reproductive child health - antenatal care

REPRODUCTIVE HEALTH & CHILD HEALTH (ANTE NATAL CARE) SERVICES IN INDIA.

DR. MAHESWARI JAIKUMAR

EVOLUTION OF MCH SERVICES IN INDIA.

1885-Association for medical aid by the women to the women of India. Established by countess of Dufferin.

1918-Lady Reading Health School. Delhi. (HV).

1992-Lady Chelmsford League was formed to develop MCH services.

1931-Indian Red Cross Society established. Victoria Memorial Scholarship fund established.

1938-Indian Research Fund Association for assessing causes of IMR,MMR.

1946-Bhore Committee report.

1931-Madras State – MCH Welfare.

1951-BCG vaccination prog.

1952.PHC established

1953-NFPP started.

1962-Mudhaliar Committee report.

1970-AIHPPP started.

1971-MTP Act passed.

1974-75-ICDS prod enunciated.

1976-National Prog for Prevention of Blindness formulated.

1977-MPHW scheme launched.

1978-EPI launched.

1983-NHP launched.

1985-UIP launched.Separate dept of women & child development launched under Min of HRD.

1987-Safe Motherhood Campaign launched by the World Bank.

1990-ARI Cont Prog –pilot project.

1992-Infant Milk Substitute,Feeding bottles & Infant Food (Regulation of Production,Supply & Distribution Act).

1994-Prenatal Diagnostic Technique & Prevention 0f Misuse Act.In force from 1996.

1995-ICDS,PPP launched. (Dec-20 Jan 1996).

1996-PPP, Family Welfare Prog made target free approach.

AIMS & OBJECTIVES OF MCH / RCH SERVICES.

To give expert advice to the the couples to plan their families.

Provide health supervision for AN mothers.

To detect “High Risk” cases & provide special attention.

To fore see complication & prevent them.

To give skilled assistance at the time of child birth & during Puerperium.

To supervise trained Dias.

To give newborn & child health supervision.

To impart useful knowledge on desirable health practices to be adopted during provision of MCH care.

ANTE NATAL CARE.

AIMS OF ANTE NATAL CARE

To promote & maintain good mental & physical health during pregnancy.

To monitor the progress of pregnancy.

To detect & treat medical & obstetrical conditions.

To ensure safe delivery of mature & healthy infant.

To prepare the women for delivery,breast feeding & subsequent care of the child.

To encourage concept of having regular AN care.

IMPORTANCE OF ANTENATAL CARE.

To confirm pregnancy & assess the period of gestation.

To prevent maternal & neo natal tetanus.

To facilitate health education regd diet,rest,avoidance of un necessary travel & preparation for delivery.

COMPONENTS OF AN CARE.

Identification of pregnant women’s & importance of early registration.

Diagnosis of pregnancy.

Clinical assessment.

Advice during AN visit.

Nutrition.

Management of minor ailments.

Risk assessment & appropriate management.

Complications & management.

Complications of late pregnancy.

Management of medical disorders during pregnancy.

Screening for congenital malformations during pregnancy.

Management of Anaemia during pregnancy.

IDENTIFICATION / REGISTRATION.

Early identification helps,

Assessing the health status of the mother.

Obtain baseline information of the mother.

Screen for factors, referral to FRU.

Recall LMP easily.

Do MTP if required.(< 10 wks.)

Counsel on hygiene diet , rest.

Build up rapport with pregnant women.

12 wks..

WITH IN 20 Wks.

Screen & treat anemia.

Initiate prophylaxis against anemia.

Screen risk factors & medical conditions.

Develop individualized birth plan.

Immunize with tetanus toxoid.

Investigate – Hb,bld grp, typing,urine examination, VDRL, Bld grouping.

28-32 WksAimed at the following.Detect,

PIH.

Multiple gestation.

Anemia.

Develop individualized birth plan.

Give TT.

Assess IUGR.

Repeat HB estimation.

36 Wks.

PIH.

Detect the following.

Identify foetal & presentation.

Rule out CPD in primi gravida.

DIAGNOSIS OF PREGNANCY.

Women may report with symptoms of,

Cessation of menstruation.

Nausea with or without vomiting.

Disturbance in micturation.

Fatigue.

Perception of fetal movements.

O/E………………….FIND,

Breast enlargement.

Changes in skin colour of areola.

Discoloration of vaginal mucosa.

Enlargement of abdomen.

Softening of cervix & uterus.

Uterine enlargement.

Internal & external ballotment.

Ability to discern fetal parts.

CLINICALLY,

Perception of fetal movements by the examiner.

Detection of fetal heart sounds at 20 wks.

Detection of HCG in urine.

Detection of fetus & placenta on USG.

CLINICAL ASSESMENT.

Age.

Duration of marriage.

The order of pregnancy.

Number of living children.

A.General history.-Date,LMP.

Last child birth.

Last abortion.

Problems during previous pregnancy.

PROBLEMS DURING PREVIOUS PREGNANCY

Abortion or premature birth.

Eclampsia/Pre-Eclampsia.

APH.

Malaria ,anemia,UTI.

Complicated delivery,PROM.

Sepsis.

CONT….

Sepsis.

Operations.

Still birth,Neonatal death.

Induced labour.

Baby weigh at birth, Sex,alive,well.

HISTORY OF SYSTEMIC ILLNESS.

Heart diseases.

DM

TB.

HT

UTI.

Malaria.

Thyroid diseases.

FAMILY HISTORY.

Twins.

Congenitally mal formed baby.

COMPLAINTS DURING PRESENT PREGNANCY.

Breathlessness.

Excessive tiredness.

Palpitation.

Puffiness of face.

Tightening of bangles.

Headache,blurring of vision.

Bleeding,leaking PV.

Pain Abdomen,fever,presence of fetal movements.

PHYSICAL EXAMINATIOIN

Ht.

Wt.

Bp,Hb,grouping,typing,U/S, U/A.

Pallor.

Odema.

Breast examination.

Respiratory rate.

CVS-prominent neck vein.

ABDOMINAL EXAMINATION.

16 wks-Just above symphysis pubis.

20 wks-Midway between symphysis pubis & umbilicus.

24 wks-At the level of umbilicus.

28 wks-At the junction of the lower third,& upper two third of distance between umbilicus & xiphisternum.

32 wks-Junction of upper & middle third between umbilicus & xiphisternum.

40 wks- Fundal height comes down but flanks are full.

If the fundal ht does not co-rrelate with period of amenorrhea, it could be due to,

Wrong dates.

Full bladder.

Multiple pregnancy.

Hydramnios.

Molar pregnancy.

Pregnancy with pelvic tumor.

IF less,

Wrong dates.

IUGR.

Missed abortion.

IUD.

Molar pregnancy.

Trasverse lie.

ADVICE DURING AN VISIT.

Iron & folic acid supplementation.

TT injections.(2), 4-6 wks apart . If the previous child birth was within 3 years-1TT.

To bring AN card during every visit.

Pregnant women may continue her usual activities,throughout her pregnancy.if not tired.

Hard & strenuous work should be avoided.

Should take bath daily.

Cont…………

Should sleep for 8-10 hrs at night & 2 hrs during day.

Clean loose cotton cloth should be worn.

Retracted nipples should be corrected during the last 6 wks.

Coitus should be avoided during 1’st & last trimester.

Travel by vehicles having jerks is to be avoided.

AN mothers & the at tender to be told regarding minor ailments & warning signs & do’s & don’t’s .

NUTRITION

DIETARY ADVICE DURING PREGNANCY.

Advice a diet that is nutritious,easily digest able, rich in protein,minerals & vitamins consisting of normal food plus…………..at least…..

Half lit milk./ day.

One egg.

Plenty of green leafy veg.

Fruits.

Fiber rich diet.

Advice extra calories for maternal health & to meet the needs of the growing foetus.

Advice diet keeping in mind the socio economic condition.

MANAGEMENT OF MINOR AILMENTS.

VOMITING IN PREGNANCY.

Wanes off at 12-14 wks.

Advice small frequent feeds.

Avoid greasy foods.

Include plenty of green leafy vegetables.

Advice plenty of fluids.

Encourage dry foods in the morning.

HEART BURN & NAUSEA.

Avoid spicy , rich foods.

Take cold milk & bland diet.

If severe administer antacids.

FREQUENCY OF MICTURATION.

Experienced more frequently up to 10-12 wks is mostly self limiting.

CONSTIPATION.

Encourage increased fiber intake.

RISK ASSESSMENT & MANAGEMENT.

OBSTETRIC FACTORS.

Gravidity- Primigravida./ Grand multipara.

Age- >35 yrs, below 19 yrs.

Height-<145 cm (pre pregnancy wt less or overweight 20% as per height weight standard.

Multipara with BOH – loss of previous baby, caesarian section,HY, recurrent premature labour,abortion,IU fetal death,III stage abnormalities, congenitral malformations,neo natal deaths.

Cases of disproportion.- Pelvic contraction, pelvic tumor primi gravid a with non engaged head at / near term.

Mal presentations / multiple pregnancy.

Obstetric complications---- hemorrhage , threatened abortion,APH,PIH.

High risk fetus– premature lab our, IUGR, Rh incompatibility, post maturity.

Infertility– conceived after treatment for infertility.

MEDICAL FACTORS.

Refer to FRU in following situation.

BOH,repeated abortion.

Bleeding during pregnancy.(< 12 WKS.)

PIH/ Eclampsia.

Abnormal presentations.

Multiple pregnancy/ Over distended uterus.

Grand multipara.

Previous history of operative surgery.

Floating head in primi gravid a at 38 wks, & later.

Pre term labour.

Premature rapture of membrane (labour pain does not start with in 6 hrs.)

Very big or very mall baby.

Hyper emesis gravidarum not responding to treatment.

Heart diseases in pregnancy.

Jaundice in pregnancy.

COMPLICATIONS OF EARLY PREGNANCY.

Hyper emesis gravid arum.

Retroverted gravid uterus with retention of urine.

Vaginal bleeding during pregnancy.

PREVENTION OF ANEMIA.

CAUSES.

Nutritional.

Iron deficiency.

Folic Acid deficiency.

Iron & Folic acid deficiency.

TYPES OF ANEMIA.

Hypo chromic microcytic anemia.

Macrocytic anemia.

Dimorphic anemia.

Normocytic normochromic anemia.

INVESTIGATIONS.

Hb investigations.

Stool for ova cyst.

Urine analysis, UTI.

Hb electrophorosis.

TREATMENT.

Mild-moderate– Oral Fe+ & FA.

Diet rich in protein & Iron.

Vit C supplementation.

Treatment of UTI.

Oral iron.

Supplementation of vitamins.

Referral to FRU.

CALCULATION OF IRON REQUIREMENT.

FOR PARENTERAL IRON. SUPPLEMENTATION.

Wt in pounds * deficit of Hb * .3 +300 mg.

Prophylactic-IFA Large- 1 / day.

Therapeutic-IFA large- 2 / day.

COMPLICATIONS OF ANENEMIA DURING PREGNANCY.

PRE TERM LABOUR.

Prone to infections.

CCF,APH,PPH, Maternal mortality.

IUGR,Pre maturity,IUD.

COMPLICATIONS OF LATE PREGNANCY.

IUD. Pre Eclampsia.

Eclampsia.

PROM.

IUGR.

PRE ECLAMPSIA.

Is development of hypertension with or without proteinuria with edema, induced by pregnancy after 20 wks of pregnancy.

-----diagnosis.

Bp- 140/90.mm Hg.

Or Sudden /excessive wt gain.

> 1 Kg /wk or,

3 Kgs / month.

MANAGEMENT.

Bed rest- Lt latereal position.

Exmination twice a week.

Control of Bp– Nifidipine 10 mg (o), or sublingually.

------------------Sedation- Inj Largectil (50) mg.IM.

------------------Inj Diazepam 100 mg IM.

Refer tp FRU.

ECLAMPSIA.

HYPERTENSION,PROTEINURIA,EDEMA,CONVULSIONS charecterize eclampsia.

management

Refer to FRU.

Brefore referal--- Diazepam 10 mg IM. Nifidipine 10 mg sublingual.

DURING TRANSPORTATION.

Women must lie on sides & head turned.

Put soft gag between teeth.

Monitor Bp every 20 min.

Establish IV line with splint.

Give Oxygen.

Start antibiotics.

Do continuous catheterizations.

PROM

SPONTANEOUS RAPTURE OF MEMBRANES any time during pregnancy beyond 28 wks, before the onset of labour.

CONFIRMATION OF DIAGNOSIS.

Speculum examination.

pH detection 7 – 7.5 – Liquour amni.

Fern test.

TREATMENT.

Minimal vaginal examination.

Start antibiotics ( A moxy 500 mg 6 hrly).

Bed rest.

Use vulval pad.

Ref to FRU.

Conduct delivery.

IUGR

When the birth weight is below 10 % of the average for gestational age.

MANAGEMENT.

Take adequate bed rest.

Avoid smoking & alcohol.

Correct malnutrition.

Refer to FRU.

MEDICAL DISORDERS DURING PREGNANCY.

Pregnancy with heart disease.

Pregnancy with diabetes.

Pregnancy with UTI.

Pregnancy with jaundice.

Pregnancy with malaria.

Pregnancy with TB.

SCREENING FOR CONGENITAL MALFORMATIONS.

HIGH RISK FACTORS.

Hydramnios.

Severe IUGR.

Abnormal presentation.

Elderly mother.

History of drug intake.

Uncontrolled DM.

Hypothyroidism-mother.

H/O mentally retarded offsprings in the family.

PREVENTION.

Administration of folic acid 5 mg daily – 3 months before conception.

Controlling DM.

Prevention of all kinds of infection.

Early diagnosis of malformation & termination.

Avoidance of medication ( without physician’s Prescription.).