BASIC OBSTETRIC CARE

DR. RABI NARAYAN SATAPATHY

ASST.PROFESSOR

DEPT. OF OBST.& GYNAECOLOGY

SCB MEDICAL COLLEGE, CUTTACK

MOB-09861281510

EMAIL-drrabisatpathy@gmail.com

WHY BASIC OBSTETRIC CARE FOR HOMOEOPATHY AND AYURVEDIC PHYSICIANS?

AREN’T THE OBSTETRICIANS OF

MODERN MEDICINE THERE?

THEY ARE NOT THERE WHERE THE WORST OCCURS!

Deaths Worldwide from Complications of Pregnancy and Childbirth( Maternal & Child Health-JHPIEGO)

529,000 women die per year world wide from maternal causes, 99% occur in developing countries …India leads with 136,000 deaths

Life-time risk of dying from pregnancy-related complications is 45 times higher in developing nations compared to the developed

MMR reaches 1000/100,000 live births in some countries

India’s MMR 400 to 500/100,000 (Ref: RHO ARCHIVES)

For every maternal death 100 women who survive have disability; long term consequences ( prolapse, p.i.d, fistula, incontinence, infertility, dyspareunia)

>28 million disability-adjusted life years (DALY)

18% of the burden of diseases in women

(Ref: RHO ARCHIVES)

> one million children are left motherless every year

> ½ (3.4 out of 8 million) of infant deaths per year result from poor maternal health & inadequate delivery care

(Ref: RHO ARCHIVES)

KEY REASONS OF THESE ALARMING FIGURES…..

LACK of SKILLS of the Provider at the VITAL POINT in the community at the Primary Health Care site

LACK of Drugs, Supplies & EquipmentLACK of ‘Functioning Referral System’No provider available!

EVOLUTION OF MATERNAL HEALTH IN THE WEST IN THE 19TH CENTURY - WORSE THAN WHAT WE ARE NOW ↓

IN EARLY 20TH CENTURY- INSPITE OF THE RISE IN ECONOMY AS BAD AS WE ARE NOW ↓

AFTER CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS ↓

UPGRADATION OF SKILLS AT THE SENSITIVE LINK & ATTENTION TO BROADER ISSUES

↓

DRASTIC IMPROVEMENT OCCURRED THAT CAME TO STAY

ATTENTION TO THE THIRD WORLD WITH GRADUAL GLOBALISATION IN HUMAN CONSCIOUSNESS

SAFE MOTHERHOOD INITIATIVE IN 1987- Nairobi, Kenya by World Bank WHO & UNFPA - did improve matters but IMR & MMR are still very high-

Reasons vary from country to country

SAFE MOTHERHOOD INTER-AGENCY GROUP

WHOWORLD BANKUNICEFUNPF International Confederation of MidwivesFIGO IPPF IPCFamily Care InternationalSafe Motherhood Network of NepalRegional Prevention of Maternal Mortality

Programme(Africa)

‘SAFE MOTHERHOOD INTER AGENCY GROUP’ currently focuses on……….

Skilled attendance at childbirth by the provider

Attention to broader issues like ‘policy & regulatory mechanisms’ on availability of drugs,supplies,equipments.

Presence of functioning referral system

SKILLED PROVIDER AT THE VITAL STATION…..

MIDWIFEGRADUATE DOCTORNURSE (with midwifery & lifesaving

skills)

WHY NOT THE GRADUATES OF HOMOEOPATHY & AYURVEDA???

current REQUIREMENT

Addressing…….

A VERY CRITICAL GAP IN MATERNAL CARE

GOAL for India…..

Bring down MMR to

109/ 100,000 live births

by 2015

OBSTETRIC CARE REDEFINED

EOC/CEOC= Essential Obstetric Care/Comprehensive Essential Obstetric Care:

provides not only the means to manage emergency complications when they happen but also the procedures for early detection and treatment to prevent the progression of problem pregnancies to the level of an emergency

(Ref:Global Health Council)

EmOC = a subset of EOC

Responds to unexpected complications such as hemorrhage, and obstructed labor. It does not include management of problem pregnancies, monitoring labor, or neonatal special care

(Ref:Global Health Council)

BEOC = Basic Essential Obstetric Care - it is another subset of EOC

- includes all EOC elements with the exception of surgery, anesthesia, and blood replacement

-enhances front-line care and should be able to prevent majority of complications progressing to emergent situation

- appropriate for rural settings (Ref:Global Health Council)

URGENT NEED

Build capacity of providers in ‘Basic’ & ‘Comprehensive’ Emergency Obstetric & Neonatal Care

Strengthening infrastructure, manpower etc at health care set ups

Advocate for policy guidelines & minimum set of standards of care at health care settings

Over all objective for EmOC in India

Develop capacity of General Practitioners & Non specialist Medical Officers in India to provide high quality Emergency Obstetric Care (EmOC) services in rural areas where skilled obstetricians are not available to prevent maternal mortality & morbidity

Strategy for Basic Essential Obstetric Care in India?

Develop capacity of Homoeopathy & Ayurvedic Medical Officers also in India to provide high quality Basic Essential Obstetric Care (BEOC) services in rural areas where neither skilled obstetricians nor graduate medical officers are available - to prevent maternal mortality & morbidity

WHY BEOC?

IT FORESTALLS the need for EmOCMajority of emergent life threatening

complications are prevented by BEOCCERTAINLY PREVENTION IS BETTER

THAN CURE!

ESSENTIAL SKILLS OF BASIC OBSTETRIC CARE COMPONENTS

Manage normal labour & childbirthRecognize the onset of complicationsPerform essential ‘BASIC’ emergency

interventions

Safely refer the mother &/or newborn when necessary

OTHER RELATED COMPONENTS OF THE ESSENTIAL BASIC SKILLS

Antenatal & postpartum care

Management of abortion complications

Family planning counseling & services

New born care

MANAGEMENT OF LABOR

Diagnose stages & phases of laborCare in latent laborUse of WHO partograph as management

& referral tool in active labor after 4 cm dilatation of cx

Use of specific drugs & fluids in laborIP practices

Stages of labour

1st stage – from beginning of labor until complete (10 centimeters) dilation

2nd stage – from complete dilation to complete birth of baby

3rd stage – from complete birth of baby to complete birth of placenta

4th stage – from complete birth of placenta to 2 hours after birth

Phases of 1st stage

Latent phaseCervix: 1-3 centimeters dilatedContractions: Irregular, variable frequency,

duration < 20 seconds

Active phaseCervix: 4-10 centimetersContractions: Regular, increase to 3-5/10

min; duration may become > 40 seconds

Care in 1st stage of labor

Ongoing assessmentOngoing supportive careKey action: once active phase begins,

start a partograph

Care in latent phase of labor

Provide plenty of nutritious drinksEncourage small meals as toleratedEncourage woman to empty bladder at

least every 2 hoursDo NOT give an enema

Latent phase care cont…

Encourage bath before active phase begins

Replace soiled blankets, sheetsUse proper infection prevention

procedures:hand washingantisepsis before exams

Do not shave vulva

Supportive Care during Active Phase: Activity and Comfort Measures

Allow freedom to choose positionAssist her in relaxing between contractionsEncourage position changes throughout

laborMassage or apply pressure to back as

woman desiresCoach in effective breathingProvide comfort measures such as cool

cloth to face

Supportive Care during Active Phase: Hygiene

Maintain clean environmentClean genital area if needed prior to examWash hands before and after each examWear gloves for all vaginal examsClean up spills immediatelyReplace soiled or wet blankets, sheets, or

clothes

Key Action: Start Partograph

A decision-making tool rather than only a record

Start when dilation reaches 4 centimetersUse throughout labor to help:

Evaluate fetal and maternal well-beingAssess progress of labor Identify problemsGuide decision making for careProvide a record of findings

CHILD BIRTH

Conduct as per clinically standardized best practices

Restricted use of episiotomy and repairBasic new born resuscitation & care AMTSLRepair of Perineal injuries, cervical tearsRecognize onset of complications

Recognition of complications & Rapid Initial Assessment

Every woman presenting with a danger is assessed for: Breathing difficulty (respiratory distress)Convulsion/loss of consciousnessShockHypertension with proteinuriaFever

BASIC EMERGENCY PROCEDURES

Antibiotics (injectables) useOxytocics (injectables) useAnti-convulsants (injectables) useManual removal of placentaRemoval of retained productsAssisted vaginal deliveries ( vacuum

extraction & forceps)

Early Referral

Unsatisfactory progress of labor-Ante-partum hemorrhageEclampsia –after instituting magsulfMorbid adherence of placentaInversion of uterusPost partum hemorrhage uncontrolled by

oxytocics & massage

Components of proper referral

safe, rapid transportation

care during transport

communication with referral facility

follow-up with client

Antenatal (assessment & care)

ASSESSMENT (oriented to excluding risk)

-History (Personal info, MH, OH, Lifestyle, Medical, Interim)

-Physical examination( General, Abdominal, Pelvic)

-Testing (Hb%, VDRL, HIV, Grouping & Rh typing, others as per prevalence)

CARE PROVISION:-

- Diet & Nutrition – including daily iron/folate tabs

- Develop Birth plan, educate on danger signs etc

- Advice on common discomforts

- Counseling on hygiene; Rest & activity; Early exclusive breast feeding; FP;

-Encourage questions

-Ask questions to ensure she understands

IMMUNISATION & OTHER PROPHYLAXIS (as per region specific need)

Tetanus ToxoidIron folate & diet rich in vit. CAnti-malarialMebendazoleVitamin AIodine

Postpartum care

Ongoing assessment for first 6 hoursBasic assessment

HistoryPhysical ExaminationTesting

Note: Before performing assessment:welcome woman offer her (and companion, if she desires) a seat ensure that she has undergone quick check

Focus physical examination on following:

General well-being (every visit)Vital signs (every visit)Breasts (every visit) Abdomen (every visit)Legs (every visit)Genitals (every visit)

Postpartum fundal height

Post partum examination

Gait and movement – no limp, steady/moderately paced gait and movements

Facial expression – alert, responsive, calmBehavior – normal for culture General cleanliness – no visible dirt, odorCondition of skin – no lesions, bruisesColor of conjunctiva – pink

Postpartum examination…

Lochia (color and character):Day 1: bright red blood, like heavy

mensesDays 2-4: red lochia, fleshy odor, new pad

every 2-4 hoursDays 5-14: pink lochia, musty odor,

decrease in amountDay 11 thru week 3 or 4: white lochia,

decrease in amount

Lochia (cont.):Foul-smelling lochia requires urgent

further evaluation/ additional care (life-threatening complication)

Red lochia (lochia rubra) for more than 2 weeks requires further evaluation/additional care (special need)

Vaginal bleeding:The following s/s require urgent further

evaluation/ additional care (life-threatening complication):Frank heavy bleedingSteady slow trickleIntermittent gushesClots larger than lemons

Postpartum care

Focus history taking on following areas:Personal history (1st visit)Daily habits and lifestyle (1st visit)Present pregnancy and labor/birth (1st visit)Present postpartum period (every visit)Obstetric history (1st visit)Contraceptive history/plans (1st visit)Medical history (1st visit)Interim history (on return visits)

During every visit: Provide all elements of basic care

packageIf abnormal s/s (based on assessment),

provide additional care

Note: Information gathered through assessment should be

taken into consideration during care provision.

Postpartum care provision

Ongoing supportive care up to dischargeBasic care package:

Breastfeeding and breast careComplication readiness planSupport for mother-baby-family relationshipsFamily planning Nutritional support Self-care and other healthy practicesHIV counseling and testing Immunizations and other preventive measures

source: Maternal & Neonatal Health

Management of abortion complications

MVA in incomplete & missed abortions, molar pregnancy

Parenteral Antibiotics Management of shockPost abortion counseling

FAMILY PLANNING COUNSELING

Skills required in communication & inter-personal relationship

Benefits of optimum birth spacing-at least 3 yrs

Method choice

Starting before fertility returns

Basic New born physical examination

Overall appearance/ general well-being:WeightRespirationTemperatureColorMovements and

posture Level of alertness and

muscle tone

SkinHead, face and

mouth, eyesChest, abdomen and

cord, external genitalia

Back and limbsBreastfeedingMother-baby bonding

New Born Care

Basic care:Early and exclusive breastfeeding Complication readiness planNewborn-care and other healthy practicesImmunizations and other preventive

measures

Breastfeeding guidelines:Give baby colostrumBreastfeed immediatelyBreastfeed exclusively and on demand

Information on benefits/general principles of breastfeeding; additional advice for mother, including breast care; and breastfeeding support – provide as needed

Maintaining warmth

Skin-to-skin contact for first 6 hoursDo not bathe in first 6 hours; and

preferably not in the first 24 hoursAvoid tight clothingCover headKeep room warm (25°C), free of draftsCheck feet every 4 hours for first day

Prevention of Infection/Hygiene

Baby’s immune system still developingWash hands before touching baby; after

changing diaperTake care of own baby as much as possibleAvoid sharing equipment/suppliesKeep baby away from sick family membersBe alert for s/s of infection

Cord Care

Wash hands before and after cord careAvoid getting cord wet – if wet, dry immediatelyApply no lotions, powders, etc.Keep cord outside of diaperIf bleeding, retie immediatelyCord should separate from umbilicus 2-7 days

after birthEnact complication readiness plan for s/s of

infection or delayed separation

Sleep and Other Behaviors/Needs

Sleeping:Should sleep on side or backWill sleep about 20 hours/day at first; will

gradually stay awake longerProtection:

Falls or harm by animals/other childrenSuffocation (e.g., from pillows)

Crying – Address cause of discomfort (e.g., hunger, dirty diaper)

Mother-baby-family relationships – provide support

Immunizations and Other Preventive Measures

Before discharge, give BCG, OPV-0, HB-1Advise mother to return for additional

newborn vaccines at 6, 10, and 14 weeks

Within 6 hours after birth, give vitamin K1 1

mg IM For newborns in malaria-endemic areas,

counsel on sleeping beneath insecticide-treated bed net

IMPLEMENTATION…

EDUCATION PROCESS & ITS SUPPORTS

EDUCATION SYSTEM

LEARNING RESOURCE PACKAGE

EDUCATION PROCESS(MASTERY/ADULT LEARNING)

Problem solving, critical thinking & clinical decision making skills

Appropriate interpersonal communication skills

Competency in a range of essential clinical skills for maternal and new born health care

EDUCATION PROCESS SUPPORTED BY…

1.Appropriate training programme

2.Skilled classroom & clinical teachers

3.Teaching methods that are current & comprehensive

policy environment of the ‘Educational System’:-Acknowledges fundamental importance of

educational continuum (Pre-service, In-service, Continuing education)

Provides enough financing to sustain the educational programme

Authorizes the skilled provider to practice the skills for which she has been trained

Incorporates comprehensive programme of supportive supervision, evaluation, feedback & monitoring in which the community serves as a vital partner

LEARNING RESOURCE PACKAGE for BEOCDoes not replace existing curriculum Includes teaching/learning methods, materials &

other resources to support implementation of educational programme for-

‘skilled providers’ homoeopathy and Ayurvedic doctors

just as midwives, doctors & nurses

of modern medical science

Partners involved in EmOC

FOGSICMC VELLORE WITH JHPIEGO

TRAINED TRAINERSAVNI Health FoundationGOVT. OF INDIASTATE GOVT.

Who then are the partners for BEOC for Homoeopathy & Ayurvedic doctors?

AYUSH?NRHM?WHO?STATE GOVT?MEDICAL COLLEGES WITH EmOC TRAINING

CENTRES?HOMOEOPATHY& AYURVEDIC

ASSOCIATIONS?OBSTETRICIANS & PEDIATRICIANS

sensitive to the issue?

The Orissa initiative in view of shortage of graduate doctors in the periphery

Mainstreaming of 1132 AYUSH doctors into the health care delivery system has been initiated by NRHM

Some of these will be identified and given the competency based Skilled Attendance at Birth (SAB) training at district head quarters by O&G specialists that are already being given to graduate doctors, nurses and female health workers

DESIGN for EmOC…

Master Training centres are set up in medical colleges with suitable infrastructures

Each training centre offers two courses- 1) short course of 3 weeks 2) long course of 16 wks

Competency based course adapted from JHPIEGO modules

What would be the design for Homoeopathy & Ayurvedic graduates?

Where should it be imparted?

Would the duration be equal,

or longer ? Certainly not shorter!

What would be the issues involved? Especially ‘legal’?

CRITERIA OF TRAINEE??

Homoeopathy/Ayurvedic Medical Officers posted in a PHC/ Dispensary/ FRU whether or not actively involved with labour cases ?

Providing/oriented to provide minimum level services as per GOI guidelines?

By capacity building of Homoeopathy & Ayurvedic graduates in BEOC…..

CAN WE FURTHER PREVENT THE MOTHER & NEWBORN

FROM DYING ?!

What’s your answer?