Social obstetrics

1. Social obstetrics Dr. Najah

2. The basic principles that make the women health requires special care: • Women constitute a large group of the population. • They are vulnerable due to their physiological constituents • High frequency of Pregnancy related morbidity and mortality that can be prevented by simple and cost effective interventions. • Certain problems of the mother during pregnancy e.g. malnutrition, HIV, HB, Syphilis, German measles, drug intake and smoking have their adverse effects on the fetus.

3. Factors related to maternal mortality & morbidity 1- Factors related to the consumers ( Women): 2- Factors related to Health Care

4. Factors related to the consumers ( Women): • High burden of health problems among women. • Young age at conception, short interbirth interval, high parity • Lack of awareness about health problems & factors behind them which leads to -lack of personal hygiene - Inadequate nutrition. • -Inability to recognize dangerous signs • &symptoms • -Delay in seeking health care • -Low utilization of preventive services • (Antenatal care).

5. II. Factors related to Health Care • Inaccessible Health services: Lack of transportation or long distance • Poor &inadequate referral system. • Low outreach for all services except for postnatal check up. • Shortage of drugs, equipment, transportation Facilities. • Lack of experience & training of health personnel that lead to Failure of early diagnosis , inadequate management and time of referral.

6. Maternal mortality The World Health Organization define maternal mortality as: Death of women while pregnant or within 42 days after termination of pregnancy (i.e. during pregnancy, delivery and puerperium), form any reasons related to / or aggravated by the pregnancy or its management, but not as a result of unrelated accidental or incidental causes.

7. World wide, around half a million women die yearly from maternal causes. Almost 99% of these deaths occur in developing countries • 60% of all maternal deaths occur after delivery, • 24% during pregnancy • 16% during delivery.

8. A) Direct causes: 1- Hemorrhage. 2- Eclampsia 3- Puerperal sepsis. 4- Obstructed labor. 5- Induced abortion. B)Indirect causes: Death from chronic diseases that are aggravated by pregnancy e.g. heart, liver & kidney diseases, anemia, diabetes & hypertension Causes of maternal death

10. 1-Hemorrhage • Identification: • Antepartum hemorrhage is hemorrhage from the genital tract occurring after 22 weeks of gestation till before delivery of the baby. • Postpartum hemorrhage is the loss of 500 ml or more of blood from the genital tract after delivery of the baby.

11. Complications: • 1- Maternal : • shock • cardiac failure • infection. • 2- Fetus /newborn baby : • low birth weight, • asphyxia, • still birth

12. Early detection and management • 1- Antepartum hemorrhage • No vaginal examination should be carried out at the health center • Give IV fluids if mother is shocked • Refer to hospital. • 2-In postpartum hemorrhage • if placenta is still retained perform manual separation of placenta. • If removal is impossible refer to hospital. • 3-All women with bleeding should have iron therapy in post partum period.

13. 2-Hypertensive disorders of pregnancy • Hypertension in pregnancy • The blood pressure is more than 140/90 Hg • Pre-eclampsia: • Hypertension + proteinuria • Eclampsia : • Hypertension + proteinuria +convulsion & coma.

14. Complications: • For Mothers :Maternal death & cerebrovascular strokes. • For Newborns: Low birth weight ,asphyxia • &still birth

15. Early detection of hypertensive disorders during pregnancy: • Raise the family awareness of signs and symptoms of hypertensive disorders of pregnancy. • pregnant woman should seek care if she suffers severe headache, generalized edema, blurred vision and /or convulsion. • During the antenatal care check out for edema, perform frequent blood pressure & weight measurement and urine analysis for proteinuria.

16. Management: • If B/P (diastolic) is100 mm Hg and no proteinuria • Management is at the health center • Bed rest & check B/P twice weekly. • If B/P rises and / or oedema or proteinuria develop • Refer to hospital

17. 3-Puerperal sepsis • Identification: • It is infection of the genital tract occurring at any time between the onset of labor and within the 42 days post partum in which fever (38.5oC) and one or more of the following is present: • 1- Pelvic pain. • 2- Abnormal vaginal discharge (e.g. pus or abnormal smell ). • 3- Delay in the reduction of the size of the uterus

18. Predisposing factors for puerperal sepsis : • 1 -Low resistance: • General • a-Malnutrition (anemia) • b-Infections (respiratory, urinary, or genital) • c-Hemorrhage. • d- Preeclampsia or eclampsia. • Local: • a- Premature rupture of the membrane. • b- Prolonged labor.( Forceps) • c- Presence of perineal tears. • 2-Unclean practices during delivery (manual or operative intervention)

19. Complications: Maternal complication:-septicemia, shock, death.

20. Prevention, early detection and management of puerperal sepsis: During pregnancy: 1- Correction of predisposing factors Malnutrition (anemia) infections (respiratory, urinary, or genital) Preeclampsia or eclampsia 2- Treatment of any septic focus 3- Health education on personal hygiene

21. During labor and puerperium: 1- Birth attendants should be aware of the requirement for a clean delivery: strict aseptic techniques, avoidance of repeated manipulation and transmission of infection from attendants and visitors. 2- Prophylactic use of antibiotic. 3- Health care providers should be trained to recognize puerperal sepsis, give antibiotics and refer to hospital if there is no improvement 4- Women should be aware of the early signs and symptoms of infection and be encouraged to seek treatment.

22. 4-Anemia in pregnancy • Identification: • Anemia in pregnancy is defined as a hemoglobin concentration of less than 11 gm % (11 gm/ 100 ml blood). • It is a risk factor to many complications during pregnancy. • Causes of iron deficiency anaemia: • 1-Repeated pregnancy & delivery within short intervals • 2-Parasitic Infections • 3- Deficient Iron Intake

23. Maternal complications: a-Cardiac failure. b- Increase fatality from Ant or postpartum hemorrhage. c- Increase complications due to anesthesia or operation d- Puerperal sepsis Fetus/new born complications: a- Low birth weight b-Asphyxia. c-Still birth d-Perinatal mortality. Complications of severe anemia:

24. Prevention, early detection of iron deficiency anaemia • All pregnant women should be given a standard dose of Iron /Folate during pregnancy • 2. Nutritional education • 3. Treatment of parasitic infections. • 4. Early detection by assessment for pallor & routine hemoglobin estimation

25. Management: • If moderate anemia: • - Give standard oral dose of • iron / Folate. • If severe anemia, • - Treat for a month with higher • dose or • - Give IM iron. • -If Hb level not raised after • treatment, refer to hospital

26. Maternity Care Program

27. Maternity Care Program : • It includes: • Premarital Care • Antenatal Care • Natal care • Postnatal care

28. Aims of the program: 1- Detect any potential risk to pregnancy. : Biological obstetric, medical ,social 3- Save the off springs from the heath hazards of parental origin. 4- Guide and educate partners for a healthy family

29. Premarital Care

30. Components of the Premarital Care: • a) History taking: A personal, family & medical history for diseases (diabetes, hypertension, Mental retardation, Sickle cell anaemia) • b) Medical examination. • c) Investigations: • Chest x-ray to exclude T.B. • Blood examination: ABO, Rh, blood sugar, Hb ,serological tests for Syphilis • Urine analysis for albuminuria, glycosuria & renal infection • Stool analysis for parasites. • Detected cases should be referred for management

31. d)-Parenthood and family life education: • Education on: infant care, child development & STDs • e) Genetic Counseling: For those with family history of genetic disorders • f) Immunization against • German measles • Tetanus (tetanus toxoid)

32. Antenatal Care

33. 1- Antenatal care • Components: • I- Initial visit. • II- Return visit. • III- Home visit. • IV- Registration of data and maintenance of records.

34. I- Initial Visit: 1- History a-Personal history: Name, age and residence. b-Social history: education and occupation of pregnant women and husbands, smoking. C- Medical history: Familial hereditary diseases, diabetes, hypertension, Sickle cell anaemia

35. d) Obstetric history: • Previous obstetric history: • Parity ,gravidity, birth interval, pregnancy outcome, abortion, still birth and early neonatal deaths , cesarean section, complication during pregnancy , delivery or puerperium. • Present pregnancy: • Date of last menstrual period to estimate date of delivery, dangerous symptoms.

36. 2- Physical examination • -Measurement of weight, height, blood pressure, • pulse and temperature. • -Checking pallor, edema, and lower limb • deformities. • -Examination of heart, chest, kidneys and breast. • -Abdominal or obstetric examination: fundal level, • fetal movement & fetal heart sounds. • -Dental examination to search for (septic focus).

37. 3- Laboratory investigations: • Blood examination for : • 1-Hemoglobin concentration: done periodically or at • least once every trimester for detection of anemia. • 2- Determination of blood group. • 3- Serologic test for syphilis • 4-Rh factor.

38. Detection of RH Of the pregnant women RH + RH - Nothing Investigate the husband for Rh There is possibility of erythroblastosis foetalis of the 2nd or the subsequent newborn Investigate the pregnant women for RH antibodies between 32-34 weeks of pregnancy RH + RH - Nothing RH antibodies + RH antibodies - Give the women RH IG to neutralize her RH antibodies within 48 Hs after delivery

39. Urine examination for: • - Pregnancy test to verify pregnancy. • Albumin ( to detect Preeclampsia) and sugar ( to detect diabetes)

40. 4-Management of minor conditions • Management of minor conditions detected like anemia ,Symptoms & signs of Physiological changes during pregnancy ,dental problems. • Major illness or complicated cases are referred to the specialists.

41. 5- Risk assessment during pregnancy • A) Biological risk: • 1- Maternal age: • The optimal age for childbearing is between 20 and 30 years • i) Maternal age < 16 &> 35 years increases the risk for: • Abortion • Preterm delivery. • Eclampsia. • Uterine dysfunction. • Difficult labor • Intrauterine fetal death • Down’s syndrome. • Maternal and perinatal death. • Hypertension &diabetes.

42. 2- Parity & Birth order: Maternal risk is slightly greater with the first pregnancy and fifth pregnancy & more. 2- Paternal age: There is an increased risk of Down syndrome with paternal age (over 55). 3- Inter-birth interval: More than 10 years or less than one year is considered a risk pregnancy. 4- Maternal height: Short stature of the mother (less than 152 cm) increases the prenatal morbidity & mortality. 6- Maternal weight Both underweight and obesity are considered risk factors.

43. B) Medical risk: Pregnancy with general disease e.g. cardiovascular, renal & liver diseases diabetes, anemia, …etc increase the maternal mortality

44. C) Obstetric risk: • Risk increases when there is • Obstetric history of abortion , still birth , neonatal mortality, cesarean section or instrumental delivery. • Mal-presentation , twins, hemorrhage eclampsia placenta previa……

45. D) Social risk: Poor social condition , unsanitary home, heavy smoking …… all affect maternal health. The identified risk groups may be in need of specific treatment , frequent visits for monitoring or referral to a higher level of care for assessment & delivery.

46. Reasons for considering risk assessment is of little value 1- High risk Women may not develop complications. 2- Some life threatening complications, develop suddenly, can’t be predicted by risk assessment e.g. postpartum hemorrhage. 3- Some complications can be caused by medical intervention , e.g. infection.

47. - According to the mentioned reasons , the health system should focus on improving the quality and expanding the services for the prevention, early detection and treatment of pregnancy related complications among all pregnant women not only high risk groups.

48. 6- Immunization Determination of the immune status of the mother by asking her about the number of previous doses of tetanus toxoid and the date of last one

49. Women immune status according to the number of tetanus toxoid doses

50. 7- Maternal nutrition • Nutritional disorders among pregnant women: • Anemia (iron deficiency anemia with or without folic acid deficiency), • Osteomalacia, • Underweight or obesity, • IDD (goiter).