Maternal and Child Health II

1. Maternal and Child Health II

2. Contents: 1.Antenatal care 2. Intranatal care 3. Post natal care 4. Neonatal care and examination • Neonatal examination: First and Second 5. Low birth weight

3. Antenatal Care • Antenatal visits: ANC visit, History Taking, General and P/A examination, Lab investigations, Counselling • Prenatal advice • Specific health protection • Mental preparation • Family Planning • Pediatric Component

4. Antenatal Visits • Minimum visits: 4 • 1st visit : within 12 weeks • 2nd visit : between 14 and 26 weeks • 3rd visit: between 28 and 34 weeks • 4th visit : between 36 weeks and term • Preventive services for mothers • H/o & physical examination, Lab investigation • TT immunization, FFA medication • Home visit • Referral services, Record Maintenance: MCTS

5. History Taking: • Confirm pregnancy • Identify any complications in the previous pregnancy • Identify any current medical or surgical complication • Record the LMP & calculate EDD LMP=1st June 2017……Calculate EDD • Record the symptoms • History of any current systemic illness • History of drug allergies

6. Physical Examination: • Pallor • Pulse: Normal rate: 60-90 beats per minute • Respiratory rate: Normal rate: 18-20 breaths per minute • Oedema: • Blood pressure: ≥ 140/90 mm Hg Pre eclampsia: Check urine for presence of albumin (2+): Referral • Weight: No gain vs Excess gain Rule of 10

7. Abdominal examination: • Measurement of fundal height: 12, 20 and 36 weeks • Foetal parts: About 22nd week. Head, back and limbs can be differentiated after 28th week. • Foetal lie and presentation: • Foetal heart sounds: After 6th month, 120-140 per minute • Foetal movements: After 18-22nd week • Multiple pregnancy: Abnormally larger than the estimated gestational age

8. Assessment of gestational age: USG • Lab Investigations: • At sub centre: Pregnancy detection test, haemoglobin examination, urine test for presence of albumin and sugar, rapid malaria test • At PHC/CHC/FRU: Blood group, VDRL, HIV, Blood sugar, HBsAg

9. Essential components of every antenatal check up: • History taking • Physical examination: • Abdominal examination • Lab investigations • Counselling

10. Prenatal advice • Diet: Weight gain, Replenishment of iron stores. • Personal hygiene: i. Personal cleanliness: ii. Rest and sleep: iii. Exercise: iv. Smoking: v. Alcohol: FAS 3. Drugs: Thalidomide: Teratogenic drug

11. 4. Warning signs: swelling of the feet, fits, headache, blurring of vision, bleeding or discharge per vagina, any other unusual symptoms. 5. Child care:

12. Specific health protection • Anemia: 100 mg elemental iron and 500 mcg of FA • Toxemia of pregnancy: Increased blood pressure and presence of albumin in urine • Tetanus: • Syphilis: • HIV infection: ICTC and PPTCT • Hepatitis B infection: • Prenatal genetic screening: Anomaly scan at 20th week

13. Interventions and Counseling: • Iron and Folic Acid supplementation and medication as needed • TT immunization • HE • Home visits • Inform about the incentives offered by the government

14. Risk Approach • Elderly primi • Short statured primi • Malpresentations • Antepartumhaemorrhage • Pre eclampsis and eclampsia • Anaemia • Twins, hydramnios, previous still birth • Elderly grand multiparas • Prolonged pregnancy • History of previous caesarean or instrumental delivery • Pregnancy associated with general diseases • Bad obstetric history

15. Case scenario Mrs. Zareena, a 24 year old primi gravida presents at 20 weeks of gestation to Rural Health Center, Harekala. She had no prior antenatal checkups. What is your plan of action?? What health care services will you offer her?? Counselling on which aspects??

16. Intranatal care 5 C’s Delivery Kit: Appropriate technology: Skilled birth attendants Aim: Domiciliary care: i. Familiar surroundings ii. Less chances of cross infection iii. Look after the children iv. Ease mental tension

17. Disadvantages: i. Less medical and nursing supervision ii. Less rest iii. Diet may be neglected Rooming in:

18. Danger signals • Sluggish or no pains • Cord prolapse • Meconium stained liquor • Excessive fast foetal heart rate • Excessive bleeding during labour • Post partum hemorrhage • Placenta not separated

19. Post natal care: Objectives: i. To prevent complications ii. To provide care for rapid restoration of mother iii. Check adequacy of breast feeding iv. Provide family planning services v. Provide basic health education to mother

20. Complications: • Puerperal sepsis: Infection of genital tract within 3 weeks after delivery Increased temperature, Increased pulse rate, foul smelling lochia, abdominal pain. • Thrombophlebitis: Infection of veins of the legs associated with pain, swollen legs • Secondary haemorrhage: Bleeding from vagina 6 weeks after delivery…may be due to retained placenta or membranes

21. Restoration of mother to optimum health: • Postnatal examinations: Twice a day during the first 3 days, once a day till umbilical cord falls. TPR review, breast examination, involution of uterus. ii. Anaemia: Routine hemoglobin examination • Nutrition: Home economics • Postnatal exercises: Psychological: Postpartum psychosis Family Planning: Mother Craft Clinics:

22. Neonatal care In India, 62% of all infant deaths occur within the first month of life More than half of them die in first week: External environment Risk of death : highest in 24 – 48 hours after birth

23. Objectives of early neonatal care: i. Establishment and maintenance of cardio respiratory functions ii. Maintenance of body temperature iii. Avoidance of infection iv. Establishment of satisfactory feeding regime v. Early detection and treatment of congenital and acquired disorders

24. Immediate Care: • Clearing the airway: • First and foremost is establishment of breathing • Clear the airways of mucus and other secretions • Head low position: Drainage of secretions • Gentle suction to remove mucus and amniotic fluid • Resuscitation is required if natural breathing is not established within a minute • Equip the labour wards with resuscitation equipments

25. Apgar score: At 1 minute and 5 minutes after birth, Score<5: Prompt action

26. Total score=10 Severe depression: 0-3 Mild depression: 4-6 No depression: 7-10

27. Care of the cord: Aseptic precautions Clean scissors and clean tie To cut after it has stopped pulsating Keep the cord dry Separates in 5-8 days Explain the mother about cord care

28. Care of the eyes: Clean the lid margins of newborn with sterile wet swabs from inner to outer side Instil a drop of freshly prepared 1 % silver nitrate solution to prevent gonococcal conjunctivitis To be reviewed if any discharge from the eye Care of the skin:

29. Maintenance of body temperature: • Normal body temperature of a newborn is: 36.5 to 37.5 • Little thermal control in a newborn and can lose body heat quickly • Immediately after birth, heat loss occurs through evaporation of amniotic fluid from the body of the neonate Precautions to be taken: • Avoid contact with a cool surface, exposure through window to cool air. • Skin to skin contact with mother and wrapping the baby is essential

30. Natural Vaccine: • Demand feeding • Fore milk and hind milk • Proper attachment

31. Neonatal examinations • First Examination: • Soon after birth • Ensure no injuries during birth process • Detect malformations

32. Second Examination: Within 24 hours after birth Detailed systemic examination from head to foot Following protocol: • Body weight, height • Body temperature • Skin • Cardio respiratory activities • Neuro behavioural activity: frog like posture • Head and face: • Abdomen • Limb and joints • External genitalia

33. At risk infants: Largely contribute to perinatal, neonatal and infant mortality Special attention Criteria: • Birth weight < 2.5 kg • Twins • Birth order 5 and more • Artificial feeding • Weight below 70% of the expected weight • Failure to gain weight during 3 successive months • Children with diarrhoea, other infections • Working mother, Single parent

34. Low Birth Weight Contents: • Introduction • 2 groups • Etiology • Risk factors • Prevention • Treatment

35. Low Birth Weight • Birth weight is single most important determinant of its chances of survival, healthy growth and development.

36. Two groups: • Born prematurely (Short gestation) • Foetal growth retardation (India) According to gestational age: • Preterm: Babies born before end of 37 weeks • Term: Babies born from 37 completed weeks to less than 42 completed weeks • Post term: Babies born at 42 completed weeks or later

37. According to birth weight: • Preterm • Small for date babies

38. Preterm: Babies born alive before 37 weeks of pregnancy are completed. Subcategories of preterm birth based on gestational age: • Extremely preterm (<28 weeks) • Very preterm (< 32 weeks) • Moderate to late preterm (32 to 37 weeks)

39. Preterm babies: • Babies born too early • Intrauterine growth may be normal • Weight, length and development may be normal for the duration of gestation • Given good neonatal care, these babies may catch up growth and by 2-3 years of age will be of normal size and performance

40. Causes: • Spontaneous preterm birth (PROM or following prelabour PROM) • Provider initiated preterm birth (Induction of labour or elective caesarean before 37 completed weeks of gestation) Calls for attention to appropriate antenatal and intranatal care. Included management of existing co morbidities in pregnancy

41. Risk factors in preterm birth: • Adolescent pregnancy • Advanced maternal age • Short spacing • Multiple pregnancy • Infections • Existing co morbidities • Habits • Genetic factors

42. Small for date babies: • These babies may be born at term or preterm • They weigh less than 10th percentile for the gestational age • Result of IUGR • Higher risk of dying in neonatal and infant period • Largely manifest PEM and vulnerable to infections

43. Factors associated with intra uterine growth retardation: • Age • High parity, close birth spacing • Malnutrition, Anemia • Heavy physical work • Hypertension, malaria, toxaemia • Low socio economic status • Placental insufficiency

44. Prevention: Direct Intervention measures: • Identification of at risk pregnant women • Tackling malnutrition and infection and other medical disorders: key steps Indirect intervention measures: • Family planning • Lifestyle and habits modification • Environmental measures • Adolescent health • Improvements in socio economic status • Social security schemes

45. Treatment: • < 2 kg: NICU till weight increases to 2.5 kg • 2-2.5 kg: Intensive care for 1-2 days

46. Incubatory care: Adequate oxygen supply 2. Feeding: Expressed milk 3. Prevention of infection: • Facility based newborn care services: • Newborn care corner: Institutional delivery • Newborn stabilization unit: CHCs • Special newborn care unit: District hospitals

47. Kangaroo mother care: • Introduced in Colombia in 1979 • Adopted in developing countries • Essential for LBW babies • WHO recognized method • 4 components: i. Skin to skin positioning of the baby on the mother’s chest ii. Adequate nutrition iii. Ambulatory care because of early discharge from hospital iv. Support for mother and her family in caring for the baby