components of the Partograph Part 1 : Fetal condition ( at top ) Pqrt 11 : Progress of labour ( at middle ) Part 111 : Maternal condition ( at bottom ) & Outcome
  72. 72. Part 1 : Fetal condition This part of the graph is used to monitor and assess fetal condition 1 - Fetal heart rate 2 - Membranes and liquor 3 - Moulding the fetal skull bones Caput
  73. 73. Fetal heart rate Basal fetal heart rate: 120-160/min  < 160 beats/mi =tachycardia  > 120 beats/min = bradycardia  >100 beats/min = severe bradycardia Decelerations? yes/no Relation to contractions?  Early  Variable  Late – -----Auscultation - return to baseline > 30 sec contraction ----- Electronic monitoring peak and trough (nadir) > 30 sec
  74. 74. Membranes and Liquor Intact membranes………………………….I Ruptured membranes + Clear liquor …………C Ruptured membranes + Meconium- stained liquor ……..M Ruptured membranes + Blood – stained liquor ……B Ruptured membranes + Absent liquor…………… .A
  75. 75. Moulding the Fetal Skull Bones Molding is an important indication of how adequately the pelvis can accommodate the fetal head Increasing molding with the head high in the pelvis is an ominous sign of Cephalopelvic disproportion Separated bones . sutures felt easily…………. ….O Bones just touching each other………………..+ Overlapping bones ( reducible 0 ……………...++ Severely overlapping bones ( non – reducible ) ……..+++
  76. 76. Part11 – Progress of labour  Cervical diltation  Descent of the fetal head  Fetal position  Uterine contractions  This section of the paragraph has as its central feature a graph of cervical diltation against time  It is divided into a latent phase and an active phase
  77. 77. Active phase : Contractions at least 3 / 10 min Each lasting < 40 sceonds The cervix should dilate at a rate of 1 cm / hour or faster
  78. 78. Alert line ( health facility line ) The alert line drawn from 3 cm diltation Represents the rate of dilation of 1 cm / hour Moving to the right or the alert line means referral to hospital for extra vigilance
  79. 79. Action line ( hospital line ) The action line is drawn 4 hour to the right of the alert line and parallel to it This is the critical line at which specific management decisions must be made at the hospital
  80. 80. Partogram - Maternal Name / DOB /Gestation Medical / Obstetrical issues HR / BP/ Temp Urinalysis
  81. 81. Partogram - Fetal Gestational age Fetal heart rate Liquor
  82. 82. Partogram - Progress Uterine contractions Cervical dilatation Descent of presenting part Caput / Moulding Fetal position
  83. 83. Partogram - delivery Time of birth Gender of infant Birthweight Apgar scores at 1/5 mins Cord gas Resuscitation Complications
  84. 84. MCH 3 ON 5TH Oct,2013
  85. 85. Institutional Care – About 1% of deliveries tend to be abnormal, and 4% "difficult", requiring the services of a doctor. Rooming-in – Keeping the baby's crib by the side of the mother's bed is called "rooming-in". Mothers interested in breast feeding usually find there is a better chance for success with rooming-in. It also builds up her self-confidence.
  86. 86. Essential obstetric care package Early registration of pregnancy (within 12-16 weeks). Provision of a minimum of 3 antenatal checkups by the ANM or medical officers Counseling on nutrition and provision of iron and folic acid supplementation Promotion Provision of institutional delivery of postnatal care to monitor the postnatal recovery and to detect complications early, followed by appropriate referral
  87. 87. Emergency Obstetric Care Enhance availability of facilities for institutional deliveries.  Operationalize all CHCs and at least 50 % of PHCs for providing 24 hour delivery services Ensure access to a blood bank at all district hospitals and a blood storage facility at FRUs Train MBBS medical officers in anesthetic skills for EmOC
  88. 88. JANANI SURAKSHA YOJANA ELIGIBILITY:LPS StatesAll pregnant women delivering in Government health centres like Sub-centre, PHC/CHC/ FRU / general wards of District and state Hospitals or accredited private institutions HPS States- BPL pregnant women, aged 19 years and above
  89. 89. Scale of Cash Assistance : Category Rural Area LPS Total Urban Area Mother ASHA Rs. Total Mother ASHA Rs. 1400 HPS 600 2000 1000 200 1200 700 nil 700 nil 600 600
  90. 90. Balika Samriddhi Yojana The girl children eligible under BSY will be entitled to the following benefits: ◦ A post-birth grant amount of Rs.500/-. ◦ When the girl child born on or after 15/8/1997 and covered under BSY starts attending the school, she will become entitled to annual scholarships as under for each successfully completed year of schooling:-
  91. 91. CLASS AMOUNT OF ANNUAL SCHOLARSHIP I-III Rs.300/- per annum for each class IV Rs.500/- per annum V Rs.600/- per annum VI-VII Rs.700/- per annum for each class VIII Rs.800/- per annum IX-X Rs.1,000/- per annum for each class
  92. 92. POSTNATAL CARE
  93. 93. POSTNATAL CARE Care of the mother (and the newborn) after delivery is known as postnatal or post-partal care(Up to 6 Weeks) Broadly this care falls into two areas: care of the mother which is primarily the responsibility of the obstetrician; and care of the newborn, which is the combined responsibility of the obstetrician and paediatrician. This combined area of responsibility is also known as peri-natology.
  94. 94. Objectives of post-partal care (1) To prevent complications of the postpartal period. (2) To provide care for the rapid restoration of the mother to optimum health. (3) To check adequacy of breast feeding (4) To provide family planning services (5) To provide basic health education to mother/family
  95. 95. Patho-physiology of Postpartum  Involution - rapid reduction in size of uterus and return to pre-pregnant state  Subinvolution = failure to descent  Uterus is at level of umbilicus within 6 to 12 hours after childbirth - decreases by one finger breadth per day  Exfoliation - allows for healing of placenta site and is important part of involution – may take up to 6 weeks  Enhanced by  Uncomplicated labor and birth  Complete expulsion of placenta or membranes  Breastfeeding  Early ambulation
  96. 96. Patho-physiology of Postpartum Uterus rids itself of debris remaining after birth through discharge called lochia Lochia changes: ◦ ◦ ◦ ◦ ◦ If Bright red at birth Rubra - dark red (2 – 3 days after delivery) Serosa – pink (day 3 to 10 after delivery) Alba – white Clear blood collects and forms clots within uterus, fundus rises and becomes boggy (uterine atony)
  97. 97. Postpartum Assessment Vital signs: Temperature elevations should last for only 24 hours – should not be greater than 100.4°F Bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days due to decreased blood volume Assess for BP : Look for tachycardia, hypotension, hypertension Respirations Complete systems assessment Postpartum chills or shivers are common
  98. 98. (2) Anaemia (3) Nutrition (4) Postnatal exercises PSYCHOLOGICAL: Postpartum psychosis is perhaps precipitated by birth, timidity and insecurity regarding the baby. SOCIAL: The really important thing is to nurture and raise the child in a wholesome family atmosphere.
  99. 99. Breasts Assessment Breasts should be soft, warm, non-tender upon palpation. Secrete colostrum for 1st 2-3 days – yellowish fluid - protein and antibody enriched to offer passive immunity and nutrition. Milk comes in around 3 – 4 days – feel firm, full, tingly to client
  100. 100. Uterus Assessment Monitor uterus and vaginal bleeding, every 30 minutes x 2 for first PP hour, then hourly for 2 more hours, every 4 hours x 2, then every 8 hours or more frequently if there is bogginess, position out of midline, heavy lochia flow Determine firmness of fundus and ascertain position If boggy (soft), gently massage top of uterus until firm Displaced to the right or left indicates full bladder
  101. 101. Abnormalities in Postpartum Period Elevated BP Pallor Vaginal Bleeding Foul smelling lochia Dribbling Urine REFER Pus or perineal pain Feeling unhappy Vaginal discharge Breast Problem Infection/ Breast abscess Sore or cracked nipple Engorgement Insufficient milk Cough or breathing difficulty
  102. 102. Complications of postpartal period Puerperal sepsis: Infection of the genital tract within 3 weeks after delivery, Puerperal sepsis can be prevented by attention to asepsis, before and after delivery. Thrombophlebitis: Infection of the veins of the legs, frequently associated with varicose veins.
  103. 103. Secondary haemorrhage: Bleeding from vagina anytime from 6 hours after delivery to the end of the puerperium (6 weeks) is called secondary haemorrhage, and may be due to retained placenta or membranes. Others: Urinary mastitis, etc tract infection and
  104. 104. Breast Feeding No other food is required to be given until 6 months after birth. An average Indian mother, although poor in nutritional status, has a remarkable ability to breast-feed her infant for prolonged periods, sometimes extending to nearly 2 years. Maximum amount of milk production in the 5th to 6th month of lactational period(arround 730ml/day)
  105. 105. Family Planning Motivate mothers in postnatal clinics or during postnatal contacts to adopt a suitable method for spacing the next birth or for limiting the family size as the case may be. Postpartum sterilization is generally recommended on the 2nd day after delivery.  IUD and conventional (non-hormonal) contraceptives are the choices during the
  106. 106. Because Giving birth should be about giving life not giving up a life.
  107. 107. The periods of growth have been divided as follows: 1. Prenatal-period: ◦ (a) Ovum – 0 to 14 days ◦ (b) Embryo – 14 days to 9 weeks ◦ (c) Foetus - 9th week to birth 2. Premature infant - from 28 to 37 weeks 3. Birth, full term - average 280 days
  108. 108. Maternal Health According to 2000 WHO estimations it was concluded that: ◦ From every 210 pregnant women who annually get pregnant, 8 suffer from life threatening complications. ◦ MMR globally was500/100,000 LB, ranging from2.4 in Scandinavia and Switzerland to 1200 in Yemen ◦ In India MMR is 212/100,000 LB (According 2011 SRS)
  109. 109. Other components of ANC service MAINTENANCE HOME OF RECORDS VISITS Prenatal advice : (i) DIET (ii) PERSONAL HYGIENE(a) Personal cleanliness(b) Rest and sleep(c) Bowels(d) Exercise (e) Smoking(f) Alcohol (g) Dental care (h) Sexual intercourse (iii) DRUGS: thalidomide, a hypnotic drug, which caused deformed hands and feet of the babies born.
  110. 110. Streptomycin cause 8th nerve damage and deafness in the foetus, Iodide-containing preparations cause congenital goitre in the foetus. (iv) RADIATION (v) WARNING SIGNS: (a) swelling of the feet (b) fits (c) headache (d) blurring of the vision (e) bleeding or discharge per vagina and (f) any other unusual symptoms. (vi) CHILD CARE
  111. 111. High Risk Deliveries Mother Delivery Fetus Toxemia of pregnancy Prolonged labor Prematurity Diabetes mellitus Breech presentation LBW Age < 20 yrs Cord prolapse Fetal distress Age > 35 yrs Multiple pregnancy Parity 5 + Premature rupture of membranes Meconium stained liquor amnii
  112. 112. Maternal Mortality  Nearly 2/3rds of maternal deaths worldwide results from five causes:  Hemorrhage (24%)  Obstructed labor (8%)  Eclampsia (pregnancy induced hypertension) (12%)  Sepsis (15%)  Unsafe abortion (13%)  The other 1/3rd of maternal deaths worldwide results from indirect causes or an existing medical condition made worse by pregnancy or delivery:  Malaria  Anemia  Hepatitis  AIDS  Tuberculosis  Malnutrition
  113. 113. Some Factors that Contribute to Maternal Mortality and Morbidity The ◦ ◦ ◦ ◦ 4 “too”s of pregnancy: Too young Too old Too many Too soon In other words: young or old age of pregnancy, short intervals between pregnancies, and high parity. Other factors include low socio-economic status and inadequate maternal care.

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