Introduction to maternal

Introduction to Maternaland Child health

 70% of the population of developingcountries In India women of child bearing age (15-44 Yrs) are 19% Children under 15 years 40% Together 59% They are vulnerable or special –risk group Risk –connected with childbearing forwomen Growth development and survival-children

 50% of deaths are above 70 yrs of age Same among under-five children Maternal mortality rates vary from 13- 440 per100000 live births Sickness and deaths among mothers and childrenare largely preventable This have led to the formation of special healthservices for mother and children all over theworld The present strategy is to provide maternal andchild as an integrated package of “Essentialhealth care” also known as “Primary health care”

Mother and child as one unit- because1. During the antenatal period , the fetus is partof the mother – development – 280 days,during this period fetus receives nutrition andoxygen from the mother2. Child health is closely related to maternalhealth; a healthy mother brings forth ahealthy baby; there is less chances ofpremature, still birth or abortion

1. Certain diseases and conditions of themother during pregnancy ( eg. Syphilis,German measles, drug intake) are likely tohave their effects on the fetus2. After birth, the child is dependant on themother. Up to 6 - 9 months completely forfeeding. The mental and socialdevelopment is also dependant on themother, if the mother dies the child'sgrowth and development are affected(maternal deprivation syndrome)

1. In the care cycle of women, there are fewoccasions when the service of the child issimultaneously called for . For instancepost partum care is inseparable fromneonatal care and family planning advice2. The mother is also the first teacher of thechild

Obstetrics, Pediatrics and PSM In the past , maternal and child health services were rather fragmented and providedpiecemeal “ personal health services” bydifferent agencies, in different ways andseparate clinics the current trend in manycountries is to provide integrated MCH andfamily planning services as compact familywelfare service

 This implies a close relationship ofmaternity health to child health, ofmaternal and child health to the health ofthe family; and of family to the generalhealth of the community In providing these services , specialists inobstetrics and child health have joinedhands , and are now looking beyond thefour walls of hospitals into community tomeet health needs of mothers and childrenaimed at positive health

 In the process they have linked tocommunity medicine( preventive andsocial medicine ) and as a result , termssuch as “social obstetrics” , “preventivepediatrics” and “social pediatrics” havecome into vogue

Obstetrics Obstetrics is largely preventive medicine The aims are same, to ensure that throughoutpregnancy and puerperium, the mother will havegood health and that every pregnancy may culminatein a healthy mother and healthy baby The age old concept that obstetrics is nowconsidered as a very narrow concept, and is beingreplaced by the concept of community obstetricswhich combines obstetrical concerns with theconcepts of primary health care

Social obstetrics Gained usage in recent years Defined as the study of the interplay of socialand environmental factors and humanreproduction going back to thepreconceptional or even premarital period

 The social and environmental factorswhich influence human reproduction are alegion viz. age at marriage , childbearing,child spacing , family size , fertilitypatterns, level of education, economicstatus , level of education, economicstatus , customs and beliefs, role of womenin society , etc. The social and obstetric problem in Indiadiffers from other developed countries

 While accepting the influence ofenvironmental and social factors on humanreproduction, social obstetrics has yetanother dimension, that is influence ofthese factors on the organization, deliveryof comprehensive MCH services includingfamily planning so that they could bebrought within the reach of the totalcommunity

Preventive pediatrics Like obstetrics pediatrics has a large component ofPreventive and Social Medicine There is no other discipline that teaches the value ofpreventive medicine Recent years have witnessed further specializationwithin the broad field of pediatricsviz preventivepediatrics, social pediatrics, neonatology,perinatology, developmental pediatricspediatricsurgery, pediatric neurology

 Preventive pediatrics comprises efforts toavert rather than cure disease anddisabilities It has been broadly divided into antenatalpediatrics and postnatal pediatrics The aims of preventive pediatrics andpreventive medicine are the same –prevention of disease and promotionphysical , mental and social well being ofchildren so that each child may achievegenetic potential with which he is born

 To achieve these aims , hospitals forchildren have adopted the strategy of“primary health care “ to improve childhealth care through such activities asgrowth monitoring, oral rehydration,nutritional surveillance, promotion ofbreast feeding, immunization, communityfeeding, regular health check ups etc. Primary health care with its potential forvastly increased coverage through anintegrated system of service delivery isincreasedly looked upon as the bestsolution to reach millions of children

Social pediatrics Defined as the application of theprinciples of social medicine to pediatricsto obtain a more complete understanding ofthe problems of children in order toprevent and treat disease and promote theiradequate growth and development, throughan organized health structure

 To study child health in relation tocommunity, to social values and to socialpolicy This has given rise to concept of socialpediatrics it is concerned not only with thesocial factors which influence child healthbut also with the influence of these factorson the organization, delivery andutilization of child health care services

 In other words , social pediatrics isconcerned with the delivery ofcomprehensive and continuous child healthcare services and to bring these serviceswithin the reach of the local community. Social pediatrics also covers various socialwelfare measures – local , national,international – aimed to meet the totalhealth needs of the child

Contribution of Preventive and Social Medicineto Social Obstetrics and Pediatrics1. Collection and interpretation of communitystatistics, delineating groups “at risk” for specialcare2. Correlation of vital statistics ( eg., maternal andinfant morbidity and mortality rates, perinatal andchild mortality rates )with social and biologicalcharacteristics such as birth weight , parity, age,stature, employment etc., in the elucidation ofetiological relationships

1. Study of cultural patterns, beliefs andpractices relating to childbearing andchildrearing, knowledge of which mightbe useful in promoting acceptance andutilization of obstetric and pediatricservices by the community2. To determine priorities and contribute tothe planning of MCH services andprogrammes3. For evaluating whether MCH services andprogrammes are accomplishing theirobjectives

Maternity cycle - stages1. Fertilization2. Antenatal or prenatal period3. Intranatal period4. Postnatal period5. Inter - conceptional period

 Fertilization takes place in the outer part ofthe fallopian tube. Segmentation of the fertilized ovum beginsat once and proceeds at a rapid rate The fertilized ovum reaches the uterus in8- 10 days. Cell division proceeds at a rapid rate By a process of cell division anddifferentiation, all the organs and tissues ofthe body are formed

Period of growth1. Prenatal period1. Ovum – 0-14 days2. Embryo - 14 days to 9 weeks3. Fetus – 9th week to birth2. Premature – 28 to 37 weeks3. Birth, full term – average 280 days

Objectives To promote, protect and maintain the healthof the mother during pregnancy To detect “high risk” cases and give themspecial attention To foresee complications and prevent them To remove anxiety and dread associated withdelivery

 To reduce maternal and infant mortalityand morbidity To teach the mother elements of child care,nutrition, personal hygiene andenvironmental sanitation To sensitize the mother to the need forfamily planning, including advice to casesseeking medical termination of pregnancy To attend to the under fives accompanyingthe mother

Antenatal visits Mother should attend AN clinics Once a month during first 7 months Twice a month during the next month Thereafter once a week in the ninth monthIf everything is normal

Minimum 3 antenatal visits1. At 20 weeks or as soon as pregnancy isknown2. At 32 weeks3. At 36 weeks4. At least 1 home visit by health worker

Preventive services for the mothers Prenatal services ( before delivery) First visit should include following Health history Physical examination Laboratory examination

Lab tests1. Complete urine analysis2. Stool examination3. Complete blood count, including Hbestimation4. Serological examination5. Blood grouping and Rh determination6. Chest x- ray if needed, pap tests, Gonorrheaculture (Optional)

On subsequent visits Physical examination( weight gain, Bloodpressure) Laboratory tests should include1. Urine examination2. Hemoglobin estimate

 Iron and folic acid supplementation Tetanus Immunization Group or individual instruction onnutrition, family planning, self care,delivery and parenthood Home visiting by female health worker /trained dai Referral services , where necessary

Risk approach Identify high risk cases from a large group ofantenatal mothers and arrange them forskilled care, while continuing to provideappropriate care for all mothers

At risk mothers1. Elderly primi (30 years and over)2. Short statured primi ( 140 cms and over)3. Mal-presentations( breech, transverse lie)4. Ante-partum hemorrhage, threatenedabortion5. Pre – eclampsia and eclampsia6. Anemia

1. Twins, hydramnios2. Previous still birth, intrauterine death,manual removal of placenta3. Elderly grand multiparas4. Prolonged pregnancy( 14 days afterexpected date of delivery)5. History of previous cesarean orinstrumental delivery6. Pregnancy associated with generaldiseases – cardiovascular disease, kidneydisease, diabetes, tuberculosis, liverdisease

Risk approach is a managerial tool Services for all but with special attention tothose who need them the most Maximum utilization of all resourcesincluding some which are not involved inin such care – traditional birth attendants,community health workers, women groups Improvements in coverage & quality ofhealth care

Maintenance of records Antenatal card- in first examination, thick paper tofacilitate filing Registration number. Identifying data, previoushealth history, main health events Record is kept at MCH/FP center A link is maintained between the antenatal card,postnatal card and under-fives card Essential for evaluation and further improvement

Home visits Home visiting is the backbone of all MCHservices Even if the expectant mother is attending theante natal clinic regularly, she must be paidone home visit by the health worker female orpublic health nurse More visits are required if the delivery isplanned at home

Prenatal advice Mother s more receptive to the adviceconcerning herself and her baby at this timethan at other times The talking points should cover not only thespecific problems of pregnancy and childbirthbut also about family and child health care

Prenatal advice - diet Reproduction costs energy Pregnancy in total duration consumesabout 60000 k cal over and above normalmetabolic requirements Lactation demands about 550 kcal / day Child survival is correlated with birthweight Birth weight is correlated to the weightgain of the mothewrww .dsimuilimar.ciomng pregnancy

 On an average . A normal healthy womengains about 12 kg of weight duringpregnancy Average poor Indian women gains 6.5 Kgs Thus pregnancy imposes extra calorie andnutritional requirements If maternal stores of iron are poor (as mayhappen after repeated pregnancies) and ifenough iron is not available to the motherduring pregnancy, it is possible that fetusmay lay down insufficient iron stores

 Such a baby may show a normal Hb. atbirth but will lack the stores of ironnecessary for rapid growth and increase inblood volume and muscle mass in the firstyear of life Stresses in the form of malaria and otherchildhood infections will make thedeficiency more acute, and many infantsbecome severely anemic during the earlymonths of life Therefore a balanced diet is necessary

Personal hygiene Personal cleanliness – bathe, clean clothes,hair Rest and sleep – 8 hrs sleep, 2 hrs rest aftermidday meals Bowels – constipation should be avoided bytaking green leafy vegetables, fruits and extrafluids purgatives like castor oils should beavoided

 Exercise – light household work is advisedbut manual physical labour during latepregnancy may adversely affect the foetusSmoking – should be cut down, causesIntrauterine growth retardation, low birthweight babies. Vasoconstrictor action produces placentalinsufficiency. Mothers who smoke heavily produces on anaverage 170 g less weight babies at term. The perinatal mortality amongst babieswhose mother smoked during pregnancy is10-40% higher

 Alcohol :alcohol causes fertility problemsin mothers, pregnancy loss, variousphysical and mental problems in the child,causes fetal alcohol syndrome in the child– includes IUGR, developmental delay Dental care – oral hygiene Sexual intercourse – should be restrictedespecially in the last trimester

Drugs Drugs which are not absolutely essentialshould be discouraged Can cause fetal malformations – likethalidomide – more serious when taken 4-8weeks of pregnancy LSD produces chromosomal damage,streptomycin causing deafness, iodide causingcongenital goitre

 Corticosteroids may impair growth Sex hormones – virilism Tetracyclines- growth of bones and enamelformation Anesthetics – pethidine administeredduring labour- can have depressant effectand delay the onset of respiration Certain drugs are excreted in breast milk

Radiation Exposure to radiation, X ray duringpregnancy - mortality from leukemia andother neoplasms are significantly higher Congenital malformations such asmicrocephaly X rays should be avoided in the last 2 weekspreceding menstrual cycle

Warning signs Report immediately1. Swelling of the feet2. Fits3. Headache4. Blurring of vision5. Bleeding or discharge per vagina6. Any other unusual symptoms

Child care The art of child care should be learnt Special classes to be conducted Mother craft includes – nutrition education,advice on hygiene and childrearing, cookingdemonstrations, family planning education,family budgeting etc.

Specific health protection – 1.anemia About 50% to 60% of mothers in India oflow socio economic groups are anemic inthe last trimester of pregnancy Etiology is iron and folic acid deficiency Associated with high incidence ofpremature births, postpartum hemorrhage,peuerperal sepsis and thromboembolicphenomena in the mother IFA supplementation is done by Govt. ofIndia

Other nutritional deficiencies Protein, vitamin and minerals Especially vit A and iodine Milk should be supplemented, or skimmedmilk should be given Capsules of vitamin A and D also suppliedfree of cost

Toxemias of pregnancy Presence of albumin in urine and increase inblood pressure Their early detection and management

Tetanus 2 doses of adsorbed tetanus toxoid should begiven First dose 16 – 20 weeks and second 20-24weeks of pregnancy Minimum interval between 2 doses should be1 month Second dose should be given at least 1 monthbefore the EDD

 However , no dose of TT should be deniedto the mother even in late pregnancy For a mother who have been immunizedearlier, 1 booster dose will be sufficient When such booster doses are given it willcover subsequent pregnancies in the next 5years It is advised not to immunize the mother inevery pregnancy in order to prevent hyperimmunization

Syphilis Important cause of pregnancy wastage insome countries Pregnancies in primary and secondarysyphilis end in spontaneous abortion, stillbirth, perinatal death or birth of a child withcongenital syphilis Syphilitic infection in pregnant women istransmissible to the foetus

 Neurological damage with mentalretardation is one of the most seriousconsequences of congenital syphilis Infection of the foetus does not occur in 4thmonth of pregnancy it is most likely to occur after the 6thmonth of pregnancy by which time theLanghans cell layer has completelyatrophied Infection of the foetus most likely inprimary and secondary stage of syphilis butrare in late syphilis

German measles In a long-term prospective study done inGreat Britain, when rubella is contracted tothe mother in the first 16 weeks ofpregnancy, foetal death or death during thefirst year of life occurred in 17% ofoffspring's Among survivors who were followed upthe age of 8 years, 15 % had major defectslike cataract, deafness and congenital heartdiseases

 Risk of malformations is about 20% up to20 weeks of gestation In some countries all school aged childrenare vaccinated Before vaccinating the women of childbearing age should be made sure that theyare not pregnant and they followcontraception for 8 weeks later to preventrisk of rubella to the fetus

Rh status The fetal red cells may enter the maternalcirculation in a number of difficultcircumstances, during labor, caesareansection, therapeutic abortion, externalcephalic version and apparentlyspontaneously in the late pregnancy

 The intrusion of these cells, if the mother isRh –ve and the child is Rh +ve, provokesan immune response in her so that sheforms antibodies to Rh which can crossplacenta and produces fetal RBChemolysis The same response may be seen by thetransfusion of Rh+ve blood In a pregnant woman, iso-immunisationmainly occurs in labour, so that the firstchild although Rh+ve, is unaffected exceptwhere the mother is already www.similima.com sensitized.

 In the second or subsequent pregnancies, ifthe child is Rh +ve, the mother will react tothe smallest intrusion of fetal cells, byproducing antibodies to destroy fetal bloodcells causing hemolytic disease in the fetus Clinically hemolytic disease takes the formof Hydropsfetalis, icterus gravisneonatorum( of which Kernicterus is acommon sequel) and congenital hemolyticanemia

 Routinely test the blood for rhesus typeearly in pregnancy If the women is Rh-ve and the husband is+ve , she is kept under surveillance for Rhantibody levels during antenatal care The blood should be further examined at28 weeks and 34-36 weeks of gestation forantibodies Rh anti D immunoglobulin should be givenat 28 weeks of gestation so thatsensitization during the first pregnancy canbe prevented

 If the baby is Rh +ve, the Rh anti Dimmunoglobulin is given again within 72hrs of delivery It should also be given after abortion Post maturity should be avoided Whenever evidence of hemolysis in-uterois suspected mother should be shifted tospecial centers equipped to deal with suchproblems Incidence of hemolysis due to Rh factor inIndia is 1 for every 400- 500 live births

HIV infection HIV in child may occur through placenta,delivery, breast feeding 1/3 of the children get infected throughabove routes Risk is higher if the mother is newlyinfected or she had already developedAIDS Voluntary prenatal testing for HIVinfection should be done as early inpregnancy for all wmww.simoilimtah.coemrs

Prenatal genetic screening Prenatal genetic screening includesscreening for chromosomal abnormalitiesassociated with serious birth defects,screening for direct evidence of congenitalstructural anomalies, screening forhemoglobinopathies and other inheritedconditions detectable by biochemicalassays Universal genetic screening is generallynot recommendedwww.similima.com 67

 Screening for chromosomal abnormalitiesand for direct evidence for structuralanomalies is performed in pregnancy inorder to take decisions regardingtherapeutic abortions Typical examples are Down’s syndromeand severe neural tube defects Women aged above 35 years and thosewho are having afflicted child are at higherrisk

Mental preparation It is also important A free and frank talks on all aspects ofpregnancy and delivery Removing the fears about confinement The mother craft classes at the MCH centers

Family planning Related to every phase of maternity cycle Mothers are psychologically morereceptive to the advice on family planningthan at other times Motivation and education should be doneduring the antenatal period If the mother has had 2 or more childrenshe should be motivated for puerperalsterilization All India post partum programme servicesare available

Pediatric component Pediatrician should be in attendance at allantenatal clinics to pay attention to the underfives accompanying the mother

 Childbirth is a normal physiological process, butcomplications may arise Septicemia may result from unskilled and septicmanipulationsand tetanus neonatorum from theuse of unsterile instruments The need for effective in tranatal care isindispensable The emphasis is on cleanliness 5 cleans - clean hands and fingernails,a cleansurface for delivery, clean blade for cutting thecord, clean cord tie, clean cord stump and care ofthe cord

 Keep the birth canal clean by avoidingharmful practices Hospital and health centers should beequipped for delivery with midwifery kits, aregular supply of sterile gloves and drapes,towels, cleaning materials, soap and antisepticsolution, as well as equipment for sterilizinginstruments and supplies

 There are delivery kits available with theitems needed for basic hygiene for deliveryat home, where a midwife with amidwifery kit is not likely to be present

AIMS1. Thorough asepsis2. Delivery with minimum injury to theinfant and mother3. Readiness to deal with complications suchas prolonged labour, antepartumhaemorrhage, convulsions,malpresentations, prolapse of the cord4. Care of the baby at delivery- resusitation,care of the cord, eyes etc.

Domiciliary care Confinement can be in home if the conditionsare satisfactory In such cases delivery may be conducted bythe health worker female or trained dai This is called as domiciliary midwiferyservice

Advantages of domiciliary care1. The mother delivers in the familiarsurroundings of her home and this maytend to remove the fear associated withdelivery in a hospital2. The chances for cross infection aregenerally fewer at home than innursery/hospital3. The mother is able to keep an eye uponother children and domestic affairs; thismay tend to ease her mental tension

Disadvantages of domiciliary care1. The mother may have less medical andnursing supervision than in the hospital2. The mother may have less rest3. May resume her duties too soon4. Her diet may be neglected5. Many homes in India may be unsuitable foreven a normal delivery

 Since 74% of India’s population live inrural areas, most deliveries will have totake place at home with the aid of femalehealth workers and trained dai’s Female health worker who is a pivot ofdomiciliary care should be adequatelytrained to recognize the ‘danger signals’during labour and seek immidiate help intransferring the motherto the nearestPrimary health center or hospital

Danger signals1. Sluggish pains or no pains after rupture ofmembranes2. Good pains for an hour after rupture offmembranes but no progress3. Prolapse of cord or hand4. Meconium stained liquor or a slow irregularor excessively fast fetal heart rate

1. Excessive ‘show’ or bleding during labour2. Collapse during labour3. A placenta not separated within half anhour after delivery4. Post partum hemorrhage or collapse5. A temperature of 38 deg C or over duringlabourThere should be a close liaison betweendomiciliary and institutional deliveryservices

Institutional care About 1% of deliveries tend to beabnormal and 4% difficult requiring theservices of a doctor Recommended for all high risk cases andwhere home conditions are unsuitable The mother is allowed to rest in bed on thefirst day after delivery, next day to be upand about, discharge after 5 days of lyingperiod

Rooming in Keeping the baby’s crib by the side of themother’s bed is called “rooming in” This arrangement gives an opportunity for themother to know her baby Mothers interested in breast feeding usually findthere is a better chance for success It also allays the fear in the mother’s mind thatthe baby is not misplaced in the central nursery It also builds up her self confidencewww.

 Care of the mother and the newborn afterdelivery is known as postnatal care or postpartal care Broadly this care falls into 2 areas - care ofthe mother ( primarily the responsibility ofthe obstetrician), care of thenewborn( combined responsibility of thepediatrician and the obstetrician) The combined area of responsibility is alsocalled perinatology

Care of the motherThe objectives of postpartal care are1. To prevent the complications of postpartalperiod2. To provide care for the rapid restoration of themother to the optimum health3. To check the adequacy of breast feeding4. To provide family planning services5. To provide basic health education to mother/family

Complications of the post partumperiodShould be recognized early and dealt with promptly1. Puerperal sepsis ; this is infection of the genitaltract within 3 weeks after delivery2. This is accompanied by rise in temperature andpulse rate, foul smelling lochia, pain andtenderness in lower abdomenPrevented by asepsis before, during and afterdelivery

2. Thrombophlebitis: infection of the veins ofthe legs, frequently associated withvaricose veinsThe leg may become tender, pale andswollen3. Secondary hemorrhage : Bleeding fromvagina anytime from 6hrs after delivery tothe end of peurperium(6weeks ) is calledsecondary hemorrhage, and may be due toretained placenta or membranes4. Others UTI, mastitis

Restoration of the mother to optimumhealth Physical Psychological Social

PhysicalPostnatal examinations- health check ups must befrequent- twice a day during first 3 days andsubsequently once a day till the umbilical corddrops off. At each of these examinations, the FHWchecks temperature, pulse and respiration,examines the breasts, checks progress of normalinvolution of uterus, examines lochia for anyabnormality, checks urine and bowels and adviseson perinatal toilet including care of the stitches, ifany

 The immidiate postnatal complications, vizpeurperal sepsis, thrombophlebitissecondary haemorrhage should be kept inmind At the end of 6 weeks , an examination isnecessary to check up involution of uteruswhich should be complete by then Further visits should be done once a monthduring the first 6 months, and thereafteronce in 2-3 months till the end of 1 year

 In rural areas only limited postnatal care ispossible Efforts should be made by the FHWs togive at least3-6 postnatal visits The common conditions seen during thepostnatal period are subinvolution ofuterus, retroverted uterus, prolapse ofuterus and cervicitis.

1. Anemia – to be detected and treated2. Nutrition – breast feeding mothers shouldbe given nutritious diet3. Postnatal exercises –are necessary to bringthe stretched abdominal and pelvicmuscles back to normal as quickly aspossible

Psychological Fear and insecurity which is generally born ofignorance – to be eliminated by prenatal instruction Timidity and insecurity regarding the baby To endure cheerfully the emotional stresses ofchildbirth, she requires the support andcompanionship of her husband Postpartum psychosis - rare

Social Women to have a baby – part of the truth To nurture and raise the child in awholesome family atmosphere She with her husband should develop her ownmethods

Breastfeeding Breast milk provides the main source of nourishment– first year of life and in India up to 18 months oflife Feeding bottle is nutritionally poor andbacteriologically dangerous Indian mothers feed up to 2 years They secrete 400- 600ml of milk /day during firstyear

 Exclusive breast feeding up to 6 months Complementary or supplementary foodsthereafter weaning

Family planning Related to every phase of maternity cycle Motivate mothers when they attend maternity clinics Spacing or terminal Post partum sterilization generally recommended onthe second day Lactational amenorrhea cannot be relied on forcontraception

 To ask the mother to come at firstmenstrual cycle may be too late Contraceptive should not affect lactation IUD and non hormonal are choice in first6months Oral pills to be avoided DMPA- successful without suppressinglactation, but causes irregular bleeding andprolonged infertility- so not recommendedfor general use

Basic health education Hygiene – personal and environmental Feeding – mother and infant pregnancy spacing Importance of check –up Birth registration

Introduction to maternal

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Introduction to maternal