ALL INDIA INSTITUTE OF LOCAL SELF

GOVERNMENT

DELHI

“ METERNAL HEALTH CARE for paramedics“

DR.P.P.SINGH

By

Dr. P.P.SINGH

Faculty AIILSGD

Ex Medical Superintendent Cum Consultant pathologist HRH Delhi

Ex. Director India Population Project 8 Delhi..

Obstetrics

Management of Pregnancy/ labor . Purpurium under natural & abnormal circumstance aiming at healthy Maternal & child .

Social Obstetrics ;

Study of social & environment factor related to Reproduction Health .

Social Pediatrics;-

study of social & environment factor related to promotion of growth development- prevention of Mortality .Provision of comprehensive health care to children

M& CH Services

- Making available

- Ensuring utilization.

Staff

Hospital Quality

Patients’ Status

Community participation.

Preventive , Promotive & Curative Health services to Mother

and Child at Primary Health care.

Need for specialized PHS for M & Child

1. Large Section of Population.

Mother 22%

Child 42%

Total 65%.

2. High Risk group

MMR – 4-5/1000

Morbid in community.

80% life scar – child bearing ,

child rearing

2/3rd Anemic Mother

½ anemic Non pregnant.

Early marriage

Early Menarche

Repeated Pregnancy – High rate

of complications

First few year following Menarche

1.Anemia – Incomplete Pelvic Growth

- Obstructed Labor

2.90% Indian Women are high Risk.

-Anemia

--short Stature

-- Bad Obstetric history.

-Child Hood – period of growth / development , personality

formation

3.Child survival

4.Disease/ Environment

-5.Quality & availability of Health , community servicers .

-- 6.high IMR -80/1000---- 2015 44/1000 . 50% ist week NNMR with in

48 hrs ( prenatal ) CDR under Five- 50/1000.

3. Preventable morbidity & mortality

-UIP

--ANC / PNC

-- Safe delivery.

-4. Physically compact Units

- MOTHER – HEALTHY – HEALTHY CHILD

-( Neonate , Child and Maternal care.)

-5. Unified , integrated , Simultaneous care of Women & children

-- ANC/PNC

--Infant

-- Under Five care.

-6. Unified Training of all those involved

- Logistic for Intervention, Simultaneous Supervision , management

/ evaluation is possible & feasible

7. Socio-economic Factors

Contribute to Reproduction are Controlable - 57% Girl married 15- 19

years.

11% Below 15 years.

Assessment Need for MCH

1. Birth Rate – helps to find base line – ANC 28/1000.

2. MMR – 2/3rd are preventable by hospital intervention ( Anemia, APH,PPH

Puerperal infections)

3. Prenatal mortality Rate --- 50/1000

28 weeks of pregnancy – 7 days of birth

BITWA --- Birth Injury, Infection , Trauma Weight – poor. Asphyxia

4. Place of Delivery . Large number at Home 95% are normal – needs

Environment , Transport &emergency OC.

5. Attendant at delivery – DAI / TBA

6. Prematurity – 25% premature either – Gestational or Weeks IUGR ( Intra

Uterine Growth Retardation) 50% cases are due to Poor Habits, Smoking,

Poverty , Undernourished Toxemia

7. ANC – Crux of MCH , Complete regular Check up , Minimum 3 visits., early

registration.

8. Resources

Rural area – 4% need Doctor, 1% need Hospital

Well trained Para medical One PHC – One Medical Officer.for 30

thousand population –

In one year- 40 delivery ,1000 care of Infant 5000 Child under

Five.

MPW at sub center 5000 population

Look after 160 ANC / year

TBA – per 1000 population.

Eligible Couple & Expected ANC

• Family Welfare.

•Post partum programme

•Medical Termination of

Pregnancy Act 1971.

•Training TBA.

•Urban Revamping Scheme.

•Free education to Girls.

Reservation in occupation

employment paid leaves.

Special Nutrition programme.

ICDS , Prevention of

Nutritional Anemia

UIP

Mid day meal .

Act of Marriage age.

National policies for child

etc.

National Programmes

TARGET POPULATION

Pregnant women – 3.2%

Live birth --- > 3%

Post Natal --- > 3%

INFANT --- 92% ( PXB 1000-1)

Child ( 9months to 3yrs) --- 8%

Under Five ---- 13%

MATERNAL DEATH

A death while pregnancy or 42 days of delivery but not

related to accidents.

MMR

Total no of death due to complication of pregnancy ,Chlid

birth

OR with in 42 days of delivery , puerperal causes in a year

= -----------------------------------------------------------------------------------

X 1000

Total number of Live births in same year.

Includes all Deliveries / Abortions , Pregnancy wastage , Still

Births.

CAUSES OF MATERNAL DEATHS.

I Obstetric cause, Hemorrhage APH /PPH , Infections , Toxemia (

Pre eclampsia/ Eclampsia)

II Non Obstetric causes. Anemia , Accidents Diseases –

Tuberculosis, Malaria , Malnutrition, RHD, diabetes , hyper tension

, Pelvic inflammation.

III Social Causes

Early& late marriage

Grand Multi para.

Repeated pregnancies.

Large family size.

Poor Nutrition.

Lack of Health services .

Poor sanitation

Transportation

Communication

Education

High incidence of Communicable diseases

Low status of Women

Shortage of Medical / paramedical staff.

Poor working & managerial ability

PREVENTIVE MEASURES of MMR

Preconception – Knowledge – priority intervention for

Safe Mother hood.

Ist Priority – Intervention.

2nd priority - Improving nutrition & Education

3rd priority – Increase over all socio economic up

lift of women.

Early Registration --- ANC

Timely Referral

Intra partum care.

Post natal care (PNC)

A . Essential care for all Early Registration of ANC – before 12- 16 weeks.

Minimum three visits 12, 32, & 36 Weeks.

Prevention of Nutritional Anemia ( PANA) Prophylactic IFA (

100 mg Iron & 0.5 mg Folic acid ) two tab daily / 100days.

Therapeutic – three tablet / day 100days. , Deworming in 3rd

trimester

B Immuinisation – TT – two doses at the interval of one month, 3

weeks before expected date of delivery.

C. Ensure – FIVE cleans – HAND, Surface, Cord , Thread &

Blade.

D. Post natal Care – to avoid sepsis, hemorrhage , Spacing advice

.

E. Early detection of Complication ;- Anemia, APH ,PPH,

Toxemia ( Wt gain > 5 Kg in month, BP > 150mmof Hg.

F. Emergency care ;- vacuum extraction, Anesthesia., Blood

transfusion , Caesarian Sections, Manual removal of Placenta.

Suction curettage

Sterilization

F Care of Women in reproductive age ;; No Conception below 20

years and above 30 /35 years.

ANTE NATAL CAREThree Trimester – 280 days

LMP – 12 Wk. –Ist Trimester

13wk – 28 wks – IInd trimester

29wk – 40 wks – IIIrd trimester

Purpose of ANC Checkup to monitor ,progress & to identify the

complications.

To make aware about FRU

To have advance arrangements for transport,

anticipate Emergency.

Blood donor

Number of Visits At least three visits 20,32 & 38 wks. More often

in Third trimester

First Contact Examination1. Registration – Bio data

2. History of Pregnancy

• LMP – EDD

• Problem Anemia's etc

• Iron folic acid

• H/O infestation ,Radiation ,Drugs and Diet etc

3. History of Previous Pregnancy

ANC, Place of delivery. ( Home ? Institutional)

H/O hemorrhage , immunization , Abortion contraception

practice.

4. General Examination

Weight, ( 2kg / month) Height ( 140 Cm) HB- > 10 gram%

Lymph adenopathy, Neck veins Thyroid, Peritoneal edema

,

Pulse , BP ( any change 30/15 mm in Systolic/diastolic ),

Jaundice

5. Systemic Examination for

o Diabetes , Hypertension, Goiter ,RHD, Hepatitis –

STD/AIDS.

o PID or Malignancies

o Family history – Twines, congenital abnormalities

o Appetite , Habits – Smoking, Alcohol, drugs ,

Tobacco.

Obstetric Examination 1. Confirm Pregnancy.

2. Breast Size

Erectile hyper pigmented Areola.

Montgomery’s tubercles on areola.

Nipple secretions – 12th weeks onward

Chlosma gravidonn face.

Linea Vigra from xephisternum to pubic

symphysis.

Striao graviodorum

3. Per Abdomen Examination

Fundal height

16 wks – half way pubis/ umbilicus

28wks at umbilicus.

32 wks upper 1/3rd / lower third 2/3rd

38 wks side bulge by 40 wks.

4. Foetal parts – active movements 20 wks

5. Foetal Heart (FHS) 18-20 wks. Rate 120-140/minutes

6. Per Vaginal Examination – pap smear prepared.

BASE LINE INVESTIGATION

o HB, Peripheral Smear.

oUrine – albumin / sugar

oBP

oPap smear

oBlood group- RH status

oSerological test – VDRL

oBlood sugar

oAustralia antigen / HIV

ADVICE/SERVICESS Subsequent visit.

Identify high risk – APH ,Spotting,Multy para ,

Primigravida, Previous C/S , Hieght, Twins, Hydroamnios ,

Anaemia.

Examination /Investigations

Diet – 300 calories extra.,14gram Protein, IFA, Iodine,

green leafy vegitables , 1gram Calcium Lactate.( Social

ceremony – DOHAL -Jewan

Personal Hygiene - cleaniliness, Exercise, sleep , rest

after meal, avoid tobacco/alcohol radiation and hand

scrubs.

Immunisation – TT- 5th & 7th month. Earlier in first

pregnancy.

About Warning Signals – bleeding , discharge, Abdominal

or pelvic pain, fever, swellingof feet, blurring of vision,

dizziness , reduction of urine out put, nauseating vometing

, headache / fluctuating BP, loss of foetal movements.

Contraception & child rearing. Breast feeding etc.

Home visit

Stress.

IDENTIFYING HIGH RISK

Primi gravid - <15 years or > 35 yrs.

Height below 140 cm.

Multi para – 4 or more

Bad obstetric history--- Abortion, still birth ,

premature ,ectopic, C/S , PPH, APH.

Medical conditions – TB, Diabetes, Hypertension ,

Heart disease.

Conceived after infertility treatment.

First Trimester <12

wks

Nausea, Vomiting ,

weight gain 1-2kg

Absence of period

frequent urination ,

Tubal pregnancy ,

Hyper emesis

dehydration

Veginal bleeding

Abortion

II Trimester 13 – 28

wks

Slight fluid in nipple ,

quickening

Gradual increase in

fundal height,

noticeable

enlargement of

Abdomen

Fetal jerks

/movements

FHS

Weight Gain 3.5- 5 Kg

Abortion

Toxemia

IIIrd Trimester 29- 40

Wks

Frequent urination

,Fundus reaches

Diaphragm , Slight

oedema

Weight gain 11Kg.

Hemorrhage , mal

presentation of head.

Excessive fluid (

Hydroamenios)

NORMAL PREGNANCY & POSIBLE

COMPLICATIONS

TBA _ Trained/ Traditional Birth Attendant

Training at PHC – 8 days Theory & 22 days practice

General Anatomy & Physiology

Labor Diagnosis & Pregnancy.

High risk identification

Identification of danger sign

About Referral system

Care of Cord.

Removal of Placenta.

.

WARNNING SIGNALS

Sluggish Pains -- Slow progress.

Cord or hand prolapse ---Sudden Change in FHS

Poor progress of good uterine contractions

Mucconium Stain --- Sever Headache

Fever & Convulsions. ----Bleeding APH or PPH

Placenta not separated with in 30 minutes.

Deterioration of condition

Sever Anemia leads to CHF.

Preparation of Labour

DDK-- Disposable Delivery Kit

Five cleans – Surface, Hands , Blade ,Thread & cord.

LABOUR STAGES – THREE

I- From time of pain start to time CX fully dilated .

II- Full dilatation of Cx to delivery of baby.

III – Delivery of baby to delivery of Placenta

P.S. ;- 12- 13 hrs in Prime gravid. ½ in multi gravid

PARTO GRAPH

Useful clinical guide for early detection of mother

who are not likely deliver normally needs medical assistance.

Following point are to be recorded;-

1. FHS

2. Cervical dilatation.

3. Descent of Head

4. Uterine contractions

5. Maternal vital conditions.

Recognition of;-

1. Obstructed labour

2. Uterine rupture

3. PPH

PS;-1.if All above are recognized early can reduce the

MMR .

2. If No increase in cervical dilatation or blood

loss more than ½ liters case needs to be referred to PHC or

District Hospital

Ist Stage of Labour labour pains Regular / Strong uterus become

hard.

Period 10 hrs in Primi / 5 hrs in second

Encourage – emptying of bladder

Give soap and water enema.

Can walk till bag of water is broken

Membrane brake in later should not move

about chances of cord prolapse.

II nd stage of Labouro1-2 hrs.

oEncourage to push only during pains.

oShe must relax in between

oProvide support to perineum with pad of clean

cloth.

oWhen baby head is about to come till mother to

stop pusing and take deep breath – deliver head

slowly

oCut cord 2.5 inches from the umblicus

Harmful Practice women should not push in Ist stage.

Uterus should not be massaged or pushed

Do not give any medicine / inj in Iind stage.

III rd stage of Labour – 10 – 15 minutes normal

Dry baby & put to the breast.

Always ensure Five clean.

Signs of separation of Placenta.Uterus is hard & globular.

Sudden gush of blood

Extra valval portion of cord lengthen.

If fundus of uterus is gently pushed up forward umblicus

cord will not reced in to the vagina.

Check the placenta as soon as delivered , if it is not

complete – refer immediately.